CPM Provider Newsletter Digest

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					 I N S I D E T H I S I S SU E :
 March: Daylight, Spring, &
                               2    Daylight Saving Time Reminder     11                                ICD-10
 Healthcare Reforms Adds       8    CA Legislation New Web Features   12
 Requirements for Physicians                                                                         Myths & Facts
 Urgent PT Employment Bill     10 Coming Soon!          13
 Has Docs & PTs at Odds                                                                                - page 3
 Red Flags Rule Decision       11   Faith & Begorrah! It’s St.         2
 Clarified                          Paddy’s Day

                                                  CPM Provider Newsletter Digest
                                               March 2011                                                Volume 7, Issue 03

ICD-10 Implementation Looms for the
United States - Are You Ready?
                                               make the transition, not just those
 Report by: Linda Seidelman
                                               who submit Medicare or Medicaid              A Message from the National
                                               claims.                                         Coordinator for Health
                                                                                              Information Technology
                                               Compliance Timelines

                                               The first ICD-10-related compliance                ll of us who are working to
                                               date is less than 1 year away. On                  achieve adoption and
                                               January 1, 2012, standards for                     meaningful use of electronic
                                               electronic health transactions                     health    records     (EHR)
                                               change from Version 4010/4010A1           throughout our health care system
                                               to Version 5010. Unlike Version           know that the journey is a long one.
                                               4010, Version 5010 accommodates                               There will be
                                               the ICD-10 code structure. This                               many milestones

                                               change occurs before the ICD-10                               along the way,
           n October      1,   2013,           implementation date to allow                                  each one hard-
           medical coding in U.S.              adequate testing and implementation                           earned. But I
           health care settings will           time.                                                         believe that when
           change from ICD-9 to ICD-
                                                                                                             we look back on
10.      ICD, is an acronym for                Firm Compliance Deadlines                                     the road we
International Classification of                The compliance dates for both the
Diseases, and is headed up and                                                                               traveled, the
                                               Version 5010 transition and the ICD-      year 2011 will stand out not merely
overseen by the World Health                   10 implementation are firm and not
Organization (WHO). The WHO has                                                          as one more milestone, but as the
                                               subject to change. CMS reports and        time when medical care entered a
released the ICD-10 in not only the            states on their website that If you are
six official member state languages,                                                     new era – the age of meaningful use
                                               not ready, your claims will not be
but 36 others as well.                                                                   of health information.
                                               paid—and that preparing now can
                                               help providers avoid potential
The United States transition will                                                        On the one hand, this milestone is
                                               reimbursement issues.
require business and systems                                                             easy to spot: 2011 is the year it
changes throughout the health care                                                       became possible for providers to be
industry. Everyone who is covered                                                        meaningful users of EHRs, and to earn
by the Health Insurance Portability            (continued on page 3)                     a financia l re ward for this
and Accountability Act (HIPAA) must                                                      accomplishment. (continued on page 6)
                                                                                Faith n’ Begorrah,
                                                                               It’s St. Paddy’s Day!
                                                                       E     very year since 1991, March has been
                                                                             proclaimed Irish-American Heritage
                                                                       Month by the US Congress. Today, Saint
                                                                       Patrick's Day is widely celebrated in America
                                                                       by Irish and non-Irish alike. It is typically one
                                                                       of the busiest days of the year for bars and
                                                                       restaurants. Many people, regardless of
                                                                       ethnic background, wear green clothing and
                                                                       items. Those who are caught not wearing
                                                                       green are pinched affectionately.

  Page 2                                     CPM Provider Newsletter                                  March 2011

                                                        tax season. Boo/Hiss. I hate doing taxes.
       Ramblings From the Editor
                                                        Well, anyhoo, hope your March is lovely and remember to
                         L. A. Seidelman, Editor        stop and smell the beautiful Spring flowers every once in
                                                        a while. Oh, and sorry about that lost hour of sleep...

March: Daylight, Spring &

 Well, we’ve made it to March, eh? The first
 quarter of the year is done and dusted. Can you
 believe it? Tempus fugit !

 Last month we discussed how even though
 February was but a wee month, it had 4 worthy
 holidays to recommend it. March, has only one
 pseudo-holiday, that being St. Patrick’s day.

 Although the Irish holiday is not officially
 recognized as a federal holiday, it is roundly
 celebrated by all Irish, including the kind of Irish
 that’s “one for a day”, with beer, revelry, corned
 beef, and more beer. Can’t beat that, right?

 But there’s more to March than meets the eye.
 It’s the month, since 2007, that ushers in Daylight
                                                                                        Linda Seidelman
 Saving Time, and it is host to the first day of
 Spring. Doesn’t come much sweeter than that.

 But, caveat emptor, April looms like a bristling
 lion with it’s windy, rainy days, and worst of all,
                               ICD-10 Implementation Looms for the United States
                               - Are You Ready?                     (continued from pg 1)

                               Report by: Linda Seidelman
                                                                    that use ICD-9 codes. This could include clinical
                                                                    documentation, encounter forms/superbills, practice
                                                                    management system, electronic health record system,
Basic Steps to Prepare for Version 5010/ICD-10                      contracts, and public health and quality reporting protocols.
                                                                    It is likely that wherever ICD-9 codes now appear, ICD-10
Begin preparing now for the ICD-10 transition to make               codes will take their place.
sure you are ready by the October 13, 2013,
compliance deadline. The following quick checklist will
assist you with preliminary planning steps.                     • Talk with your practice management system vendor about
                                                                  accommodations for both Version 5010 and ICD-10 codes.
• Identify your current systems and work processes                Contact your vendor and ask what updates they are

    March 2011                                  CPM Provider Newsletter                                              Page 3

     planning to your practice                 Consider changes to existing                 Version 5010/ICD-10 codes with
     management system for both                processes including clinical                 your payers and clearinghouses.
     Version 5010 and ICD-10, and              documentation, encounter forms,              Testing is critical. Allow yourself
     when they expect to have it ready         and quality and public health                enough time to first test that your
     to install. Check your contract to        reporting.                                   Version 5010 transactions, and
     see if upgrades are included as                                                        subsequently, claims containing
     part of your agreement. If you are    •   Assess staff training needs. Identify        ICD-10 codes are being
     in the process of making a                the staff in your office who code, or        successfully transmitted and
     practice management or related            have a need to know the new codes.           received by your payers,
     system purchase, ask if it is             There are a wide variety of training         clearinghouses, etc. Check to see
     Version 5010 and ICD-10 ready.            opportunities and materials available        when they will begin testing, and
                                               through professional associations,           the test days they have scheduled.
•    Discuss implementation plans              online courses, webinars, and onsite         See the "Compliance Timelines"
     with all your clearinghouses,             training. If you have a small practice,      link below for important interim
     billing services, and payers to           think about teaming up with other            deadline information.
     ensure a smooth transition. Be            local providers. You might be able,
     proactive, don't wait. Contact your       for example, to provide training for a
     payers, clearinghouse, billing            staff person from one practice, who
     service with whom you conduct             can in turn train staff members in
     business, ask about their plans           other practices. Coding                        MYTHS & FACTS
     for the Version 5010 and ICD-10           professionals recommend that              REGARDING THE ICD-10
     compliance, and when they will            training take place approximately 6         IMPLEMENTATION
     be ready to test their systems for        months prior to the October 1, 2013
     both transitions.                         compliance date.                          MYTH:       The October 1, 2013
                                                                                         compliance date for implementation of
•    Talk with your payers about how       •   Budget for time and costs related to      ICD-10 should be considered a flexible
     ICD-10 implementation might               ICD-10 implementation, including          date
     affect your contracts. Because            expenses for system changes,              FACT:       All Health Insurance
     ICD-10 codes are much more                resource materials, and training.         Portabilty and Accountability Act
                                                                                         (HIPAA) of 1996 covered entities
     specific than ICD-9 codes, payers         Assess the costs of any necessary
                                                                                         MUST implement the new code sets
     may modify terms of contracts,            software updates, reprinting of           with dates of service, or date of
     payment schedules, or                     superbills, training and related          discharge for inpatients, that occur
     reimbursement.                            expenses.                                 on or after October 1, 2013.

•    Identify potential changes to work    •   Conduct test transactions using                            (continued on page 4)
     flow and business processes.
                            ICD-10 Implementation Looms for the United States
                            - Are You Ready?                     (continued from pg 3)

                            Report by: Linda Seidelman
                                                          FACT: HHS has no plans to extend the compliance date
                                                          for implementation of ICD-10; therefore, covered entities
                                                          should plan to complete the steps required in order to
                                                          implement ICD-10 on October 1, 2013.
     THE ICD-10 IMPLEMENTATION                            MYTH: Non-covered entities, which are not covered by
                                                          HIPAA, such as Workers’ Compensation and auto insurance
MYTH: Implementation planning should be undertaken        companies, that use ICD-9 may choose not to implement ICD-
with the assumption that the Department of Health and     10.
Human Services (HHS) will grant an extension beyond       FACT: Because ICD-9 will no longer be maintained after
the October 1, 2013 compliance date.                      ICD-10 is implemented, it is in non-covered entities’ best

 March 2011                                CPM Provider Newsletter                                             Page 4

Interest to use the new coding         implemented, all coding will need to be   FACT: As with ICD-9, ICD-10 codes
system. The increased detail in        performed electronically.                 should be based on medical record
ICD-10 is of significant value to      FACT:     ICD-10 code books are           documentation.               While
non-covered entities. The Centers      already available and are a               documentation supporting accurate
for Medicare & Medicaid Services       manageable size—one publisher’s           and specific codes will result in
(CMS) will work with non-covered       book is two inches thick. The use of      higher-quality data, nonspecific
entities to encourage their use of     ICD-10 is not predicated on the use       codes are still available for use
ICD-10.                                of electronic hardware and software.      when documentation doesn’t
                                                                                 support a higher level of specificity.
MYTH: State Medicaid Programs          MYTH:      ICD-10 was developed a         As demonstrated by the American
will not be required to update their   number of years ago, so it is probably    Hospital Association/American
systems in order to utilize ICD-10     already out of date.                      Health Information Management
codes.                                 FACT: ICD-10 codes have been              Association field testing study,
FACT:      HIPAA requires the          updated annually since their original     much of the detail contained in ICD-
development of one official list of    development in order to keep pace         10 is already in medical record
national medical code sets. CMS        with advances in medicine and             documentation but is not currently
will work with State Medicaid          technology and changes in the             needed for ICD-9 coding.
Programs to ensure that ICD-10 is      health care environment.           The
implemented on time.                   coding systems will continue to be        MYTH: Implementation of ICD-10 can
                                       updated until such time that a            wait until after electronic health records
MYTH: The increased number of          decision is made to “freeze” the          and other health care initiatives have
codes will make the new coding         code sets prior to implementation.        been established.
system impossible to use.              For instance, the health care             FACT: Implementation of ICD-10
FACT: Just as an increase in the       community may request that ICD-9          cannot wait for the implementation
number of words in a dictionary        and ICD-10 codes not be updated on        of other health care initiatives. As
doesn’t make it more difficult to      October 1, 2012 and be frozen with        management of health information
use, the greater number of codes       October 1, 2011 updates.        If the    becomes increasingly electronic,
in ICD-10 doesn’t necessarily          freeze is approved through formal         the cost of implementing a new
make it more complex to use.           rulemaking, it would provide a year       coding system will increase due to
                                       or more of stability and an               required systems and applications
MYTH:       ICD-10 was developed       opportunity to develop coding             upgrades.
without clinical input                 products and training materials. ICD
FACT: The development of ICD-10        -10 could then be updated again on        MYTH: ICD-10 based super bills will
involved significant clinical input.   October 1, 2014, after providers have     be too long or too complex to be of
A number of medical specialty          had a year of experience under the        much use.
societies contributed to the           new coding system.                        FACT: Practices may continue to
development of the coding                                                        create super bills that contain the
system.                                MYTH: Unnecessarily detailed medical
                                       record documentation will be required                       (continued on page 5)
MYTH: There will be no hard copy       when ICD-10 is implemented.
ICD-10 code books. When ICD-10 is
                          ICD-10 Implementation Looms for the United States
                          - Are You Ready?                     (continued from pg 4)

                          Report by: Linda Seidelman
                                                       bills nor ICD-10 based super bills provide all possible
                                                       code options for many conditions.       The super bill
                                                       conversion process includes:
                                                       •        Conducting a review that includes removing rarely
      THE ICD-10 IMPLEMENTATION                                 used codes; and

Most common diagnosis codes used in their              •        Crosswalking common codes form ICD-9 to ICD-
practice.   ICD-10 based super bills will not                   10, which can be accomplished by looking up
necessarily be longer or more complex than ICD-9                codes in the ICD-10 code book or using the
based super bills. Neither currently used super                 General Equivalence Mappings (GEM).

    March 2011                          CPM Provider Newsletter                                            Page 5

MYTH: The GEMs are intended to      FACT: The GEMs are a crosswalk
facilitate the process of coding    tool developed by CMS and CDC for
medical records.                    use by ALL providers, payers, and           COMPLIANCE TIMELINE
                                    data users. The mappings are free
FACT: Mapping is not the same       of charge and are in the public
as coding:                          domain.
                                                                               JANUARY 1, 2011
• Mapping links concepts in two     MYTH:       Medically unnecessary
  code       sets   without         diagnostic tests will need to be           • Payers and providers should begin
  consideration of patient          performed in order to assign an ICD-10       external testing of Version 5010 for
  medical record information;       code.                                        electronic claims
  and                                                                          • CMS begins accepting Version
• Coding      involves      the     FACT: As with ICD-9, ICD-10 codes            5010 claims
  assignment of the most            are derived from documentation in
                                    the medical record. Therefore, if a        • Version 4010 claims continue to be
  appropriate code based on
  medical record documentation      diagnosis has not yet been                   accepted
  and applicable coding rules/      established, the condition should be
  guidelines                        coded to its highest degree of             DECEMBER 31, 2011
                                    certainty (which maybe a sign or           • External testing of Version 5010 for
The GEMs can be used to convert     symptom) when using both coding              electronic claims must be complete
the following databases from ICD-   systems. In fact, ICD-10 contains
                                                                                 to achieve Level II Version 5010
9 to ICD-10:                        many more codes for signs and
                                    symptoms than ICD-9, and it is better        compliance
•    Payment systems;               designed for use in ambulatory
•    Payment and coverage edits;    encounters when definitive                 JANUARY 1, 2012
•    Risk adjustment logic;         diagnoses are often not yet known.         • All electronic claims must use
•    Quality measures; and          Nonspecific codes are still available        Version 5010
                                    in ICD-10 for use when more detailed
•    A variety of research                                                     • Version 4010 claims are no longer
                                    clinical information is not known.
     applications involving trend                                                accepted
                                    MYTH:       Current Procedural
                                    Terminology (CPT) will be replaced by      OCTOBER 1, 2013
MYTH: Each payer will be required
to develop their own mappings
                                    ICD-10.                                    • Claims for services provided on or
between ICD-9 and ICD-10 as the                                                  after this date must use ICD-10
                                    FACT: ICD-10 will only be used for           codes for medical diagnosis
GEMs that have been developed by
                                    facility reporting of hospital inpatient
CMS and the Centers for Disease
                                    procedures and will NOT affect the         • CPT codes will continue to be used
Control and Prevention (CDC) are                                                 for outpatient services
                                    use of CPT.
for Medicare use only.
                                                                 system hugely more effective and efficient.

                                                 from pg 1
                                                                 We have been many years – actually, many decades – in

         n the other hand, the real significance of this         arriving at this threshold. The potential for information
         moment might be easily overlooked. The age of           technology to support and improve health care was
         meaningful use is only partly about the use of EHRs     recognized early. Government and private support for
and the major financial incentives now available to support      development and assessment of health informatics began in
this. Even more, this new era creates opportunities to           the 1960s. Yet, even as computers transformed almost
revolutionize the work of health professionals and health        every other sector of the economy, health care (except for
care institutions, and to make them and the health care
                                                                 billing!) remained mostly paper-based.

   March 2011                                   CPM Provider Newsletter                                            Page 6

In 2009, Congress and the President       As an incentive program, meaningful            ONC is supporting a system of 62
took a definitive new step when they      use went live in January. That was when        RECs across the nation. They provide
enacted the Health Information            registration opened for eligible               customized, on-the-ground support
Technology Economic and Clinical                                                         for providers, especially for smaller
                                          providers and hospitals to take part in
Heath Act (HITECH), part of the                                                          primary care practices and for small
American Recovery and Reinvestment        the Medicare and Medicaid incentive            and rural hospitals. ONC aims for
Act. HITECH authorized up to $27          payments programs. Surveys in the              RECs to support 100,000 primary
billion in incentive payments for         latter part of 2010 by the American            care physicians in achieving
providers, and $2 billion to build a      Hospital Association and CDC’s National        meaningful use. As of mid-February,
national infrastructure for the           Center for Health Statistics indicated         more than 45,000 providers have
adoption of EHRs. Most importantly,       that 81 percent of hospitals and 41            enrolled for REC assistance.
HITECH established the goal of the
                                          percent of office-based physicians were
meaningful use of electronic health                                                    • Workforce Training – Rapid growth
records. However cryptic this term        already planning to achieve meaningful
                                                                                         in EHR deployment will require HIT
may have seemed at first, it holds the    use and qualify for incentive payments.
                                                                                         specialists. ONC supports a six-
key to unlocking the power of             In January alone, 21,300 providers
information to transform health care                                                     month training curriculum at 84
                                          initiated the registration process.
for the better.                                                                          community colleges, most of them
                                          To create an infrastructure supporting         offering distance as well as on-
Put plainly, “meaningful use” is a        meaningful use, the Office of the              campus enrollment. The first “class”
shorthand for three things:               National Coordinator for Health                of 3,400 will complete the
                                          Information Technology (ONC) has               curriculum this spring, and we aim
1. An incentive program, rewarding        implemented new programs authorized            for enrollment of over 10,000 per
   not only deployment of EHRs but        by HITECH and has pursued longer-              year in the future.
   also their effective use for patient   standing objectives:
                                                                                       • Certification – A crucial aspect of
   benefit;                                                                              the meaningful use approach is
2. A new national infrastructure to       • Regional Extension Centers (RECs) –
                                                                                         certification of EHR products to
   support deployment and beneficial

                                                                                         ensure that they support the
   use of EHRs; and
                                                                                         objectives that providers must
3. A vision for the evolving, dynamic
                                                                                         achieve to qualify for incentive
   and optimal uses of information to
   support health and health care                              ven as computers          payments. As of mid-February, there
   improvement – the tip of the spear                          transformed almost        were 350 certified products on the
   for an information-powered leap                                                       market, including 219 complete
                                                               every other sector
   in the quality, safety and                                                            EHRs and 131 EHR modules. This is a
   effectiveness (including cost           of the economy, health care (except
                                                                                         dramatic increase in both the
   effectiveness) of our health care       for billing!) remained mostly paper-
                                           based.                                                          (Continued on pg 8)
                                                                   now invest in EHRs with confidence that certified
                                                                   systems will support the required meaningful use
                                                  from pg 6        objectives.

    number and usefulness of EHR systems, compared with
                                                               • Interoperability and trust – A key benefit of HIT-
    pre-HITECH numbers. Altogether, 231 vendors have
    certified products, and 64 percent are small businesses      assisted health care will be the availability and
    with less than 50 employees. That means the private          exchangeability of health data, provided in combination
    sector is rising to the opportunity with a flood of          with strong cyber security and strict protection for
    innovative new products that will make EHRs cheaper          personal health information. The health care,
    and more user friendly. Most important, providers can        consumer, and HIT communities are working together
                                                                 with ONC to develop policies and standards for

    March 2011                                  CPM Provider Newsletter                                            Page 7

    information transfer and exchange      pace at which they should be pursued.       disposal. Meaningful use will help
    of different kinds. ONC is working     Finally it is a device for encouraging      usher them into routine, widespread,
    to fashion a governance structure,     development and innovation in the           and effective use.
    standards, protocols and policies      technology itself.
    to support the Nationwide Health                                                   For individual providers and patients,
    Information Network. Numerous          This vision really calls for a new          these powers will support care that is
    projects will be highlighted at the    perception of clinical care and what we     more reliable, safer, higher quality
    Healthcare Information and             can do for and with patients. We have       and lower in costs. For the health
    Management Systems Society             been accustomed to thinking of medical      care system as a whole, they will
    (HIMSS)          conference            information as being statically recorded    enhance total performance and cost
    “Interoperability Showcase” ONC        on paper. Meaningful use challenges us      effectiveness.
    and the HHS Office for Civil Rights    to imagine the way electronic
    are working with other federal         information can “take on life” and serve    A decade ago, the Institute of
    agencies to develop privacy and        providers and patients in entirely new      Medicine stated in its landmark report
    security policies appropriate to       ways.                                       that: “Between the health care we
    the electronic age.                                                                have and the care we could have lies
                                           Electronic information, especially          not just a gap, but a chasm.” HIT has
•   State Health Information               standards-based information, can            long been seen as a fundamental
    Exchange (HIE) programs – ONC          become dynamic, interacting with other      enabler for closing that chasm and
    supports state-level HIT               information to (for example) generate       delivering the care we should have.
    coordination that enables states       useful safety alerts, call attention to     Meaningful use is vital support for the
    and regions to develop solutions       treatment alternatives, enable              bridge to a transformed health care
    that work for their particular         instantaneous assessments of quality of     system.
    circumstances, consistent with         care or outcomes for patients, or
    broader interoperability               contribute to public health surveillance.   We have indeed entered the age of
    standards. So far, 35 states have      We have never, in the history of            meaningful use – a time of action and
    HIE plans approved for                 medicine, had such tools at our             transition, a time of opportunity and
                                                                                       challenge, and hopefully a time for
                                                                                       keeping our eye on the ball. Success is

Most important is the role of                                                          not guaranteed. Hard and focused
meaningful use as a vision of how                                                      work has brought us this far, and
information can be brought to bear in
                                                                                       more of the same lies ahead.
new ways for the improvement of                               etween the health
health and health care. That vision is a
                                                               care we have and        Warmest Regards,
device for defining, encouraging, and
supporting the optimal use of                                  the care we could
information for patient care. It is                           have lies not just a     David Blumenthal, MD, MPP
likewise a device for reaching                                                         National Coordinator for Health
                                                      gap, but a chasm.                Information Technology
consensus on specific goals, and the
                                                                  that affect physicians under existing broad federal
                       Health Care Reform                         regulations relating to fraud and abuse.   In addition,
                       Adds Requirements                          provisions of the Act are being incorporated into
                                                                  regulations. Three of these requirements are discussed
                       for Physicians                             below: stark law, false claims act, and DME and home

        lthough the Patient Protection and Affordable Care        Stark. First, Section 6003 of PPACA amended the federal
        Act of 2010 (PPACA), also referred to as the health       law prohibiting Physician Self-Referral (known as the Stark
        care reform act, is currently being challenged on         Law) by adding a disclosure requirement to the in-office
        constitutional grounds, and threatened with non-          ancillary services exception.    This provision relates to
funding and piecemeal repeal; the fact remains that many          physician practices furnishing advanced imaging services,
portions of the Act are already effective and may be              such as MRI, CT, PET, and potentially other advanced
enforced. Several sections of PPACA contain requirements          diagnostic imaging services. On Nov. 29, 2010, CMS
                                                                  published the Physician Fee Schedule Final Rule in the

  March 2011                                      CPM Provider Newsletter                                               Page 8

Federal Register, finalizing the            “Supplier” specifically has the meaning of     that the notification be signed by the
applicable regulations with significant     a physician or other practitioner, or an       patient and maintained in the patient’s
modification from those originally          entity other than a “provider,” that           medical record, the final rule should be
proposed.                                   furnishes health care services under           less burdensome than the proposed
                                            Medicare. The commentary to the                rule.
Under the PFS Final Rule, a physician       regulation specifically permits inclusion
must comply with added requirements         of “providers” (hospitals) on the list, but    In summary, when relying on the in-
if a physician intends to refer a patient   only if the requisite number of “suppliers”    office ancillary services exception to
who is a Medicare beneficiary to the        is included. Other suggestions in the          the Stark Law with respect to a referral
physician’s sole practice or group          commentary include that the list be            for MRI, CT, or PET to his or her group
practice for an MRI, CT, or PET             updated annually for accuracy, and that        practice, at the time of referral the
imaging test.      Such a referral is       the physician would be prudent to              physician must provide the following:
normally made in keeping with the           establish a method by which the
requirements for the exception for in-      physician shows compliance with the            1. A reasonably understandable
office ancillary services in the Stark      requirement, such as making a note in             written notification that the patient
regulations. The new regulation adds a      the patient’s chart that the document had         may obtain the services from
requirement for the physician to provide    been given. These suggestions are not             someone other than the referring
an additional written notice to the         actually required as part of the final rule,      physician or someone in the
patient. The notice must inform the         but should be considered as best                  referring practice; and
patient in reasonably understandable        practices for internal policies.               2. A list of five suppliers who furnish
language that the patient may receive                                                         those services within a 25-mile
the service from another supplier. The      Since the proposed rule had included              radius of the physician’s office
notice must include a list of other         requirements for a list of 10 suppliers, a        location including the names,
suppliers who provide the same service      written estimation of the distance of each        addresses, and telephone numbers
(the MRI, CT, or PET) which are             supplier from the physician’s office, and         of the suppliers.
located within a 25-mile radius of the
physician’s office. The list of suppliers                                                  This new disclosure requirement for in-
only needs to include five suppliers           Related: Doctor Owned                       office ancillary services exception
within a 25-mile radius of the referring       Centers Spark Criticism,                    applies to services furnished on or
physician’s office. It must include each          Scrutiny: http://                        after Jan. 1, 2011. The rule appears in
supplier’s address and phone number.                                                       the Code of Federal Regulations at 42
If there are fewer than five suppliers in                                                  CFR 422.351(b)(7).
that area, the list must include all of              dyn/content/
those suppliers.                                 article/2011/02/28/                       (continued on pg 9)
                                                                  matter of best practices and because the physician may not
                 Health Care Reform Adds                          always know whether the patient might be a Medicare
                 Requirements for                                 beneficiary even if he or she has other insurance, it would
                                                                  be prudent to give the notification to all patients at the time
                 Physicians                                       of the referral.
                 (from pg 8)
                                                                  False Claims Act.
Neither the statutory language of Section 6003 of PPACA           Another PPACA requirement expands previous legislation
nor the final rule made any changes to the applicability of       relating to the False Claims Act. In a two-step process, the
the Physician Self-Referral prohibition to designated health      False Claims Act was amended, creating potential new
services furnished to Medicare beneficiaries. Technically,        exposure for providers and suppliers who bill Medicare and
therefore, the notification is required to be given only to       Medicaid. The legislation added new provisions on
those patients that the self-referral prohibition affects, and    “overpayments” which essentially convert an overpayment
would not be required for insured or self-pay patients. As a      into a false claim if it is not refunded to Medicare in a timely
                                                                  manner. For step one, the Fraud Enforcement and

  March 2011                                      CPM Provider Newsletter                                                Page 9

Recovery Act of 2009 (“FERA”) revised       how to determine exactly when an                Medicare provider but who had validly
the False Claims Act to make a              overpayment is “identified.” However,           “opted-out” of the Medicare program
knowing and intentional retention of an     since False Claims Act liability is an          (with and NPI number and a record in
“overpayment”, a violation of the False     added possibility, health care providers        the PECOS system) would be an
Claims Act.                                 will need to review their compliance            exception to this requirement. These
                                            plans to increase focus on billing and          regulations also expanded this
For step two, PPACA Section 6402(a)         reimbursement practices, on routine             provision to apply to imaging services,
expanded on FERA by defining                audits, and on processes to identify            lab, and specialist services.
“overpayment” to be any funds that a        causes of overpayments, such as billing
person receives or retains under            errors, lack of necessary documentation,        In addition, Section 6407 of PPACA
Medicare or Medicaid to which the           or duplicate billing, among others.             requires that physicians must conduct
person, after applicable reconciliation,                                                    a face-to-face encounter with the
is not entitled. PPACA also provided        DME and Home Health                             patient within the six months prior to
that the overpayment must be reported       Third, PPACA added two provisions in            the order before the physician can
and returned to the appropriate             an effort to curtail fraud in the provision     certify eligibility for home health
government agency, carrier,                 of durable medical equipment and home           services or DME paid by
intermediary, or contractor no later than   health services. Section 6405 requires          Medicare. Physicians are required to
60 days from the date on which the          that, for a Part B claim to be paid for a       maintain documentation concerning
overpayment was identified, or the date     referral for durable medical equipment or       orders or referrals for DME or home
on which any corresponding cost report      home health services, the referring             health services and submit to the
is due, whichever is later. As part of      physician or eligible professional must be      Secretary of HHS if requested. HHS
the report, the provider must disclose in   enrolled in the Medicare program. The           may also determine other services to
writing the reason for the overpayment.     regulations applicable to this provision        be covered by this requirement.
If not refunded timely, the government      issued in May 2010 provided that a
may consider it to be a false claim,        physician who had been enrolled as a            Summary
which carries significant potential                                                         Given the current concern with

penalties. PPACA gave the OIG the                                                           curtailing fraud and abuse, it seems
authority to impose civil monetary                                                          unlikely that these sections will be
penalties and gave state Medicaid                         oyce McLaughlin is an attorney    repealed.     Awareness of the new
programs the authority to permissively                     and senior counsel member of     provisions and of additional regulations
exclude providers that knowingly fail to                 Davis & Wilkerson, P.C., based     as they are issued will help a practice
refund any identified overpayments.         in Austin, Texas. Joyce specializes in health   adjust its processes to stay abreast of
                                               law, representing everything from large      these new conditions.
These provisions raise a number of            hospitals to small businesses. She can be
questions in practical application, such        contacted at
                                                             An Urgent PT Employment Bill—
                                                                   Currently In Legislation—
                                 SY                    Has Docs & Physical Therapists at Odds

                                    Report by L.A. Seidelman      hundreds of Physical Therapists, strongly disagree and vow
                                                                  to “aggressively fight” against the bill.
               nder cover of the President’s Day holiday,
               California Assemblymember, May Hayashi (D-         At issue is AB 783, which would override current state law
               Hayward) introduced, according to her press        which prevents physician corporations from employing
               release, a “...Bill To Save Physical Therapy       physical therapists and referring patients to their own
               Jobs”.                                             physical therapy clinics.

National and State Physical Therapy associations along with       However, in Assemblymember Hayashi’s Press Release,
                                                                  she states “the California Board of Physical Therapy has

  March 2011                                      CPM Provider Newsletter                                            Page 10

supported the employment of physical        It is because of these types of issues that   the Physical Therapy Board of
therapists in these (doctor and other)      California enacted the Moscone-Knox           California (PTBC) has declared its
organizations since 1990” but that “the     Act. This Act is found in the California      intent to discipline physical therapists
Board is reversing its position and         Corporations Code 13401.5, with               employed by medical corporations.
threatening to take action against the      provisions in the California Business and
licenses of physical therapists if they     Professions Code, that were legislatively     The California Medical Association
continue to practice physical therapy as    designed to prevent the unlawful practice     finds the worries of “kickbacks” and
employees.”                                 of a special licensed profession by those     absurd claims that physicians are
                                            not holding that same professional            illegally hiring PTs for financial gain,
According to Assemblymember                 license.                                      “ludicrous...and without merit as
Hayashi, “Approximately 80 percent of                                                     California has some of the most robust
physical therapists                         In short, the current statutory               anti-kickback laws in the nation which
work in such settings.”                     construction prevents the CMA and their       would be unaffected by this bill (AB
hence the reason for                        physicians from owning physical therapy       783)”.
the urgency clause                          practices or controlling and directing
attached to the bill.                       physical therapists in how they exercise      The CA Medical Association went on
This means that the bill is on fastrack     their independent, professional judgment      to say that physical therapists, along
for not only voting, but also for the act   because that would be against the public      with other physician extenders
to immediately take effect upon             policy protected by Moscone-Knox.             including psychologists, nurses,
passing.      Hayashi states this must                                                    physician assistants and podiatrists
occur in order to correct ambiguities in    In September 2010, the California             have                             been
the law that threaten “thousands” of        Legislative Counsel rendered an opinion       working                         within
physical therapists with the choice of      declaring employment of physical              the legal                       bound
losing their jobs or losing their license   therapists by medical corporations illegal.   -aries of                     medical
to practice.”                               Current law supports that opinion, and        corporations for decades. “AB 783 was

                                                                                          introduced to clarify ambiguity in the
However, studies by the Medicare                                                          law. The current language does not
Payment Advisory Committee and the                             he Physical Therapy        specifically call out the numerous
Office of Inspector General examining                                                     physician extenders that are legally
                                                                 Board of CA has
physician-owned physical therapy                                                          employed to work within medical care
services (POPTS) have found over-                              declared its intent to     settings to provide timely and
referrals, excessive costs and                                   discipline physical      coordinated access to care for
substandard care in over 91 percent of                         therapists employed        patients.” Stay tuned.
reviewed cases.
                                                    by medical corporations
                                    An Urgent PT Employment Bill—
                                        Currently In Legislation—
                               SY Has Docs & Physical Therapists at Odds
                 CON             Report by L.A. Seidelman            Urgency
CURRENT BILL STATUS:                                                 2/3 Vote Required
                                                                     Non-State Mandated Local Program
AUTHOR(S): Hayashi
TOPIC:      Professional corporations; licensed physical
                                                                     Non-Tax Levy
                                                              LAST HIST ACTION DATE: 02/18/11—read first time
                                                              LAST HIST ACTION: May be heard in committee March 20
                                                              TITLE: take effect immediately

  March 2011                                   CPM Provider Newsletter                                         Page 11

        AMA                              challenging the application of the red
                                         flags rule to attorneys.
                                                                                    of the District of Columbia and
                                                                                    joined by 26 national medical
        Welcomes                         "The court's decision reinforces the
                                                                                    specialty societies, will now
                                                                                    formally end.
        Decision                         intent of new legislation clarifying the
                                         scope of the red flags rule and helps
Supporting New                           eliminate any further confusion about
                                         the rule's application to physicians,"
Legislation                              AMA President Cecil B. Wilson, MD,             Don’t Forget!
                                         said in an AMA news release. "The
Clarifying Red                           AMA will remain vigilant that the FTC         Daylight Saving
Flags Rule                               respects the meaning and intent of
                                         the Clarification Act."                        Time Begins

                                         The AMA has worked closely with
                                                                                         March 13th
            federal appeals court        FTC officials and Congress and is
           issued a decision March       engaged in a lawsuit with other
           4 that further validates      physician groups to challenge the
           the AMA's long-standing
                                         FTC's efforts to extend the red flags      CLOCKS WILL MAKE the switch to
argument to the Federal Trade
                                         rule to all physicians. The lawsuit,       daylight saving time on March 13, but
Commission (FTC) that physicians                                                    some timepieces could unexpectedly
who bill after rendering services are    filed by the Litigation Center of the
                                                                                    jump another hour ahead in a few
not subject to the red flags rule as     AMA and the State Medical                  weeks.
creditors.                               Societies, the American Osteopathic
                                         Association and the Medical Society        Some electronic clocks that are more
The U.S. Court of Appeals for the                                                   than a few years old are pre-
District of Columbia Circuit found                                                  programmed to switch to daylight-

the present regulations of the FTC                                                  savings time on the first Sunday in
invalid in light of the Red Flag                                                    April..
Program Clarification Act of 2010,
passed by Congress last December                             he lawsuit, ...will    The problem lies with the federal
to shed much needed light on who                                                    government’s decision to begin
                                                            now formally end.       daylight saving time three weeks
is considered a creditor under the
                                                                                    earlier, beginning in 2007.
red flags rule. The court issued the
judgment in a lawsuit filed by the
American Bar Association
  March 2011                                    CPM Provider Newsletter                                     Page 12

                                                                      The State of California’s Official Legislative
                                                                      Information site has added a New Features page
                                                                      that enables citizens to access information on
                                                                      recent, current, and in progress legislation as
                                                                      well as New Laws, Daily Journal’s, Calendars,
                                                                      Protocols, and Subscription services.
citizens to send comments on bills directly to the Legislator         Another note worthy feature is the Send
who authored it.                                                      Comments to the Author link. This allows
To access this new page, go to:
index.html All links are accessible from this page.

New Laws Report is a list of all bills enacted in a calendar year during the Regular Session of the Legislature.
The list identifies the bill and chapter number, lead author, and the subject of the measure. All bills on the list
become effective on January 1 following the year of enactment, unless otherwise noted.

1999-2008 Cumulative Statutory Record now available in PDF and HTML. Note that when viewing the
document, clicking on the chaptered bill number links directly to the chaptered bill text within LegInfo.

FTP Protocol - This feature currently allows users to download categories of bill information, statutory text, and
other legislative information by connecting to a flat-file database. While we are retaining this option, you can now
download a structured, relational database, which will facilitate a user's ability to search, sort, and analyze the
information in a variety of software environments. You may access this relational database, and instructions on
its use from the "FTP Protocol" portion of the "Accessing California Legislative Information on the Internet," a link
that is found on the Leginfo home page.

Bill Information - The Current Legislative Session has been added to the session drop down list. Bill Information
can be accessed via the "Bill Information" page.

California Law - All California Codes have been updated to include the 2010 Statutes.

Author Search - An author search feature has been added. You can display a list of bills authored by a specific
Legislator by using the author search feature on the "Bill Information" page.

Assembly Daily Journal / Senate Daily Journal - A link to the Assembly Daily Journal is now available under
the "Legislative Publications" option. The Assembly Daily Journal is the official record of business that has been
transacted in the Assembly. The Senate Daily Journal information is also available under the "Legislative
Publications" option. The Senate Daily Journal is the official record of business that has been transacted in the

Legislative Calendar for the Current Session of the Legislature is available under the "Your Legislature" option.

Send Comments to Author- for Assembly bills only, you can send comments on their bills directly to the bill's
author. Select the "Send Comment to Author" button that can be found by displaying the Assembly bill on your
screen, then scrolling to the bottom of the Bill Document screen.

Subscription Services are available for the current session. E-mail notices will be sent when there is legislative
action on a subscribed bill. Coming Soon! —                                           Access to Multiple Payers with Single Sign-on

                              Physicians, hospitals and other health care        including claim status, charge and line item
                              professionals can soon check their patients’       detail – all in real time for your Anthem Blue
                              health coverage by going to Availity, a multi-     Cross patients and patients insured by other
                              payer portal that gives providers access with      carriers. If you need to conduct an imaging pre-
                              one sign-on to multiple payers’ information.       certification you can access American Imaging
                              Availity offers a variety of online functions to   Management (AIM) through the Availity portal.
                              help providers reduce administrative costs         You can also submit your specialty pharmacy
                              by eliminating paperwork and phone calls.          drug requests.

                              With Availity, you can check eligibility and       Anthem Blue Cross will unveil this new service
                              benefits information; do a claim inquiry,

  March 2011                                        CPM Provider Newsletter                                              Page 13

to all network providers later this year.     Streamlined workflow by accessing             monitor their users’ transactions in real
Once registered, with just a few key          multiple insurers’ information within one     time. If a portal administrator finds that
strokes, you can gain extra time for          portal.                                       a user needs additional assistance in
patient care by accessing the one-stop        Strengthen patient relationships              using the website, Availity also offers
                                                                                            Client Services for users, as well as
-approach made available through              by providing more efficient service.
                                                                                            webinars and on-site training for
Availity.                                     Consistent display of information
                                                                                            provider groups.
                                              across payers.
A small group of providers have been          Reduced administrative costs due to           These features were noted by a pilot
piloting Availity’s functionality since mid   fewer phone calls and shorter wait            manager who stated,
-November. They have noted real               times.
advantages in going to one site for           Additional claims information for             “Availity is really nice because it allows
multiple payers. An office manager            many Anthem National Account                  me to monitor my staff as they are
stated,                                       members.                                      working on claims or checking eligibility
                                                                                            and it lets me verify errors or problems
                                              The Availity site complies with the           that they may experience. The training
“In working with Availity, the office has
                                              Health Insurance Portability and              that we received before we went ‘live’
found it to be easier to access eligibility
                                              Accountability Act (HIPAA).                   was very comprehensive, and we even
information and claim status look-up is                                                     received a phone call from an Availity
                                              A secure site that supports 128-bit
much simpler. We have encountered                                                           training representative to make sure we
                                              encryption, it’s supported by client
no real difficulties and it is easier to go                                                 had all the assistance we needed. The
                                              service representatives, as well as
to one area and look up information for       comprehensive help, demonstrations            personal touch given by the Availity
different insurances than to have to go       and training online. In addition to           staff was very much appreciated.”
to each individual website. By using          providing access to HIPAA compliant
Availity, it saves on time and computer       transactions such as eligibility and          In offering this new portal service,
frustrations.” A pilot provider noted,        benefits and claims inquiry, Availity         Anthem Blue Cross’s goals include
                                              gives portal administrators the ability to    helping simplify the health care benefit/
“The Availity site works well, is set up
                                                                                            payment process so doctors, hospitals
clean and easy to use. You can look at
                                                                                            and other health care professionals can
it and know right where to find the                                                         spend more time on patient care and
information you need for each payer.”                                                       less time on paperwork. Every penny

                                                                                            saved on forms, claims and
With a single sign-on, you can perform                                                      administrative expenses is money that
numerous administrative tasks for                                                           can be invested in innovative products
                                                                   vaility gives portal
patients covered by other payers. A full                                                    and services that improve the health of
                                                               administrators the ability   our members and their communities.
list of participating payers for each
                                                                 to monitor their users’    Stay tuned for more information
state is available on
                                                               transactions in real time.   regarding the launch of the Availity
The benefits of Availity include:
 March 2011                                 CPM Provider Newsletter                                           Page 14

                                                  Works Cited

"AMA Welcomes Court Decision Supporting New Law Clarifying Red Flags Rule (AMA)." American Medical Association -

        Physicians, Medical Students & Patients (AMA). 09 Mar. 2011. Web. 10 Mar. 2011. <http://www.ama->.

"Assembly Bill Enables Doctor 'Kickbacks' at the Expense of Patients Physical Therapists Say Patients Will Suffer If MDs

        Are Allowed to Refer Patients for Profit." CNBC. California Practice Group, 23 Feb. 2011. Web. 08 Mar. 2011.


Blumenthal, David. "The Age of Meaningful Use." U.S. Dept of Health & Human Services. United States Government,

        23 Feb. 2011. Web. 07 Mar. 2011. <


McLaughlin, Joyce. "Health Care Reform Adds Requirements for Physicians." Physicians News. 03 Mar. 2011. Web. 08

        Mar. 2011. <


"Physical Therapy Group Distorts Intent Of AB 783 - Patient Access To Care At Issue." - RSS Health

        News. California Medical Association, 28 Feb. 2011. Web. 08 Mar. 2011. <


"Provider Resources - ICD-10." U.S. Dept of Health & Human Services. United States Government, 22 June 2010. Web.

        07 Mar. 2011. <>.

State of California. State Assembly. Assemblymember Mary Hayashi Introduces Bill To Save Physical Therapy Jobs.

        California Assemblymember Mary Hayashi. State of California, 28 Feb. 2011. Web. 08 Mar. 2011. <http://>.
  March 2011                                             CPM Provider Newsletter                                                              Page 15

The articles contained in this Newsletter were prepared as a service to our subscribers and is not intended to grant rights or impose obligations. These
articles may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general
summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations
and other interpretive materials for a full and accurate statement of their contents.

We do our best to provide you with the most accurate and up-to-date information possible. However, due to circumstances beyond our control some
of the information can change without our knowledge. Because of the possibility of human error and other circumstances beyond its control, Clinical
Practice Management is not responsible for any errors or omissions which shall include any direct, indirect, incidental, consequential or any other
damages arising out of or in connection with the information available in this Newsletter Digest. The information provided in this digest is solely for non
-profit educational purposes (17U.S.C.§107) and no other purpose(s) is to be derived or implied. We have, when necessary, condensed certain
articles for space purposes but without having diluted, in our opinion, the original message or intent of the cited author(s). Source references of
articles used in this digest lead directly to cited work by original author. The information provided in this digest does not constitute an endorsement
from nor of any company, corporation, person or other entity.

 If you find an error or omission on any of our pages, please inform us as soon as possible by email at:

                            Clinical Practice Management
                             Provider Newsletter Digest
                         2200 W. Orangewood Ave., Ste. 212
                                  Orange, CA 92868                                              Your comments, suggestions and letters are welcome!
                                   1-888-550-2112                                               Please feel free to relay any and all information to us.
                                                                                                Direct all correspondence, letters, etc., to the Editor:
                                                                                                Linda Seidelman, Editor,
Kimberly Saalfeld, Manager                          714-450-4999                      
Linda Seidelman Editor                              714-450-4980 X 1251

                      John O’Connor, Joseph Donohue, Owners

                                                              The 4-1-1 On Us!
                                                              Clinical Practice Management’s
                                                              (CPM) story began in 1998 by a                 The launch of CPM was a success!
                                                              group of Physical Therapists who
                                                              decided to provide, what they                  We’ve enjoyed continued
                                                              themselves were looking for, in a              growth due to the strength of
                                                              billing company.                               our pledge to provide stellar
                                                                                                             clinical services to our clients!
                                                              •    Compliance
                                                              •    Compassion                                CPMs client references speak
                                                              •    Knowledge                                 to our reputation in the
                                                              •    Integrity                                 Rehabilitation healthcare
                                                              •    ...and of course...Cash!                  community—
                                                                                                             as well as CPMs status in being a
                                                                                                             PTPN Preferred Provider!
   L to R; John O’Connor, Kimberly Saalfeld,
   Joe Donohue

                                 CPM is Not Your Run of the Mill Billing Company — Keeping You on Target and in Control!
March 2011                                    CPM Provider Newsletter                                                    Page 16

             2200 W. Orangewood Ave | Ste 212                            contact: Linda Seidelman

             Orange, CA 92868                                            phone: 714-450-4950 X 1251


                                 The Clinical Practice Management Family

              Your comments, suggestions and letters are welcome! Please feel free to relay any and all information to
              us. Direct all correspondence, letters, etc., to the Editor:

              Linda Seidelman, Editor,

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