A Medicare Update - Dr. Tom Seymour

Hello Everyone,

Please enjoy the information contained in this edition of Frontier Focus. Please be sure to share it with your members, colleagues, providers and office billing staff. Thank you for your continued efforts to broadcast Medicare information to the providers in Region VIII.

Table of Contents

1. Physician and non-physician practitioners who order or refer must be enrolled in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and must be of the types/specialties that are eligible to order/refer services for Medicare beneficiaries Effective April 5, 2010.

2. 2011 Physician Quality Reporting Initiative Listening Session

3. The Medicare Learning Network Celebrates Its 10th Anniversary!

4. New from the Medicare Learning Network

5. Nursing Home Five-Star Reporting Updates

6. Your January Flu Message

7. A new “twist” in the law makes it easier to save on your prescription drug costs.

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The Centers for Medicare & Medicaid Services (CMS) will delay, until April 5, 2010, the implementation of Phase 2 of Change Request (CR) 6417 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Claims Processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs)) and CR 6421 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplier Claims Processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs)). CRs 6417 and 6421 are applicable to Part B claims only.

The delay in implementing Phase 2 of these CRs will give physicians and non-physician practitioners who order items or services for Medicare beneficiaries or who refer Medicare beneficiaries to other Medicare providers or suppliers sufficient time to enroll in Medicare or take the action necessary to establish a current enrollment record in Medicare prior to Phase 2 implementation.

Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare. A current enrollment record is one that is in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and also contains the physician/non-physician practitioner’s National Provider Identifier (NPI). Under Phase 2 of the above referenced CRs, a physician or non-physician practitioner who orders or refers and who does not have a current enrollment record that contains the NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected.

CMS continues to urge physicians and non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now. If these physicians and non-physician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS.

For physicians and non-physician practitioners who order or refer—

· If you are not enrolled in the Medicare program, or if you enrolled more than 6 years ago and have not submitted any updates or changes to your enrollment information in more than 6 years, you do not have an enrollment record in PECOS. In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application. You may do so either by (1) using Internet-based PECOS (which transmits your enrollment application to the Medicare carrier or A/B MAC via the Internet—be sure to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application), or (2) filling out the appropriate paper Medicare provider enrollment application(s) (CMS-855I and CMS-855R, if appropriate) and mailing the application, along with any required additional supplemental documentation, to the local Medicare carrier or A/B MAC, who will enter your information into PECOS and process your enrollment application. Information on how to enroll in Medicare is found on the Medicare provider/supplier enrollment web site at www.cms.hhs.gov/MedicareProviderSupEnroll.

· If you are already enrolled in Medicare, make sure you have a current enrollment record. You can find out if you have an enrollment record in PECOS by calling your designated carrier or A/B MAC or by going on-line, using Internet-based PECOS, to view your enrollment record. We will be posting information to the Medicare provider/supplier enrollment web site that will guide you through this process. Information about Internet-based PECOS and a link to Internet-based PECOS can be found on the Medicare provider/supplier enrollment web site. Before using Internet-based PECOS, we recommend that you read the information that is posted there and that is available in the downloadable documents section.

· If you are a dentist or a physician with a specialty such as a pediatrics who is eligible to order or refer items or services for Medicare beneficiaries but have not enrolled in Medicare because the services you provide are not covered by Medicare or you treat few Medicare beneficiaries, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

· If you are a physician who is employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense Tricare program but have not enrolled in Medicare because you would not be paid by Medicare for your services, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

If you are a resident who has a medical license but have not enrolled in Medicare because you would not be paid by Medicare for your services, you do not need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries. The teaching physician—not the resident—should be identified in claims as the ordering/referring provider when a resident orders or refers items or services for Medicare beneficiaries.

CMS actions to mitigate the number of informational messages:

Since many Part B providers and suppliers are receiving a high volume of informational messages in their Remittances, CMS is taking the following actions to reduce the number of informational messages being generated:

1. Prior to the implementation of Phase 2, CMS will systematically add the NPIs to the PECOS enrollment records of all physicians and non-physician practitioners whose enrollment records are in PECOS but do not contain their NPIs. Because the NPI is one of the matching criteria used in implementing the two new edits on the Ordering/Referring Provider, it is essential that the NPI be in the PECOS enrollment record. Because the data file used to implement the two edits contains only the eligible physicians and non-physician practitioners who are in PECOS with NPIs in their enrollment records, this action will add many more physicians and non-physician practitioners to that data file.

2. Prior to the implementation of Phase 2, CMS will make publicly available on the Internet the names and NPIs of the Medicare physicians and non-physician practitioners who are eligible to order or refer in the Medicare program. The name displayed will be that of the physician or non-physician practitioner as it appears in his or her PECOS enrollment record. This will allow Part B providers and suppliers who furnish and bill for items or services based on orders or referrals to determine if the Ordering/Referring Provider being identified in their claims will pass the two new edits prior to submitting the claims to Medicare.

3. Prior to the implementation of Phase 2, CMS will issue instructions to carriers and A/B MACs that will assist them in processing enrollment applications from physicians who are employed by the Department of Veterans Affairs, the Public Health Service, and the Department of Defense Tricare program. The instructions will also state that the teaching physician should be reported as the Ordering/Referring Physician in situations where a resident orders or refers items or services for Medicare beneficiaries. The instructions will also note that dentists and pediatricians, who sometimes order or refer items or services for Medicare beneficiaries, may be enrolling in Medicare in order to continue to order and refer.

4. CMS will be preparing a Special Edition Medicare Learning Network (MLN) Matters Article on the implementation of these two new edits. This MLN Matters Article will expand upon the information currently available in MLN Matters Articles MM 6417 and MM 6421.

Note: If you have problems accessing any hyperlink in this message, please copy and paste the URL into your Internet browser.

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2. 2011 Physician Quality Reporting Initiative Listening Session

The Centers for Medicare & Medicaid Services (CMS) is hosting a Listening Session on the 2011 Physician Quality Reporting Initiative (PQRI). The purpose of this listening session is to discuss and solicit feedback on the individual quality measures and measures groups being considered for possible inclusion in the proposed set of quality measures for use in the 2011 PQRI program and key components of the design of the PQRI program, such as possible reporting mechanisms, reporting periods, criteria for satisfactory reporting, the group practice reporting option, and public reporting of 2011 PQRI data.

The listening session will be held on February 2, 2010 from 10 a.m. to 4:30 p.m. (EST) in the main auditorium of the Central Building of the Centers for Medicare & Medicaid Services, located at 7500 Security Boulevard, Baltimore, MD 21244–1850.

There is still time to register to participate in this event! Although we are no longer accepting registrations for participation via teleconference, there is still space to participate in person. In order to participate in the meeting, you must complete the online registration at http://www.usqualitymeasures.org on the internet, by no later than 5 pm EST on January 27, 2010.

A summary of the measures and measures groups suggestions received and other background materials for the listening session will be posted on the PQRI section of the CMS Web site at www.cms.hhs.gov/PQRI on the CMS website, in the coming weeks.

For more information, please see the Federal Register meeting notice posted at http://edocket.access.gpo.gov/2009/pdf/E9-30122.pdf on the Internet.

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3. The Medicare Learning Network Celebrates Its 10th Anniversary!

The Medicare Learning Network – Celebrating 10 Years As Your Medicare Educational Resource!

This year marks the 10th anniversary for the Medicare Learning Network (MLN) – the home for official information for Medicare Fee-For-Service providers. We’re located within the Centers for Medicare & Medicaid Services (CMS) and over the past decade, we’ve been very busy:

· Producing quality educational products designed to meet the needs and learning styles of busy health care professionals;

· Adding continuing education credits to many of our online courses; and

· Developing new and different ways to make our products accessible and available to the FFS provider community.

Whether you’re familiar with the Medicare Learning Network or just curious about us, our upcoming marketing campaign will help you to discover or re-discover the features and benefits that so many members of the FFS provider community turn to on a daily basis. So, check your e-mails and join us as we enter our second decade of dedication to providing the Medicare FFS provider community with the education and information resources it needs.

Learn More about the Medicare Learning Network Right Now!

Download the Medicare Learning Network Marketing Brochure

View our new Marketing Brochure online to learn what the Medicare Learning Network has to offer – print copies of this brochure will soon be available on our Product Ordering System.

Order The Medicare Learning Network DVD– A Good Place to Start

This DVD contains quick and basic information about the Medicare Learning Network and its benefits to providers. The DVD is suitable for self instruction, as well as exhibits and training events. National and local provider associations are encouraged to post this product on their websites and/or distribute via electronic newsletters or mailing lists. Run time is 7 minutes, 7 seconds.

Visit the Medicare Learning Network Product Ordering Page and scroll down to the “Educational Tool” topic category to find the DVD and place your order. You can also view the video online.

Stay tuned for more!

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4. New from the Medicare Learning Network

Quick reference charts can be handy lists for looking up information! The Medicare Learning Network (MLN) has produced two QUICK REFERENCE CHARTS, which provide information on frequently used CMS web pages.

· The Quick Reference: All Medicare Providers (DEC2009) chart includes a list of CMS web pages that ALL Medicare providers use most frequently.

· The Quick Reference: New Medicare Provider (DEC2009) chart includes a list of CMS web pages that NEW Medicare providers use most frequently.

These charts can be bookmarked and viewed online or they can be printed and used as ready references. Both charts can be located at http://www.cms.hhs.gov/MLNProducts/MPUB/list.asp on the MLN Publications page. Use search key word “quick” to locate these publications.

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Looking for help with the fundamentals of the Medicare Program? This NEW web-based training (WBT) course from the Medicare Learning Network (MLN) can help!

The World of Medicare WBT is designed for health care professionals who want to understand the fundamentals of the Medicare Program. After completing this course, participants should be able to differentiate between Medicare Part A, Part B, Part C, and Part D, identify Medicare beneficiary health insurance options, eligibility, and enrollment, as well as recognizing how Medigap and Medicaid work with the Medicare Program.

This WBT course offers continuing education credits, please see the course description for details. This training can be accessed by visiting http://www.cms.hhs.gov/MLNgeninfo/ and scrolling to the “Related Links Inside CMS” page section. Within these links, select Web Based Training (WBT) Modules and then World of Medicare (January 2010) from the list of trainings provided.

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The revised Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals (Oct 2009), which offers general information about the Medicare Program, how to become a Medicare provider or supplier, Medicare payment policies, Medicare reimbursement, evaluation and management services, protecting the Medicare Trust Fund, inquiries, overpayments, and fee-for-service appeals, is now available in print and CD-ROM format from the Centers for Medicare & Medicaid Services Medicare Learning Network. To place your order, visit http://www.cms.hhs.gov/MLNGenInfo/ , scroll down to “Related Links Inside CMS” and select “MLN Product Ordering Page.”

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The revised Home Health Prospective Payment System Fact Sheet (January 2010), which provides information about coverage of home health services and elements of the Home Health Prospective Payment System, is now available in downloadable format from the Centers for Medicare & Medicaid Services Medicare Learning Network at http://www.cms.hhs.gov/MLNproducts/downloads/HomeHlthProsPaymt.pdf .

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5. Nursing Home Five-Star Reporting Updates

1. The Five-Star provider preview reports will be available beginning Tuesday, January 19, 2010. Providers can access the report from the Minimum Data Set (MDS) State Welcome pages available at the State servers for submission of Minimum Data Set data.

Provider Preview access information:

· Visit the MDS State Welcome page available on the State servers where you submit MDS data to review your results.

· To access these reports, select the Certification and Survey Provider Enhanced Reports (CASPER) Reporting link located at the bottom of the login page.

· Once in the CASPER Reporting system,

i. Click on the ‘Folders’ button and access the Five-Star Report in your ‘st LTC facid’ folder,

ii. Where st is the 2-digit postal code of the state in which your facility is located, and

iii. Facid is the state assigned facid of your facility.

2. The helpline will reopen beginning Tuesday, January 19 until Wednesday, February 3, 2010. BetterCare@cms.hhs.gov is also available to address any Five Star rating questions and concerns.

3. Nursing Home Compare will update with January’s Five-Star data on Thursday, January 28, 2010.

4. Please visit http://www.cms.hhs.gov/CertificationandComplianc/13_FSQRS.asp for the latest Five-Star Quality Rating system information.

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6. Your January Flu Message

It’s Not Too Late to Get the Seasonal Flu Shot. While seasonal influenza outbreaks can happen as early as October, influenza activity usually peaks in January.[1] The seasonal flu vaccine is the best way to prevent infection and the complications associated with the flu. Re-vaccination is necessary each flu season because flu viruses change each year.

CMS is asking our health care provider community to please encourage your Medicare patients who haven’t already done so to get their annual flu shot. It is also important to be sure that you immunize yourself and your staff.

Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part D covered drug.

For information about Medicare’s coverage of the seasonal influenza virus vaccine and its administration, as well as related educational resources for health care professionals and their staff, please go to http://www.cms.hhs.gov/MLNProducts/Downloads/flu_products.pdf on the CMS website. You will find a variety of resources that explain Medicare coverage and claims submission policies related to the seasonal influenza vaccine.

For information on Medicare policies related to H1N1 influenza, please go to http://www.cms.hhs.gov/H1N1 on the CMS website.

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[1] Seasonal Influenza, 2009-2010. Key Facts About Seasonal Flu Vaccine [online]. Atlanta, GA: The Centers for Disease Control and Prevention, 2009 [cited 23 December 2009]. Available from the World Wide Web:
(http://www.cdc.gov/flu/protect/keyfacts.htm)

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7. A new “twist” in the law makes it easier to save on your prescription drug costs.

http://www.ssa.gov/prescriptionhelp/

Under a new law, more Medicare beneficiaries could qualify for Extra Help with their Medicare prescription drug plan costs because some things no longer count as income and resources. The Extra Help is estimated to be worth an average of $3,900 per year. To qualify for the Extra Help, a person must be on Medicare, have limited income and resources, and reside in one of the 50 states or the District of Columbia.

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