The Centers for Medicare & Medicaid Services (CMS) recently published an informative document, “Physician Quality Reporting Initiative (PQRI): 2007 Reporting Experiences.” It highlights common errors made by both the agency and medical practices participating in the PQRI during the 2007 PQRI reporting period. The issues raised may help practices contemplating participation in the 2009 PQRI.
Additionally, CMS announced modest efforts to review claims submitted for the 2007 PQRI using updated analytics that take into account these unanticipated issues. This review could result in some 2007 PQRI participants receiving adjusted payments and/or additional medical practices qualifying for the incentive payment. However, it is unclear how many providers will be affected. CMS will not make payments based on re-examined 2007 PQRI data until fall 2009.
When the Medical Group Management Association and other national provider organizations met with CMS officials last week regarding this announcement, the agency also provided a chart showing aggregate causes of invalid data submission or reporting.
Friday, December 19, 2008
Tuesday, December 16, 2008
New CMS rule affects contracted interpretations for diagnostic tests
Beginning on Jan. 1, the Centers for Medicare & Medicaid Services (CMS) will apply a new rule to certain diagnostic tests (excluding clinical diagnostic lab tests) ordered and billed by physicians or their group practices.
In an attempt to curb what it sees as overuse of diagnostic tests and abusive arrangements between providers, CMS has expanded a Medicare billing rule that prevented physicians from marking up the cost of the technical component (TC) of diagnostic tests purchased from an outside supplier (the "purchased diagnostic test rule"). Now referred to as the "anti-markup rule," the new rule will prohibit a billing entity, such as a physician or group practice, from marking up either the professional component (PC) or the TC of a test that was performed by a physician who does not share a practice with the billing entity. The rule will apply when the ordering physician and the billing entity are the same or are related through common ownership or control.
To determine whether the performing physician shares a practice with the billing entity, CMS has devised two tests. Under the first test, the agency will consider a physician to share a practice with the billing entity if the physician furnishes at least 75 percent of his/her services through the billing entity. If this test is met for both the physician performing the PC and the physician supervising the TC (assuming they are not the same physician), the newly expanded anti-markup rule will not apply.
If either physician does not provide 75 percent of his/her services through the billing entity, the anti-markup rule may still not apply if the physician shares a practice with the billing entity under CMS' second test, which focuses on where the test was performed. If the performing physician is an owner, employee or independent contractor of the billing entity and the TC or the PC is performed in the office of the billing supplier, the performing physician will be deemed to share a practice with the billing entity. Importantly, if the billing entity is a physician organization (that is, a physician, a physician practice or a group practice meeting the requirements set forth in the physician self-referral law), the service must be performed in space where the ordering physician provides substantially the full range of patient care services that the ordering physician provides generally.
If neither test is met, payment to the billing entity will be subject to the anti-markup rule. For the part of the service performed by a physician who does not share a practice with the billing entity, the entity will be paid the lowest of:
The performing supplier's net charge to the billing entity;
The billing physician's actual charge; or
The Medicare fee schedule amount for that service.
In an attempt to curb what it sees as overuse of diagnostic tests and abusive arrangements between providers, CMS has expanded a Medicare billing rule that prevented physicians from marking up the cost of the technical component (TC) of diagnostic tests purchased from an outside supplier (the "purchased diagnostic test rule"). Now referred to as the "anti-markup rule," the new rule will prohibit a billing entity, such as a physician or group practice, from marking up either the professional component (PC) or the TC of a test that was performed by a physician who does not share a practice with the billing entity. The rule will apply when the ordering physician and the billing entity are the same or are related through common ownership or control.
To determine whether the performing physician shares a practice with the billing entity, CMS has devised two tests. Under the first test, the agency will consider a physician to share a practice with the billing entity if the physician furnishes at least 75 percent of his/her services through the billing entity. If this test is met for both the physician performing the PC and the physician supervising the TC (assuming they are not the same physician), the newly expanded anti-markup rule will not apply.
If either physician does not provide 75 percent of his/her services through the billing entity, the anti-markup rule may still not apply if the physician shares a practice with the billing entity under CMS' second test, which focuses on where the test was performed. If the performing physician is an owner, employee or independent contractor of the billing entity and the TC or the PC is performed in the office of the billing supplier, the performing physician will be deemed to share a practice with the billing entity. Importantly, if the billing entity is a physician organization (that is, a physician, a physician practice or a group practice meeting the requirements set forth in the physician self-referral law), the service must be performed in space where the ordering physician provides substantially the full range of patient care services that the ordering physician provides generally.
If neither test is met, payment to the billing entity will be subject to the anti-markup rule. For the part of the service performed by a physician who does not share a practice with the billing entity, the entity will be paid the lowest of:
The performing supplier's net charge to the billing entity;
The billing physician's actual charge; or
The Medicare fee schedule amount for that service.
medicare launches Web-based provider enrollment
CMS rapidly expands access to Web-based provider enrollment system
The Centers for Medicare & Medicaid Services (CMS) launched the long-awaited Internet-based version of Provider Enrollment, Chain and Ownership System (Internet-based PECOS) for use by individual practitioners in 15 states and the District of Columbia on Dec. 4. Internet-based PECOS is a scenario-driven system that enables practitioners to complete their Medicare provider enrollment application online. By Dec. 15, the agency expanded access to the system to an additional 19 states.
A practitioner will use his/her national provider identifier (NPI) user identification and password to access Internet-based PECOS. Because of this, CMS recommends that individuals reset their user IDs and passwords before accessing Internet-based PECOS, and then resetting them at least once a year. The agency suggests that individual practitioners not share this information with others, including billing services, consultants and practice staff. Instead, CMS expects that individual practitioners will use the system to enroll and/or update their own information.
Currently, Internet-based PECOS is available in the following states and the District of Columbia: Alaska, Idaho, Nebraska, Pennsylvania, Arizona, Kansas, Nevada, South Carolina , connecticut, Kentucky, New Jersey, South Dakota, Delaware, Maryland, New York, Tennessee, Florida, Michigan, North Carolina, Utah, Hawaii, Minnesota, North Dakota, West Virginia, Illinois, Missouri, Ohio, Wisconsin, Indiana, Montana, Oregon, Wyoming, Iowa
CMS anticipates that Internet-based PECOS will be available to all individual practitioners by the end of January. Stay tuned to mgma.com for information on the system's availability in your state.
After CMS has made the system available to individual practitioners nationwide, it will begin offering it to entities enrolling in the Medicare program.
Access the CMS Web site to learn more about Medicare provider enrollment via PECOS Web.
Access PECOS Web.
For help using PECOS Web, call the CMS External User Services Help Desk toll-free at 866.484.8049 or via e-mail.
The Centers for Medicare & Medicaid Services (CMS) launched the long-awaited Internet-based version of Provider Enrollment, Chain and Ownership System (Internet-based PECOS) for use by individual practitioners in 15 states and the District of Columbia on Dec. 4. Internet-based PECOS is a scenario-driven system that enables practitioners to complete their Medicare provider enrollment application online. By Dec. 15, the agency expanded access to the system to an additional 19 states.
A practitioner will use his/her national provider identifier (NPI) user identification and password to access Internet-based PECOS. Because of this, CMS recommends that individuals reset their user IDs and passwords before accessing Internet-based PECOS, and then resetting them at least once a year. The agency suggests that individual practitioners not share this information with others, including billing services, consultants and practice staff. Instead, CMS expects that individual practitioners will use the system to enroll and/or update their own information.
Currently, Internet-based PECOS is available in the following states and the District of Columbia: Alaska, Idaho, Nebraska, Pennsylvania, Arizona, Kansas, Nevada, South Carolina , connecticut, Kentucky, New Jersey, South Dakota, Delaware, Maryland, New York, Tennessee, Florida, Michigan, North Carolina, Utah, Hawaii, Minnesota, North Dakota, West Virginia, Illinois, Missouri, Ohio, Wisconsin, Indiana, Montana, Oregon, Wyoming, Iowa
CMS anticipates that Internet-based PECOS will be available to all individual practitioners by the end of January. Stay tuned to mgma.com for information on the system's availability in your state.
After CMS has made the system available to individual practitioners nationwide, it will begin offering it to entities enrolling in the Medicare program.
Access the CMS Web site to learn more about Medicare provider enrollment via PECOS Web.
Access PECOS Web.
For help using PECOS Web, call the CMS External User Services Help Desk toll-free at 866.484.8049 or via e-mail.
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