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 Availity.com 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
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
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
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.
MYTHS & FACTS REGARDING
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:
MYTHS & FACTS REGARDING
• 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 email@example.com.
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.
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
MEASURE: AB 783
Non-State Mandated Local Program
TOPIC: Professional corporations; licensed physical
LAST HIST ACTION DATE: 02/18/11—read first time
TYPE OF BILL:
LAST HIST ACTION: May be heard in committee March 20
TITLE: ...to 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
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
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: http://www.leginfo.ca.gov/
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.
Availity.com 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
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 availity.com.
transactions in real time. regarding the launch of the Availity
The benefits of Availity include:
March 2011 CPM Provider Newsletter Page 14
"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. <http://healthit.hhs.gov/portal/server.pt?
McLaughlin, Joyce. "Health Care Reform Adds Requirements for Physicians." Physicians News. 03 Mar. 2011. Web. 08
Mar. 2011. <http://www.physiciansnews.com/2011/03/03/health-care-reform-adds-requirements-for-
"Physical Therapy Group Distorts Intent Of AB 783 - Patient Access To Care At Issue." Healthwd.info - RSS Health
News. California Medical Association, 28 Feb. 2011. Web. 08 Mar. 2011. <http://www.healthwd.info/news/
"Provider Resources - ICD-10." U.S. Dept of Health & Human Services. United States Government, 22 June 2010. Web.
07 Mar. 2011. <http://www.cms.gov/ICD10/05a_ProviderResources.asp#TopOfPage>.
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
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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!
• 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,
CPM is Not Your Run of the Mill Billing Company — Keeping You on Target and in Control!
March 2011 CPM Provider Newsletter Page 16
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Your comments, suggestions and letters are welcome! Please feel free to relay any and all information to
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