Medicare Changes – Overdue?

Medicare has some big changes in the coming two years – here are two big ones to keep an eye on and prepare for:

The End of Social Security Numbers as ID

Thanks to the Medicare Access and CHIP Re-authorization Act of 2015, they will be phasing out the use of Social Security Numbers in the Medicare ID#. You are likely familiar with the current use of the patient social security with a letter at the end (usually “A”). Starting in April of 2018, they will be issuing new “Medicare Beneficiary Identifier (MBI)” to their beneficiary. How will this look?

  • MBI will be 11 characters and made up of numbers and uppercase letters.
  • There will be a transition period from 4/1/18 to 12/31/19 where you can use either HICN or MBI.

Keep an eye out for any delays issued from CMS, but currently, the transition is set to begin on 4/1/18. With HIPAA such a focus for healthcare, it seems overdue to keep a patient’s social security number as secure as possible.

The End of PQRS

For a refresher on what PQRS is, you can read our blog post here. Don’t study too much though, because it is going away! It ends December 31, 2016 and is replaced with Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). This represents a shift from Fee-For-Service payments to “Value-Based” Payments.

  • Most practitioners will fall under the MIPs model rather than the APMs model.
  • The base Fee Schedule will raise by 0.5% per year through 2019, and beginning in 2019 you are eligible to receive positive or negative adjustments to that fee schedule based on your MIPs performance.
  • Contains broader exemptions for smaller providers. If your Medicare billing charges are less than $30,000/year and you see less than 100 Medicare patients/year, you will not be subject to MIPS. NOTE: Many of the published information on the MIPs exclusion for small providers show $10,000 yearly limit, however this has been amended to $30,000 after feedback.
  • First year providers do not participate.
  • As with PQRS, payment adjustments are reflected 2 years after initial data collection/reporting. Initial reporting in 2017 will be due/analyzed in 2018, and payment adjustments based on that data will show in 2019. This also means if you participated in PQRS through 2016, you should still receive your 2% incentive in 2017 and 2018.

There are great resources available for CMS here, and an informative visual guide here from CMS.

If you are a client of In Charge Office Solutions and are interested in participating, we can guide you where to find the 2017 measures that may be available for you to report on. Delaying even one year will result in no increase in payment until 2020, so it is best to start in 2017 if you are participating.

PQRS: It Doesn’t Have to be Painful

There are a few topics that consistently return the most questions in my Continuing Education classes, and one of them is PQRS (Physician Quality Reporting System).  Mainly, why do we have to do this and why are they reducing my Medicare payments if I do not?

What is PQRS?

The Physician Quality Reporting System (PQRS) is a voluntary Centers for Medicare & Medicaid (CMS) program, with the stated purpose of “encouraging health care professionals and group practices to report information on health care practices.” Their goal through this is to lead to better care for Medicare patients.

As a provider, you participate either through Individual or Group Measures. There are hundreds of available measures (download from CMS as an Excel spreadsheet here), and you can chose applicable measures for your office. One of the most widely applicable measures is Medication Documented (Measure #130). There are also measures for Pain Assessment and Follow Up (Measure #131), Functional Outcome Assessments (Measure #182), and many more.

Why Participate?

CMS hopes that participating in these quality measures will lead to better patient care, and more informed care for the patient. On top of that, as an added “incentive” to participate, CMS imposed a 2% fee schedule reduction for providers who do not participate in the program. If you do not participate, you likely already see this on your Medicare Remittance Advices:



If your Medicare patient volume is high enough, it could cause a noticeable decrease in reimbursement. It is a technically voluntary program, so you can decide whether or not your practice should participate based on the administrative load it would require and the decrease in payments you face for not participating.

How to Participate?

Many Electronic Health Record (EHR) programs compile the PQRS relevant information from the patient’s chart and send on for you. This is the most efficient way to participate, and should take the least administrative time for the office. They may also suggest some measures you did not realize your practice would be eligible to report.

If you are not using a full EHR program or if your EHR system does not have PQRS capability, you can report the measures on claims. The measures can be reported using dedicated “G” codes. Each applicable “G” code is added as a line item to your claims. These codes hold no value with Medicare and no reimbursement for them will be made.

Another option is to use a PQRS program. There are many PQRS alternatives to EHR that you can purchase. You must enter all of the information into their system, but they compile it for you and send it on to CMS on your behalf. They can also identify deficiencies and suggest new measures if applicable.

How Many Measures?

CMS suggests each practice report 9 individual measures.  If there are not 9 applicable measures to your practice you can, however, still avoid the reduction. A good example of this is with Chiropractic practices. Reporting on 2-3 measures for a Chiropractic office is usually enough to avoid your 2% reduction in fee schedule.


If any of our clients need PQRS guidance, email to find out if you’re already reporting or how to get started.

BREAKING: Anthem Announces Intent to Acquire Cigna

Whenever I hear the notification of an email to my business account after 8pm on a Friday, I know it’ll be something juicy. Nice PR move: release something slightly controversial (or very controversial) on a Friday, hoping it will be forgotten by next Monday’s news cycle.

WELL, I received one such notification last night and to my surprise, the Subject Line says, “Cigna Anthem Announcement.” Cigna Anthem Announcement? But those are two different things? Well, apparently not for long if everything goes as they plan, with a merger deal on the table.  The announcement says they expect finalization of the merger in the second half of 2016. They state that the “combined company” will expand networks for patients and make care more accessible. Anthem already has a strong medicaid network which has become increasingly important with the Affordable Care Act. Cigna will be able to utilize this, while those covered by Anthem will now have access to Cigna’s broad network of specialty care.

Why does this matter and how will things change?

Cigna Anthem Merger

Cigna Anthem Merger

Well, for us here at In Charge Office Solutions and most people who deal with insurance companies daily, you get to know each insurance company and their medical policies, procedures, and authorization processes. Cigna and Anthem have been quite
different companies to deal with to this point, and should the acquisition go through it will be interesting to see how/if those things change.

Beyond this, the insurance industry is already a relatively narrow one with large, recognizable companies covering the majority of people. Small insurance companies are few and far between, and often cannot compete with the larger companies. When a person is offered insurance coverage through their employer, there are usually only two or three options. Does the industry really need to narrow the field even more, taking a major player out? It is doubtful another will rise in its place.

This brings me to the most important point: this is definitely not a done deal.

It faces scrutiny by the Department of Justice and the Federal Trade Commission who have to review the agreement for antitrust issues. It also was not well received in the business world, with shares falling for both companies.

Whether or not it does go through, the agreement is a sign of the changing times in the industry. With such rapid changes in regulations, it is inevitable that insurance companies will restructure and adapt. Adaptation has always been a necessity in our business, so we will continue to do just that.


2015 Brings Changes to Modifier 59

Modifier -59 is one of the most well known and used modifiers, because it has the potential to have a large impact on your reimbursement from health insurance companies. Because of its popularity (and often misuse), CMS has rolled out 4 new modifiers that essentially replace modifier 59.

What is Modifier 59?

It is defined in the CPT manual as a “Distinct Procedural Service.” It allows the provider to indicate that a procedure or service should be considered separate from another during the same encounter. This is only necessary on codes that are usually considered bundled services. For example:

CPT code 97140 (manual therapy) is usually bundled with CPT code 98940 (CMT, spinal).  When the manual therapy is performed as a separate service for a separate issue (diagnosis), then it can be shown by appending modifier -59 to the CPT code 97140.

This makes both codes payable rather than just the one. This also, of course, needs to be supported by the medical record.

What are the Changes?

CMS has created 4 new modifiers as subsets to modifier -59 that are intended to ultimately take the place of modifier -59. They are more specific, and allow the provider to more specifically indicate why the service is separately identifiable from another.

  1. XE – Separate Encounter
  2. XS – Separate Organ/Structure
  3. XP – Separate Practitioner
  4. XU – Unusual Non-Overlapping Service

How to Implement

The modifiers became effective January 1, 2015, and CMS is encouraging immediate use but is also still accepting modifier -59. It is also important to note that private insurance carriers may not yet be accepting them. Anthem Blue Cross has stated they will accept them for dates of service 1/1/15 and later, but they will not be accepted until the system update in February. It is important to check with your contracted carriers before making the switch, but equally as important to ensure a plan is in place.

BREAKING: Senate Passes Bill Delaying ICD-10

stopsignOn 3/31/14, the Senate passed a bill that includes delay of ICD-10 implementation to October 1, 2015 – an entire year extension. It states “The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002of title 45, Code of Federal Regulations.”

This puts many feet in mouths, including my own.

While on the surface this may seem like a relief, the amount of time, money, and energy spent to transition on October 1st of this year is immeasurable. To delay another year puts the brakes on something that all of us in the healthcare industry have prepared for. Software vendors have upgraded their systems, clearinghouses have begun ICD-10 testing, and coding educational institutions have begun teaching the new code set.

Delay also does not help to convince people that ICD-10 is a good thing, which is the point of the whole transition. More effective reporting, advanced specificity, and accuracy in claims reporting; these are all good things.

Our current plan is to continue with preparation as we were. Our clearinghouse is also moving forward with ICD-10 testing, even with the delay. Sign up for our newsletter to receive updates, or email if you have any specific questions: .


2014 ACA Implementation: One Month In

Happy New Year!

With 2014 came the roll out of the “ACA compliant” health insurance plans. The Covered Ca website is up and running with enrollment far exceeding projections; the most recent figures released  show enrollment of 500,108 in 2013.

The new plans’ high deductibles and co-payments have been the focus of much discussion, but it looks as if the real issue may be low enrollment rate of Healthcare Providers in the networks. The combination of low provider enrollment with no out-of-network benefits leaves little option for the 500,000+ enrollees when it comes to their healthcare.

Why Not Join?

Providers are reluctant to join the networks for many reasons. When insurance plans shift more out of pocket responsibility to the patient, it becomes more difficult to recoup payment for services. Patients may not understand their benefits and why they have to pay out of pocket, and resistance is met. This is already common in the business of healthcare, but higher deductibles and co-payments will only exacerbate the issue. Putting too much focus on payment with the patient can make some providers feel the focus shift too far from care to business. It is a delicate balance.

In the same vein, many providers are reluctant to join because fee schedules are either unclear or unacceptable. Typically, PPO fee schedules hover near and slightly above Medicare, but many Covered California plans reimburse slightly above Medi-Cal rates. Medi-Cal rates are unsustainable for many practices in California, and many providers have opted out of Medi-Cal participation for years. Why then, would those same providers join networks reimbursing near the same? Without a large enough Provider Network, many patients will find themselves having to switch providers or wait long hours for care.

Affordable Care Act: It’s Here, Now What?

Lately it seems difficult for people to discuss the Affordable Care Act (ACA) without things turning political, but that is what we are going to try to do here. Like it or not, changes are coming and some have already taken place

Insurance companies have had to create new plans that align with the provisions of the ACA, and with those new plans come new provider networks. These networks are generally EPOs – Exclusive Provider Organizations – which carry no out-of-network benefits.  Blue Shield of California recently sent out a “Q&A” about their ACA compliant EPO highlighting the fact that any services provided by a non EPO provider will receive no benefit. If the percentage of EPO plans increases greatly, it will be more important than ever to check a patient’s benefits before they are seen and make sure your practice is a part of their network. Get new patient insurance information over the phone at the time the initial appointment is made, and make it a routine part of your office processes.

Since  many practices are also small businesses, the reform will affect them in multiple ways.  Many of my clients have already received notice that their employee’s health plans will need to be changed to comply with the ACA, and with those new plans come higher premiums. A higher bill is the last thing any business wants, BUT, if there are truly more insured patients (and that is the plan), the increase in patient flow may make up for the increase in cost to your business.

With so much information thrown at those of us in the healthcare industry, it is important to sift through it and stay informed. There will be parts of the ACA that necessitate a change in how your practice is run. Only time will tell how many of these changes will ultimately effect business, and more importantly, patient care.

Palmetto to Noridian: What is the Difference?

If you are a Medicare participating provider in California, Nevada, or the other territories formerly known as Jurisdiction-1B, your Medicare Administrative Contractor (MAC) has changed. Effective September 16th, 2013, Noridian Healthcare LLC Jurisdiction E has taken over the contract for the areas formerly known as Jurisdiction-1B under Palmetto GBA.

What Changes

    • Payer ID  and Claims Address. This is a simple one time update in your system and shouldn’t have an impact on reimbursement.
      Payer ID: 01112 for Northern CA.
      Claims Address:
      Medicare Part B Claims
      P.O. Box 6774
      Fargo, ND 58108-6774
    • How paper claims are edited. Most claims are not billed on paper these days, but all offices have HCFAs on hand for when it is necessary. The edits of paper claims by Noridian differ slightly from Palmetto’s, but enough that they may deny your paper claims and ultimately delay reimbursement.  Noridian has provided a handy guide here, but at the moment of this blog post their website is down and has been for some time. The transition must have been a bit hard on their website’s servers! It gives box by box instruction, so it is worth a visit back when the site is up.
    • New Provider Portal. Obviously, you’ll no longer go to Palmetto’s provider portal unless you’re accessing information for claims submitted prior to the transition. Noridian will use the Endeavor portal, and if you were registered with Palmetto you were automatically enrolled with Endeavor. An email was sent to the email address associated with your account.

What Remains the Same

      • Local Coverage Determinations (LCD). From a claims reimbursement perspective, the fact that the LCDs are unchanged from Palmetto’s is huge. Most of us know the applicable ones for our practice(s) like the back of our hand, or at least where we can find them. Your LCD# will change, but the contents will not.
      • Your EFT, ERA, submitter number. If you are already set up to receive electronic remittances and to submit electronic claims with Palmetto you will not need to reapply with Noridian. You’ll only need to change their claims payor ID (mentioned above).
      • Your status with Medicare. No Re-Validation required!

Questions or comments? Leave them below, or give us a call any time (925)583-5328.



Dual Coding & ICD-10 Transition

ICD-10 implementation is looming, and the industry is scrambling to prepare for the transition. Our post in May gives a broad overview of ICD-10 and how to prepare, but let’s talk now more specifically about “Dual Coding.”

ICD-10 Chalk


What is “Dual Coding?”

Dual Coding is the term that describes claims that have both ICD-9 and ICD-10 diagnosis codes. When a major change occurs, there is usually some leeway in the first few months that would allow for this type of claim to squeak through. This gives time for all players to get acclimated to the new requirements and how to implement them. Dual Coding has been a hot topic of sorts in our industry, with many wondering if it would be allowed.  With this release from Medicare, that question has been largely answered with a resounding “NO.” All claims after October 1, 2014 will be denied if they contain ICD-9 diagnosis codes. Private insurers are sure to follow suit.

What Can You Do?

Prepare! Medicare shows no indication of delaying the transition, and is pushing for quick and relatively painless transition. Rather than allowing for acclimation in the first few months, your practice will need to be prepared PRIOR to the transition date. October 1, 2014 may seem like a long way off, but this transition will require a complete overhaul of many office processes. Do not let your practice’s cash flow be affected by needless denials!

Quality Data Code (QDC) Registry Open Now.

All Ambulatory Surgical Centers (ASCs) are asked by Medicare to participate in Quality Data Code (QDC) reporting. Reporting for the measures is handled in two parts, the second of which is now open after a brief delay. More on this below.

 Part 1: “G” codes

As of October 1, 2012, ALL Medicare ASC claims were to be reported along with “G” codes. The codes are used to report any adverse events that occur, hospital admissions/transfers, and whether any IV antibiotics were ordered/used. These “G” codes carry no Relative Value Units (RVUs), which means they are not reimbursable. The use of the codes on your claims indicates your participation in the QDC reporting program, and no additional registration is required.

Part 2: Registry Reporting

The second part is the reporting via registry ( on measures ASC-6 and ASC-7, and covers data from January 1, 2012 through December 31, 2012.

  • ASC-6: Safe Surgery Checklist Use. Simple yes or no to the question, “Does/did your facility use a safe surgery checklist based on accepted standards of practice during the designated period?”
  • ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures. For a specific set of CPT codes, report the total number of times they were performed during the reporting period.

This information was to be reported during the time period of July 1, 2013 through August 15, 2013. That window was changed near July 1 due to technical issues with QualityNet, and they opened the registry for reporting on July 9. They only extended the deadline to August 18, despite the delay. If you haven’t logged in to the Quality Net portal, do not wait until August 18 to allow for any potential technical issues to be worked out.

No RVU – Why Participate?

If an ASC does not participate in the QDC program, they face a 2% reduction in Medicare fee schedule. This reduction begins in 2014, and is significant when put in line with the 2% sequestration cut. If time is money and you are spending time without any additional return, it can become frustrating to maintain. In Charge Office Solutions is set up to easily report these measures for our clients, ensuring they receive the highest reimbursement possible without additional burden to your facility.