THE HEALTH CARE REFORM

LAW: HOW IT AFFECTS YOUR

MEDICARE PAY
PREPARE YOUR PRACTICE
FOR THE CHANGES
Link to Slides at:
www.scribd.com/doc/30938016/PPCA-Impact-on-Medicare-Pay

Torrey Kim, MA, CPC

Editor-in-Chief
Part B Insider
torreyk@inhealthcare.com
2 Torrey Kim, MA, CPC
Editor-in-Chief, Part B Insider

When I’m not working on Part B Insider, I’m trying to

wrangle my three boys!
 Patient Protection and Affordable Care Act –
3 Signed Into Law March 23

Coding and billing staffers may feel like the woman on the right when they think
about how the law might create systems confusion
 Agenda
4

 What Is the PPACA?

 How Will the PPACA Impact Medicare?

 What Are the Implementation Timelines?

 Who is Responsible for Making Changes to

Your Systems?
 What Steps Should You Take Now?

 Health Care Reform Resources

 What is the PPACA?
5

 The Patient Protection and Affordable Care Act, also known as the
PPACA, HR 3590, or simply the “health care reform law,” includes over
2,000 pages of health care-related provisions that will take effect over the
next four years.

 Many of the PPACA’s other provisions, such as pre-existing condition

coverage, have received widespread media attention, but some practices
are still unclear of how it impacts Medicare

 Today’s presentation will break down a few of the most important factors
involving Medicare pay that the PPACA has in store
 How Will The PPACA Impact Medicare?
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Annual Wellness Visits (Sec. 4103)

 Every year other than the patient’s first year on Medicare, beneficiaries
will benefit from a “health risk assessment,” not subject to their deductible
or coinsurance, which includes an exam of height, weight, blood pressure,
and other routine measurements

 Based on the results of the health risk assessment, the provider will:
 Provide a screening schedule for the next 5 to 10 years
 Create a list of risk factors, counseling services, and referrals to other professionals
to provide interventions on such issues as weight loss, smoking cessation, nutrition,
fall prevention, and physical activity

 The wellness visits will take effect as of Jan. 1, 2011

 How Will The PPACA Impact Medicare?
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10% Bonus for Primary Care (Sec. 5501)

 Effective Jan. 1, 2011, primary care practitioners “shall be paid (on

a monthly or quarterly basis) an amount equal to 10 percent of the
payment amount for the service,” in addition to their normal fees
 Who qualifies? Doctors, nurse practitioners, clinical nurse
specialists, or physician assistants with the primary specialty
designation of family medicine, internal medicine, geriatric
medicine, or pediatrics qualify for the bonus.
 The catch: These practitioners will have to bill at least 60 percent
of their allowed charges as ‘primary care services,’ which are
defined by codes 99201-99215, 99304-99340, or 99341-99350.
 How Will The PPACA Impact Medicare?
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You Have One Year to Submit Claims (Sec. 6404)

 In the past, Part B providers had 15 months or more to submit

their claims to Medicare, but the new legislation requires you
to submit your claims “one calendar year after the date of
service” for services provided on or after Jan. 1, 2010.

 Caveat: The legislation states that “the Secretary may specify

exceptions to the 1 calendar year period,” but does not yet
indicate what types of situations might qualify for exceptions.
 How Will The PPACA Impact Medicare?
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Health Professional Shortage Area (HPSA) Bonuses (Sec. 5501)

 Major surgical procedures performed between Jan. 1, 2011 and Dec. 31,
2015 by a general surgeon in a health professional shortage area will
qualify for a 10 percent bonus
 The 10% payment will be disbursed “on a monthly or quarterly basis”
 A general surgeon is defined as a doctor who has designated specialty code
02 (General surgery) as their primary specialty
 “Major surgical procedures” are those with 10- or 90-day global periods
 HPSA basics: Medicare will adjust your payment accordingly if you
provide services in a ZIP code that falls within a pre-designated HPSA
county; however, if you practice in a county not designated as an HPSA but
your town is designated as one, you’ll have to append modifier AQ
(Services provided in an HPSA) to your claims
 How Will The PPACA Impact Medicare?
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Outpatient Therapy Cap Exceptions Extension (Sec. 3103)

 The law extends the exceptions process for outpatient therapy caps,
which means that these therapy providers may continue to submit
claims with the KX modifier (Specific required documentation on
file) when an exception is appropriate, for services furnished between
Jan. 1 and Dec. 31, 2010

 The current outpatient therapy cap is $1,860 for physical therapy and
speech language pathology services combined, and a separate $1,860
limit for occupational therapy services provided in a calendar year.
 How Will The PPACA Impact Medicare?
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Labs Can Bill TC for Hospital Patients (Sec. 3104)

 Effective retroactive to Jan. 1, 2010, independent labs

can submit claims to Medicare for the technical
component of physician pathology services furnished to
hospital patients, whether the patient was an inpatient or
an outpatient
 Labs that were previously denied for such services

should contact their MACs “for further instructions,”

CMS advises.
 How Will The PPACA Impact Medicare?
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Extension of 5% Mental Health Bonus (Sec. 3107)

 Three years ago, CMS reduced Part B payments for mental health
services during what it called a “Five Year Review” period.
Congress gave mental health providers a 5 percent bonus payment
in 2008 to make up for these cuts, but that expired on Dec. 31,
2009. The PPACA restores the 5 percent bonus payment through
Dec. 31

 The law makes the 5 percent bonus retroactive to Jan. 1, 2010

 How Will The PPACA Impact Medicare?
13

PQRI Program Extended (Sec. 3002)

 The following PQRI incentives/reductions are now applicable

through 2016 and beyond:

 2011: Incentive payment of a 1 percent bonus
 2012 through 2014: Incentive payment of a 0.5 percent bonus
 2015: Penalty of 1.5 percent
 2016 and beyond: Penalty of 2 percent

 The PPACA calls for an informal appeals process to be in effect as

of Jan. 1, 2011 for providers “to seek a review of the
determination that an eligible professional did not satisfactorily
submit data on quality measures”
 How Will The PPACA Impact Medicare?
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Timeliness of Refunding Overpayments (Sec. 6402)

 If you receive an overpayment from Medicare, you must report

and return the overpayment within 60 days after the overpayment

was identified, or the date any corresponding cost report is due
(whichever is later)
 You must notify the secretary, state, intermediary, carrier, or

contractor in writing and inform them of the reason for the

overpayment
 “Overpayment” refers to “any funds that a person receives or retains…to
which the person, after applicable reconciliation, is not entitled”
 How Will The PPACA Impact Medicare?
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Other Ways the Legislation Will Affect Medicare:

 Effective Jan. 1, 2011, your claims must include an NPI (Sec.

6402)
 Any applicable manufacturer must submit a report on March 31,

2013 and on the 90th day of each calendar year thereafter that
includes information regarding “transfers of value” that they made
to covered recipients (including physicians). These include cash,
items, services, consulting fees, gifts, entertainment, education,
travel, and other fees (Sec. 6002)
 The PPACA expands the Recovery Audit Contractor (RAC)

program and rolls it out into Medicare Parts C and D by the end of
2010 (Sec. 6411)
 What Are the Implementation Timelines?
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 Question: The healthcare reform bill included several pay boosts that
were retroactive to Jan. 1. When will the fee schedule incorporate those
retroactive changes?

 Answer: “There’s a complex calculation of a variety of those changes that

we are going through to put them together,” said CMS’s Amy Bassano
during an April 13 CMS Open Door Forum. CMS must prepare before it
incorporates the pay boosts, which could take “a month or two,” she said

 Plus: Even after CMS releases the new rates, “We still have our Medicare
contractors do extensive tests on those to make sure they are correct, so
that takes a little bit of time as well,” said CMS’s Stewart Streimer on the
April 13 call.
 Who Is Responsible for Making
Changes to Your Systems?
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 Billing Dept: If your practice chronically submits claims

more than one year after the date of service, talk to your
billing department or outsource company about how to make
claims processes more efficient

 Front and Back Office: Prepare to institute internal systems

that will allow for annual wellness visits without collecting
deductibles or coinsurance, effective in 2011

 Practice Manager/Physicians: If you don’t have an NPI yet,

enroll via the online NPPES system or using a paper form
 Steps to Take Now
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 Be ready for questions from Medicare patients,

who may expect changes to be in effect
immediately
 Tighten up your billing systems or talk to your
billing outsource companies to prepare for the new
1-year deadline for claims filing

KEEP IN MIND:
CMS staffers don’t even have all of the
answers yet, so you may not either.
 Health Care Reform Resources
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 You can read the entire PPACA law (2,393 pages) at

www.opencongress.org/bill/111-hh3590/show
 To determine whether your area qualifies as a health professional
shortage area, visit www2.cms.gov/HPSAPSAPhysicianBonuses
 To obtain an NPI, visit
www.cms.gov/NationalProvidentStand/03_apply.asp
 Updates are continuing in Part B Insider and via our webinars,
visit our Web site at www.supercoder.com
 Email me any time at torreyk@inhealthcare.com

Thank you!
 Thank
YOU!

20 Helping coders
help physicians!
 Supercoder.com

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