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Medicare Compliance & Reimbursement

Part B Update:

Despite CPT® Revision, Medicare Won't Update 'New Patient' E/M Rules for 2012

Published on Thu Mar 01, 2012

Plus: Claims reprocessing has completed, so make sure your claims have been corrected.

As many veteran coders are aware, just because CPT® makes a change, you aren't guaranteed to see Medicare follow suit. That's the case with the latest "new vs. established" patient definition that CPT® 2012 published, which won't have much impact on Part B claims, CMS reps said during a Jan. 24 Open Door Forum.

Background: CPT® 2012 states, "A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years." The portions of the description that are new for 2012 are underlined.

What wasn't clear to many practices was that many payers -- including Medicare -- don't acknowledge subspecialty designations in their computer systems, making the new definition irrelevant.

"CMS claims processing systems do not recognize physician subspecialties," said CMS's Erin Smith during the call. "Therefore, CMS's instructions for billing new and established E/M codes has not changed for 2012. Physicians and practitioners should continue to interpret the phrase 'new patient' to mean a patient who has not received any professional services (that is, E/M or other face-to-face services such as a surgical procedure) from the physician or another physician in the same group practice and same specialty within the previous three years," she added.

Keep in mind: Interpreting a diagnostic test in the absence of a face-to-face service does not affect the designation of a new patient.

For Medicare services, the same specialty is determined by the physician's or the practitioner's primary specialty enrollment in Medicare, Smith said. In addition, she added, each type of non-physician practitioner has a specialty code designation. For instance, all PAs are specialty code 97. Recognized Medicare specialties can be found online at www.cms.gov/MedicareProviderSupEnroll/Downloads/JSMTDL-08515MedicarProviderTypetoHCPTaxonomy.pdf.

Contact your MAC if you aren't sure of which specialty your practitioners enrolled under.

A caller asked whether CMS is considering any enhancements to its system that will allow practitioners to register with Medicare as both a specialty and a subspecialty, but a CMS rep said the agency has no current plans to pursue any such change. "If you feel like your specialty is clearly defined and you do specialized work that is separate from the specialty, you could apply for a separate specialty code," the CMS rep. said. But the CMS rep. confirmed that even if a physician currently registers with both a specialty and subspecialty, Medicare has no way for its computerized systems to actually look at the subspecialty.

Claims Reprocessing Finally Completed

Remember two years ago, when the Affordable Care Act drastically changed reimbursement for certain medical procedures? CMS has been struggling to reprocess claims affected by the law ever since it was passed, but the procedure was slow-going -- until now.

Good news: "We've been reprocessing claims as a result of the Affordable Care Act having a retroactive effective date for claims paid under the Medicare Physician Fee Schedule (MPFS), as well as some corrections to the 2010 MPFS, and I am pleased to announce that we are done," said CMS's Stewart Streimer during the call. "For all of the over 240 million claims that had to be reprocessed through this initiative, we got our last report this week. There may be a few loose ends here and there, but for the most part we have completed the claims reprocessing initiative."

Good idea: If your claims were impacted by the Affordable Care Act and you were awaiting a payment adjustment during reprocessing, go into your accounts receivable system and confirm that you received any money you were due.

E-Prescribing Penalties Kicked In

Unfortunately for some practices (and their wallets), CMS's e-prescribing penalties have now taken effect. As you are probably aware, practitioners are subject to a one percent payment adjustment on your Part B pay this year if you didn't successfully participate in e-prescribing during 2011 and you didn't qualify for any of the exemptions that CMS offered.

"The 2012 e-prescribing payment adjustment has started," said CMS's Lauren Fuentes during the call. "We'd like to advise eligible professionals to review their remittance advices for claims submitted for dates of service on or after Jan. 1, 2012."

"If you did not successfully e-prescribe in 2011, you still have an opportunity to avoid the 2013 payment adjustment [of 1.5 percent] by recording ten e-prescribing events via claims for services provided between Jan. 1 and June 30, 2012," Fuentes said. She advised practices to visit www.cms.gov/erxincentive  for more information on the penalties.

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