• For professional claims (CMS-1500 Form and 837P) submitted by physicians and other suppliers that include span dates of service, the line item“From” date will be used to determine the date of service and filing timeliness. (This includes supplies and rental items).  For physicians and other suppliers that bill claims with span dates, these span date services cannot exceed one month.
• For institutional claims that include span dates of service (i.e., a “From” and “Through” date span on the claim), the “Through” date on the claim will be used to determine the date of service for claims filing timeliness.
• BE AWARE: If a line item “From” date is not timely, but the “To” date is timely, Medicare contractors will split the line item and deny untimely services as not timely filed.
• Claims having a date of service of February 29th must be filed by February 28th of the following year to be considered as timely filed. If the date of service is February 29th of any year and is received on or after March 1st of the following year, the claim will be denied as having failed to meet the timely filing requirement.

Change request (CR) 6960 specified the basic timely filing standards established for FFS reimbursement, which are a result of Section 6404 of the Patient Protection and Affordable Care Act of 2010 (ACA) that states that claims with dates of service on or after January 1, 2010, received later than one calendar year beyond the date of service will be denied by Medicare.

In researchers’ sampling of 10 nonprofit BCBS plans, seven held more than three times the amount of surplus that regulators consider to be the minimum amount needed for solvency protection. For example, BCBS of Arizona has surplus more than seven times the regulatory minimum as of the end of 2009. Health Care Service Corporation, a mutual insurer doing business as BCBS of Texas, Illinois, New Mexico and Oklahoma, has five times the regulatory minimum. Meanwhile, over the past three years both insurers continued to raise their rates.

The report calls on state insurance regulators to scrutinize surpluses when considering rate increases and set maximum limits for surpluses. 

Claims containing June 2010 dates of service which have been paid at the negative update rates will be reprocessed as soon as possible.  Under current law, Medicare payments to physicians and other providers paid under the MPFS are based upon the lesser of the submitted charge on the claim or the MPFS amount. Claims containing June dates of service that were submitted with charges greater than or equal to the new 2.2 percent update rates will be automatically reprocessed. Affected physicians/providers who submitted claims containing June dates of service with charges less than the 2.2 percent update amount will need to contact their local Medicare contractor to request an adjustment.  Submitted charges on claims cannot be altered without a request from the physician/provider. 

Physicians/providers should not resubmit claims already submitted to their Medicare contractor.

The Senate may hold votes as early as today, however debate on this bill may continue late into the week before final votes are held. If the Senate approves the substitute amendment, the House of Representatives must still pass the underlying tax extenders bill before it becomes law. If the bill is signed into law, the pending Medicare physician payment cuts would then be scheduled to take effect on Dec. 1, 2010.

 On April 15, 2010, President Obama signed into law the “Continuing Extension Act of 2010.” This law extends through May 31, 2010, the zero percent update to the Medicare Physician Fee Schedule that was in effect for claims with dates of service January 1, 2010 through March 31, 2010.  The law is retroactive to April 1, 2010.  Consequently, effective immediately, claims with dates of service April 1 and later, which were being held by Medicare contractors, are being released for processing and payment.  Please keep in mind that the statutory payment floors still apply and, therefore, clean electronic claims cannot be paid before 14 calendar days after the date they are received by Medicare contractors (29 calendar days for clean paper claims).

You won’t see receive the additional reimbursement without proper modifier use.  Use modifier AA (anesthesia services performed personally by anesthesiologist) to get 100% reimbursement. Don’t use the QK modifier, which indicates medical direction and pays only 50% of the allowed charge. Additionally, modifier GC (service performed in part by a resident under the direction of a teaching physician) indicates the teaching anesthesiologist was present or immediately available during all critical portions of the anesthesia procedure (i.e., induction, emergence).

The ASA created a teaching tool to help coders properly bill in cases where a teaching anesthesiologist is directing a resident or student-registered nurse anesthetist (SRNA).  The following is a list of medical direction scenarios provided by the ASA, with proper modifier usage:

• 1 MD + 1 Resident + medical direction of 1 CRNA in two separate concurrent cases = MD paid 100% of the allowed amount for the resident case (use the AA and GC modifiers) and 50% of the allowed amount for the CRNA case (with QK modifier). CRNA paid 50% of the allowed amount for his/her case (with QX modifier).
• 1 MD + 2 SRNAs in two separate concurrent cases = MD paid 50% of the allowed amount for each case. Note: MDs cannot be involved in more than two concurrent SRNA cases without a CRNA also being involved. Both cases filed with modifier QK.
• 1 MD medically directing 1 CRNA + 1 SRNA in two separate concurrent cases = MD paid 50% of the allowed amount for each case (bill with modifier QK); CRNA paid 50% of the allowed amount for his/her case (bill with modifier QX). No payment made for the SRNA service.
• 1 non-medically directed CRNA + 1 SRNA = CRNA paid 100% of the allowed amount (use QZ modifier).Note:Modifier GC is only used in working with a resident.
• 1 nonmedically directed CRNA + 2 SRNAs in separate concurrent cases = CRNA paid 100% of the allowed amount in each case (use QZ modifier).  The teaching CRNA must devote all his or her time to the two concurrent student nurse anesthetist cases.  To bill base units in each case, the teaching CRNA must be present with the student during the pre- and post-anesthesia care in each case.” 

Official resources:

For the CMS article describing the new rules for teaching anesthesiologists, go to: www.cms.hhs.gov/MLNMattersArticles/downloads/MM6706.pdf

For the ASA report describing different teaching anesthesiologist scenarios, go to: www.asahq.org/Washington/Payment%20Scenarios%20under%20Final%202010%20PFS.pdf

Read the entire story of Anesthesia Management aquisitions here.

As previously noted, CMS will hold all Part B claims until Jan. 15, and the Physician Annual Participation Enrollment Program was extended from Jan. 31 to March 17.

After 10 business days, contractors will begin releasing held claims into processing under the fee schedule which implements current law. This, of course, could result in claims being processed with the negative 21.2 percent update. If a new law is enacted which changes the negative update effective Jan. 1, CMS will correctly process claims under the new law and, if necessary, CMS is prepared to automatically reprocess most of those claims which have already been processed at the lower rate.

Under the Medicare statute, Medicare payments to physicians and other affected providers are based on the lesser of the actual charge or the MPFS amount.  Providers who submit charges that are greater than the negative 2010 MPFS will automatically have their claims reprocessed.