Medicare Changes Rules on Credentialing and Retro-billing
Effective April 1, 2009, practices can only retro-bill for Medicare patients seen 30 days prior to the date the credentialing form was filed. The implications are:
- New physicians need to be credentialed prior to treating patients. This requirement should be part of the pre-employment checklist. The old days of credentialing a provider after they arrive onsite is over.
- Marketing activity to introduce new physicians to the community and medical staff should be scheduled after the credentialing is completed. Sometimes this can be tricky, however the referring providers can become disenfranchised when a new provider is not ready to schedule any of their patients.
- One option is to elect to see patients at no charge, both to provide needed care, and to begin establishing their practice.
- Another option is to have new physicians spend time in the community meeting potential surgeons and other referral sources. New physicians can also spend time giving talks and going with colleagues to satellite clinic locations or volunteer clinics.
- New physicians who are not credentialed can treat self-pay patients immediately. Some practices assign the new physician to the on-call physician to assist with emergencies, which are usually a high volume of uninsured patients.
The CMS system called PECOS (Provider Enrollment, Chain and Ownership System) or PECOS Web is available for enrolling or changing individual or group information. In addition to the retro-billing component for new and re-enrolling physicians, doctors are also required to alert Medicare contractors of a change in practice location within 30 days, via the 855i form. Failure to do so may result in expulsion from eligibility to see and be paid for Medicare patients for up to two (2) years. This is a new safeguard added by CMS to combat fraud.
Providers can us the links below to access the PECOS system:
- You must have an active National Provider Identifier (NPI) and have a web user account (User ID/Password) established in NPPES (https://nppes.cms.hhs.gov/NPPES/) .
- If you are a health care provider and do not have an NPI, create a web user account and apply for an NPI at NPPES (https://nppes.cms.hhs.gov/NPPES/) .
Get Full Reimbursement for Anesthesia Teaching Cases
Use the AA and GC modifiers to claim 100% reimbursement for your teaching anesthesiologists for cases performed after Jan. 1, 2010. That’s the date teaching anesthesiologists become eligible to receive full payment under the Medicare physician fee schedule (PFS) for cases where they supervise or medically direct anesthesia residents.
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
Medicare Releases Temporary Conversion Factors
As a result of legislative action temporarily delaying the 21.2 percent payment cut, CMS announced in an educational article that the Medicare conversion factor is frozen at $36.0846 until the end of February. In addition, the national anesthesia conversion factor for this same time period is $20.925. This legislation addresses only the conversion factor; all other 2010 policy changes to the Medicare program, including the elimination of consultation codes, became effective on Jan. 1.
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.
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Robert Cox, President & Managing Partner Anesthesia Resources