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Return to newsletter archives | View the current newsletter NEWSLETTER - NOVEMBER 2006Medicare Announces Changes to Imaging Payment Levels for 2007On November 1st, CMS released a Fact Sheet that explains how Medicare imaging payments will change for 2007. The highlighted changes are: The first provision addresses payment for certain multiple imaging procedures, with full payment for the first procedure, but a 25 percent reduction in payment for additional imaging procedures furnished on contiguous body part during the same session. This is a smaller reduction for 2007 than had previously been announced in the final rule for the 2006 physician fee schedule for 2007. The second limits the payment amount under MPFS to the outpatient Department (OPD) payment amount for the technical component (TC) of certain imaging services. This payment limit is required by the Deficit Reduction Act of 2005 (DRA). Under this provision, the physician fee schedule payment amount for furnishing certain imaging procedures cannot exceed the amount paid to a hospital outpatient department. Finally, payments for imaging services are also affected by revisions to payments for practice expense. CMS is implementing a new methodology for determining practice expense payments for all services including imaging services. For an in depth explanation of these changes, go to: www.cms.hhs.gov/apps/media/press/release.asp?Counter=2046 For tables of codes affected, go to the Medlearn Matters Article SE0665 at: www.cms.hhs.gov/MLNMattersArticles/downloads/SE0665.pdf Big Radiology Coding Changes for 2007If you have not yet ordered your 2007 CPT book, better find one fast! 2007 brings major changes to the radiology section of the CPT manual. These changes go into effect January 1st, 2007 without any kind of grace period. Some of the changes include: There are new codes for fetal nuchal translucency measurement, functional MRIs, RFA of pulmonary tumors, an all in one code for uterine fibroid embolization, and placement of fiducial markers. Renumbering and relocation of numerous codes, including mammography codes, guidance codes, bone studies, and vertebroplasty codes. Please see the last page of this newsletter for a crosswalk of the renumbered codes. New Online Information for CignaMembers: Cigna will broaden the availability of benefit design option and give members more online access to quality and cost efficiency information. In addition to supporting the industry's focus on consumerism, the programs align w/the Executive Order by President Bush directing Federal agencies to provide health care quality and price information. Cigna Care Network: Cigna Care Network will be offered in more areas in January 2007. Through this benefit option, participating physicians in certain specialties who meet specific quality and cost efficiency criteria are designated Cigna Care Network physicians. Participating providers are considered in network whether or not they receive the Cigna Care Network designation. A lower member co-pay and coinsurance level applies if the member chooses a Cigna Care Network designated physician. Designations appear in the on line provider directories at www.cigna.com and the secure site for Cigna members. Physicians practicing in an impacted specialty in Cigna Care Network service area will receive notice of their 2007 Cigna Care Network designation status. In future years, physicians should consult the online provider directory to find their status. Physician Quality and Cost Efficiency Profile: In the form of a star (*) designation, profiles for participating physicians in 21 specialties will be shared with members across most service areas. Separate star designations will appear for quality and cost efficiency beginning January 2007. Quality stars are determined based on:
Outpatient Surgery/High Tech Imaging Complementing the Hospital Value Tool and Centers for Excellence program Cigna introduced tools to help members estimate the average cost of certain outpatient surgical procedure and high tech imaging services. Using the secure member website, members can view the estimated average facility cost for 16 common surgery categories and the estimated average cost for MRI/MRA, CT and PET. Pre-certification Reminder: Cigna continually reviews the pre-cert process and requirements. As part of that process updates are made throughout the year. For a list of procedures requiring pre-cert go to www.cignaforhcp.com New Integrated Claim Code Disclosure Tool Soon Cigna will enhance their website to offer access to a new claim code disclosure tool. This tool offers claims edit information for claims payment. To access the tool log on to www.cignaforhcp.com Eservices/View Claims Coding Edits Indicate a service date range to go to the McKesson site where you will be asked to enter additional information. The results include a value of allow, disallow or review. Additional clarification is available if the value shown is disallowed or reviewed. Continued Improvement - website: Cigna recently implemented a new streamlined look to the eligibility/benefits and claim status pages. Enhancements:
Planned Enhancements:
Consistent With The AHA ICD-9 Coding Clinic states that the term "consistent with" fits the definition of a probable or suspected condition. Please be aware that any condition preceded by this wording should not be used for coding and billing purposes. If there are no other findings to code for, we will code from the reason for the test and/or the history. Other terms that fall into this category are:
If you are "sure" of a diagnosis, do not use these terms in your dictation. If you must use them, please be sure to also dictate the patient's signs or symptoms so our coders have something to work with. Aetna Changes Precertification ProcessAetna has announced that they are making changes to their pre-certification program as of 1/1/2007. As of 1/1/2007, pre-certifications for outpatient diagnostic imaging procedures for all plans currently managed by NIA (National Imaging Associates) will be administered by MedSolutions. In addition, beginning 3/1/2007 pre-certifications will be required for outpatient diagnostic imaging procedures for ALL Aetna members. MedSolutions will administer pre-cert for these members as well. As a reminder- pre-certs are required for:
Continue to submit pre-certs requests to NIA through 12/31/06. How to submit pre-certs request to MedSolutions: Website: www.medsolutionsonline.com or Call: 888-693-3211 Fax: 888-693-3210 If you have questions please call: HMO 800-624-0756 (select Medical Pre-certs) PPO/indemnity: 800-632-3862 (select Medical Pre-certs) Tricare PreauthorizationsTricare has announced that effective 11/1/06, the following procedures will require preauthorization:
TriWest Healthcare Alliance recently updated the TRICARE Patient Referral/Authorization: Patient Referral Authorization Form. In addition, TriWest has created an easy-to-follow sample TRICARE Patient Referral/Authorization Form that shows providers what specific information is needed and where to place it on the form. The new form and the sample form are available at www.triwest.com in the Find a Form section. AAA Screening BenefitEffective for dates of service on and after January 1, 2007 Medicare will pay for a one-time ultrasound screening for AAA, for beneficiaries who meet the following criteria: Receives a referral for such an ultrasound screening as a result of an initial preventive physical examination (IPPE) (See MLN Matters article MM3638 at www.cms.hhs.gov/MLNMattersArticles/downloads/MM3638.pdf for more details on the IPPE.) Receives such ultrasound screening from a provider or supplier who is authorized to provide covered diagnostic services. Has not been previously furnished such an ultrasound screening under the Medicare Program Is included in at least one of the following risk categories: Has a family history of abdominal aortic aneurysm; Is a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime; Is a beneficiary, who manifests other risk factors in a beneficiary category recommended for screening by the United States Preventive Services Task Force regarding AAA, as specified by the Secretary of Health and Human Services, through the national coverage determinations process. Payment: The Part B deductible for screening AAA is waived effective January 1, 2007, but coinsurance is applicable. If the screening is provided in a physician office, the service is billed to the carrier using the HCPCS code G0389: Ultrasound, B-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening. 2007 OIG Work PlanThe section of the 2007 OIG work plan concerning interpretation of x-rays in ERs has changed. Inappropriate Payments for Interpretation of Diagnostic X-rays in Hospital Emergency Departments (revised): We will determine the extent of inappropriate payments for the interpretation of diagnostic x-rays performed in emergency departments. In 2004, more than 2.5 million diagnostic x-rays were performed in Medicare-certified hospitals with emergency departments. According to the Medicare Claims Processing Manual, contractors are to pay for only one interpretation of an x-ray procedure furnished to an emergency department patient. They pay for a second interpretation, identified through the use of modifier 77, only under unusual circumstances, for instance when the physician performing the initial interpretation believes a specialist is necessary. Documentation must be present to support the second claim. We will determine whether the services were medically necessary and if the tests were interpreted contemporaneously with the patient's treatment. (Revised 10/4/06) (OEI; 00-00-00000; expected issue date: FY 2008; new start) Medicare Carrier Websites
Draft Medicare Policies Available for CommentTrailblazers/Virginia: A draft policy on 3D Rendering, codes 76376 and 76377, will be available for comment until 12/11/06: X-45AB: 3D Interpretation and Reporting of Imaging Studies If your practice performs 3D renderings, please review this draft policy, EVEN IF YOU DO NOT PRACTICE IN A TRAILBLAZER'S REGION. We predict that this is the direction other Medicare Carrier's will soon be headed. Mississippi Medicare: www.msmedicare.com Draft policies on non-invasive cerebrovascular arterial ultrasound and non-invasive peripheral arterial and venous studies are available for comment until 1/2/2007. Happy HolidaysThe Partners and staff at Evolutions wish you and yours a joyous Holiday Season, and a Happy and Peaceful New Year. Visit Our WebsitePlease visit us at www.evolutions-mbs.com where you can find information on the services we provide, our performance metrics, and staff biographies. Take a look and see what Evolutions can do for your practice. If you would prefer to receive this newsletter via e-mail please send your e-mail address to: If you have questions concerning this information, please contact:
If you would like to talk with us about what Evolutions can do for your practice, please contact:
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