Part B Insider (Multispecialty) Coding Alert

Published on Fri Jan 28, 2011 PDF

Plus: 'Hundreds of millions of claims' to be reprocessed in coming weeks, CMS says.

CMS staffers confirmed that MACs can determine whether they'll allow licensed practical nurses (LPNs) and registered nurses (RNs) to perform annual wellness visits (AWVs) and collect from Medicare for those services. That's the word from a Feb. 22 CMS Open Door Forum, where practices called in with several questions affecting Part B providers.

One caller phoned into the forum to ask about a Q&A posted on the Web site of WPS Medicare, a Part B payer in four states, which asks whether an RN or LPN can perform "the entire annual wellness visit (AWV, G0438-G0439)." WPS responds on the site, "Yes, an RN or LPN can perform the visit. They need to be under the direct supervision of a physician and the state license needs to allow for them to do all the components of the service." (http://www.wpsmedicare.com/part_b/education/awv-faq.shtml). The caller asked whether this is a general CMS policy or if it only applies to WPS Medicare.

"Remember, the LPN's not billing," said CMS's William Rogers, MD, reminding the caller that the visit would be billed under the physician's NPI as "incident to." But the caller still considered it "odd" that an LPN could perform an AWV, since it's similar to an E/M service.

"It's a different sort of service -- there's not really any clinical judgment involved," Rogers said. "It's a service which includes a lot of sort of administrative steps, verifying that people have certain preventive services done and things like that, and so it is intended to be a collaborative service."

Keep in mind that CMS does not have a national policy allowing LPNs and RNs to perform AWVs, but reps from the agency confirmed that it's within the rights of the individual MACs to make this determination.

Payment Adjustments Will Be on the Way Soon

If you're looking for more money from your Medicare payer based on adjustments in the Affordable Care Act, CMS has some advice for you -- sit tight. The money that your MAC owes you is in process, and contractors are working diligently to get those adjustments out to you, according CMS reps on the call.

CMS incorrectly processed "hundreds of millions of claims" affected by the Affordable Care Act, and plans to reprocess those claims within the next two weeks, but the complete situation could take several months to resolve, said CMS's Stewart Streimer during the call. "It won't be something where everybody's claims will all of a sudden on one day start to be reprocessed. We have been working very closely with our Medicare claims administration contractors to make sure all of these claims get reprocessed in a very organized and deliberate fashion so we're not impeding or jeopardizing new claims that come into the program," he explained.

Important: Do not resubmit your claims in an attempt to reprocess them at the accurate levels, Streimer said. "If you resubmit claims, there's a very high likelihood that those claims will be denied as duplicate claims. Allow the systems to do their work -- it may not be as quickly as you would like, but let me assure you that we are doing our best so we can automatically reprocess as quickly as possible."

In addition, don't submit a "reopening" to your MAC regarding your claims, because that could slow down your claim processing immeasurably.

Not All Claims Can Be Reprocessed: Under certain circumstances, your MAC won't reprocess the claim automatically. If the charge submitted on a claim is below the new rate, "those affected providers will have to contact their Medicare contractor to ask for an adjustment," Streimer said. "If your submitted charge is at or above the new rate, and I'm primarily focused on physician claims paid under the Medicare Physician Fee Schedule...then those claims can easily be reprocessed, not a problem," he said.

Your MAC won't send you a payment for every claim that it reprocesses, Streimer said. Instead, the MAC will aggregate your claims and will attach the remittance to your next payment.