1. 1 2011 3 rd Party Update In the 3 rd Party Area… What has happened in the last 12 months What to expect in the next 12 months

2. 2 2011 3 rd Party Update HIPAA (EDI) HIPAA (EDI) Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

3. 3 2011 3 rd Party Update HIPAA (EDI) HIPAA (EDI) Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

4. 4 HIPAA EDI – Version 5010 The Health Insurance Portability and Accountabiliy Act (HIPAA) electronic data interchange (EDI) federal regulations require that health data be transmitted in a standardized form. The Health Insurance Portability and Accountabiliy Act (HIPAA) electronic data interchange (EDI) federal regulations require that health data be transmitted in a standardized form. HIPAA is updating that transmission method from HIPAA version 4010A1 to HIPAA version 5010 starting January 1, 2012. HIPAA is updating that transmission method from HIPAA version 4010A1 to HIPAA version 5010 starting January 1, 2012.

5. 5 HIPAA EDI – Version 5010 WHO: Any plan, clearinghouse or provider who transmits any health information in electronic form. WHO: Any plan, clearinghouse or provider who transmits any health information in electronic form. Includes changes to CMS-1500 claim forms. Includes changes to CMS-1500 claim forms. WHY: The current format is unable to support ICD-10 and pay for performance (PQRS; eRx; EHR). WHY: The current format is unable to support ICD-10 and pay for performance (PQRS; eRx; EHR). WHEN: Mandatory January 1, 2012. WHEN: Mandatory January 1, 2012.

6. 6 HIPAA EDI – Version 5010 WHAT TO DO: Providers who use practice management and other applicable software programs should make sure that their software programs feature the updated Versions 5010 and D.0 HIPAA transaction standards. Providers who use practice management and other applicable software programs should make sure that their software programs feature the updated Versions 5010 and D.0 HIPAA transaction standards. It's likely that your practice management software will need to be upgraded. It's likely that your practice management software will need to be upgraded.

7. 7 HIPAA EDI – Version 5010 WHAT TO DO: To meet the January 1, 2012 implementation date, providers should begin testing Version 5010 with their trading partners NOW. You must test before January 1, 2012. To meet the January 1, 2012 implementation date, providers should begin testing Version 5010 with their trading partners NOW. You must test before January 1, 2012. Talk to your software vendor, clearinghouse, or billing service NOW, and work together to make sure you'll have what you need to be ready. Talk to your software vendor, clearinghouse, or billing service NOW, and work together to make sure you'll have what you need to be ready.

8. 8 HIPAA EDI – Version 5010 WHAT TO DO: Contact your Medicare Administrative Contractor MAC to inquire about their testing protocols. Contact your Medicare Administrative Contractor MAC to inquire about their testing protocols. WPS Medicare http://www.wpsmedicare.com/j5macpartb/departments/edi_/ WPS Medicare http://www.wpsmedicare.com/j5macpartb/departments/edi_/ http://www.wpsmedicare.com/j5macpartb/departments/edi_/ Noridian (CEDI) http://www.ngscedi.com/5010/5010.htm Noridian (CEDI) http://www.ngscedi.com/5010/5010.htm http://www.ngscedi.com/5010/5010.htm

9. 9 HIPAA EDI – Version 5010 WHAT TO DO: Use 9-digit zip codes for billing provider address Use 9-digit zip codes for billing provider address Use 9-digit zip code for service facility locations (POS) Use 9-digit zip code for service facility locations (POS) Lock box and post office boxes are not acceptable billing provider addresses Lock box and post office boxes are not acceptable billing provider addresses http://nebraska.aoa.org/prebuilt/noa/2011-05%203RD%20Party%20Newsletter.pdf

10. 10 HIPAA EDI – Version 5010 Paper Claims: CMS-1500 claim forms will also be altered CMS-1500 claim forms will also be altered Modification proposals are now being considered Modification proposals are now being considered

11. 11 HIPAA EDI – Version 5010 Resources for 5010 Versions 5010 & D.0 FAQs Now Available! https://questions.cms.hhs.gov/app/answers/list/kw/5010 National Testing Day Message Now Available! http://www.cms.gov/Versions5010andD0/Downloads/5010_National_Testing_Day_Message.pdf 5010/D.0 Errata requirements and testing schedule http://www.cms.gov/Versions5010andD0/Downloads/Errata_Req_and_Testing.pdf Contact your MAC for their testing schedule http://www.cms.gov/Versions5010andD0/Downloads/Reminder-Contact_MAC.pdf Have you done the following to be ready for 5010/D.0? http://www.cms.gov/Versions5010andD0/Downloads/Readiness_1.pdf What do you need to have in place to test with your MAC? http://www.cms.gov/Versions5010andD0/Downloads/Readiness_2.pdf Do you know the implications of not being ready? http://www.cms.gov/Versions5010andD0/Downloads/Readiness_5010.pdf

12. 12 2011 3 rd Party Update HIPAA (EDI) HIPAA (EDI) Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

13. 13 HIPAA – ICD-9 to ICD-10 Starting October, 2013 you will be required to use ICD-10 diagnosis coding instead of ICD-9 ICD-10 Coding is completely different than ICD-9.

14. 14 HIPAA – ICD-9 to ICD-10 https://www.cms.gov/ICD10/11b1_2011_ICD10CM_and_GEMs.asp

15. 15 HIPAA – ICD-9 to ICD-10 http://www.revoptom.com/content/d/practice_management/c/14816/

16. 16 HIPAA – ICD-9 to ICD-10 https://www.cms.gov/ICD10/Downloads/ICD-10QuickRefer.pdf

17. 17 2011 3 rd Party Update HIPAA (EDI) HIPAA (EDI) Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

18. 18 HIPAA Privacy Updates Be sure to give every new patient your “Notice of Privacy Practices” (NPP) and have the acknowledge receipt in writing. Be sure to post your NPP in an obvious location in your office. If your office has a web site, you must post your NPP in an obvious location on you website.

19. 19 HIPAA Privacy Updates If you alter your NPP, be sure to give every patient a copy of the revised NPP and have them acknowledge receipt in writing. On subsequent visits, remind patient that the NPP is available. On subsequent visits, note in record whether NPP had previously be given and acknowledged in writing.

20. 20 HIPAA Privacy Updates Review your NPP with staff on a regular basis. (Dr. Quack receives HIPAA privacy questions which should be answered by the office’s NPP) Review your HIPAA Office Manual yearly, and update as needed (names of employees, etc.)

21. 21 HIPAA Privacy Updates Find “Uses and Disclosures for Treatment, Payment, and Health Care Operations,” which is at http://www.hhs.gov/ocr/privacy/hipaa/understandi ng/ coveredentities/usesanddisclosuresfortpo.html http://www.hhs.gov/ocr/privacy/hipaa/understandi ng/ coveredentities/usesanddisclosuresfortpo.html Review the “Summary of the HIPAA Privacy Rule” at http://www.hhs.gov/ocr/privacy/hipaa/understandi ng/summary/ index.html http://www.hhs.gov/ocr/privacy/hipaa/understandi ng/summary/ index.html FAQs bys by category may be found at http://www.hhs.gov/hipaafaq/. http://www.hhs.gov/hipaafaq/

22. 22 2011 3 rd Party Update HIPAA HIPAA Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

23. 23 2011 Payments Payment based on 75 percent of their total Medicare allowed charges submitted no later than two months after the end of the 2011 calendar year. The maximum allowed charges used for a 2011 incentive payment are $24,000. This means that the maximum incentive payment an EP can receive for 2011 is $18,000. Incentive payments will not be made until the EP meets the $24,000 threshold in allowed Medicare charges.

24. 24 Attestation Resources CMS has resources to help you attest to having met meaningful use requirements in order to receive your EHR incentive payment. An Attestation page, http://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp, where participants in the Medicare EHR Incentive Program can find important information on attestation. An Attestation page, http://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp, where participants in the Medicare EHR Incentive Program can find important information on attestation. http://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp

25. 25 Attestation Resources The Meaningful Use Attestation Calculator, http://www.cms.gov/apps/ehr/ which allows EPs and eligible hospitals to check whether they have met meaningful use guidelines before they attest in the system. The calculator prints a copy of each EP's or eligible hospital's specific measure summary. The Meaningful Use Attestation Calculator, http://www.cms.gov/apps/ehr/ which allows EPs and eligible hospitals to check whether they have met meaningful use guidelines before they attest in the system. The calculator prints a copy of each EP's or eligible hospital's specific measure summary. http://www.cms.gov/apps/ehr/ The Attestation User Guide for Medicare http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_User_Guide.pdf, which provide step-by-step guidance for EPs and eligible hospitals participating in the Medicare EHR Incentive Program on navigating the attestation system. The Attestation User Guide for Medicare http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_User_Guide.pdf, which provide step-by-step guidance for EPs and eligible hospitals participating in the Medicare EHR Incentive Program on navigating the attestation system. http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_User_Guide.pdf

26. 26 Attestation Resources Attestation Worksheet for http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_User_Guide.pdf, which allow users to fill out their meaningful use measure values, so they have a quick reference tool to use while attesting. Attestation Worksheet for http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_User_Guide.pdf, which allow users to fill out their meaningful use measure values, so they have a quick reference tool to use while attesting. http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_User_Guide.pdf Attestation is currently open for all participants in the Medicare EHR Incentive Program via the Medicare & Medicaid EHR Incentive Program Registration and Attestation System https://ehrincentives.cms.gov/hitech/login.action. Attestation is currently open for all participants in the Medicare EHR Incentive Program via the Medicare & Medicaid EHR Incentive Program Registration and Attestation System https://ehrincentives.cms.gov/hitech/login.action. https://ehrincentives.cms.gov/hitech/login.action

27. 27 EHR Approved Software ActivEHR™ 2011.1 by EMRlogic Systems Advantage EHR Version 10 by Compulink Business Systems Crystal Practice Management by Abeo Solutions Electronic Health Records (EHR) Version 7.6 by Medflow ExamWRITER Version 10 by Eyefinity/OfficeMate MaximEyes® SQL Electronic Health Records Version 1.1.0 by First Insight Corporation Ocular Medical Records Version 11.0 by QuikEyes Practice Director by Williams Marketing RevolutionEHR Version 5.1.0 by Health Innovation Technologies

28. 28 EHR and FAQs CMS has posted the latest EHR FAQs document on the CMS website. Go to http://www.cms.gov/EHRIncentivePrograms/Downloads/FAQsRemediatedandRevised.pdf CMS will continue to provide updates as new FAQs are added.

29. 29 2011 Attestation Q & A Do you have questions about attestation? Get answers to some of the most commonly asked questions about attestation. How will I attest for the Medicare and Medicaid Incentive Programs? How will I attest for the Medicare and Medicaid Incentive Programs? How will I attest for the Medicare and Medicaid Incentive Programs? How will I attest for the Medicare and Medicaid Incentive Programs? When can I attest? When can I attest? When can I attest? When can I attest? What can I do now to prepare for attestation? What can I do now to prepare for attestation? What can I do now to prepare for attestation? What can I do now to prepare for attestation? Where can I find user guides and other resources? Where can I find user guides and other resources? Where can I find user guides and other resources? Where can I find user guides and other resources? What will I need to login to the Attestation System? What will I need to login to the Attestation System? What will I need to login to the Attestation System? What will I need to login to the Attestation System? What is the EHR Certification Number? What is the EHR Certification Number? What is the EHR Certification Number? What is the EHR Certification Number? I am an Eligible Provider. Can I designate a third party to register and/or attest on my behalf? I am an Eligible Provider. Can I designate a third party to register and/or attest on my behalf? I am an Eligible Provider. Can I designate a third party to register and/or attest on my behalf? I am an Eligible Provider. Can I designate a third party to register and/or attest on my behalf? When will I get paid? When will I get paid? When will I get paid? When will I get paid? How will I get paid? How will I get paid? How will I get paid? How will I get paid? Will CMS conduct audits? Will CMS conduct audits? Will CMS conduct audits? Will CMS conduct audits? https://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp

30. 30 2011 3 rd Party Update HIPAA HIPAA Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

31. 31 Medicare Reimbursement Adjustment (penalty). 2012 Medicare Payments docked 1%* 2012 Medicare Payments docked 1%* 2013 Medicare Payments docked 1.5% 2013 Medicare Payments docked 1.5% 2014 Medicare Payments docked 2% 2014 Medicare Payments docked 2% *It is still unknown whether or not the -1% 2012 payment adjustment applies to ODs

32. 32 Avoiding Adjustment Must use approved eRx software as required by Medicare Must use approved eRx software as required by Medicare Must report at least 25 unique eRx events for patients in the denominator of the measure before 12/31/11. (92000 or 99000 exam). Must report at least 25 unique eRx events for patients in the denominator of the measure before 12/31/11. (92000 or 99000 exam). ODs use “Claims-based reporting” of the electronic prescribing measure. Report a successful e-Rx with G-code (G8553) for 2011 ODs use “Claims-based reporting” of the electronic prescribing measure. Report a successful e-Rx with G-code (G8553) for 2011

33. 33 Avoiding the Medicare e-Prescribing “Adjustment” (penalty) You can get e-Rx credit for re-prescribing an Rx…but you cannot get credit for giving a pharmacy permission to refill an Rx. You can get e-Rx credit for re-prescribing an Rx…but you cannot get credit for giving a pharmacy permission to refill an Rx. You can get credit if you successfully e-Rx with your approved e-Rx software, even if an intermediary changes your e-Rx to a Fax. You can get credit if you successfully e-Rx with your approved e-Rx software, even if an intermediary changes your e-Rx to a Fax.

34. 34 Exemptions and Exceptions To request an exemption to the eRx Incentive Program and the payment adjustment, there are two “hardship codes” that can be reported via claims should one of the following situations apply, plus an exemption for not having prescribing privileges. To request an exemption to the eRx Incentive Program and the payment adjustment, there are two “hardship codes” that can be reported via claims should one of the following situations apply, plus an exemption for not having prescribing privileges. There are also two exceptions There are also two exceptions

35. 35 Exemptions G8642 - The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act. G8642 - The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act.

36. 36 Exemptions G8643 - The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act G8643 - The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act

37. 37 The final rule provides additional significant hardship exemption categories for 2011 for the 2012 eRx payment adjustment: (1) eligible professionals who register to participate in the Medicare or Medicaid EHR Incentive Program and adopt certified EHR technology; New Exemptions

38. 38 (2) eligible professionals who are unable to electronically prescribe due to local, state, or federal law or regulation; (3) eligible professionals who have limited prescribing activity; (4) eligible professionals who have insufficient opportunities to report the e-prescribing measure due to limitations of the measure’s denominator. New Exemptions

39. 39 Exceptions Does not have prescribing privileges. Note: (S)he must report (G8644) at least one time on an eligible claim prior to December 31, 2011; Does not have prescribing privileges. Note: (S)he must report (G8644) at least one time on an eligible claim prior to December 31, 2011; Does not have at least 100 cases containing an encounter code in the measure denominator (92000 and 99000 exam codes) Does not have at least 100 cases containing an encounter code in the measure denominator (92000 and 99000 exam codes)

40. 40 What to Do? Go to the CMS e-prescribing web site Go to the CMS e-prescribing web site Click on “How to get Started” (left column) Click on “How to get Started” (left column) http://www.cms.gov/ERxIncentive/03_How_To_Get_Started.asp#TopOfPage

41. 41 2010 eRx Payments LE will appear on the electronic remit. LE will appear on the electronic remit. CMS created a 4-digit code to indicate the type of incentive and reporting year. For the 2010 eRx incentive payments, the 4-digit code is RX10. CMS created a 4-digit code to indicate the type of incentive and reporting year. For the 2010 eRx incentive payments, the 4-digit code is RX10. For example, eligible professionals will see LE to indicate an incentive payment, along with RX10 to identify that payment as the 2010 eRx incentive payment. For example, eligible professionals will see LE to indicate an incentive payment, along with RX10 to identify that payment as the 2010 eRx incentive payment. The paper remittance advice will read, “This is an eRx incentive payment.” The year will not be included in the paper remittance. The paper remittance advice will read, “This is an eRx incentive payment.” The year will not be included in the paper remittance.

42. 42 2010 eRx Payments Who to Contact for Questions? Provider Contact Center. The Contact Center Directory is available at http://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip Who to Contact for Questions? Provider Contact Center. The Contact Center Directory is available at http://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip http://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip The QualityNet Help Desk is available Monday through Friday from 7:00 a.m. – 7:00 p.m. CST at 1- 866-288-8912 or via qnetsupport@sdps.org. The help desk can also assist with program and measure-specific questions. The QualityNet Help Desk is available Monday through Friday from 7:00 a.m. – 7:00 p.m. CST at 1- 866-288-8912 or via qnetsupport@sdps.org. The help desk can also assist with program and measure-specific questions. qnetsupport@sdps.org The following CMS resource is available to help eligible professionals understand the 2010 eRx Incentive Payments, view A Guide for Understanding the 2010 eRx Incentive Payment [PDF 57 KB], on the CMS website. The following CMS resource is available to help eligible professionals understand the 2010 eRx Incentive Payments, view A Guide for Understanding the 2010 eRx Incentive Payment [PDF 57 KB], on the CMS website. A Guide for Understanding the 2010 eRx Incentive Payment [PDF 57 KB] A Guide for Understanding the 2010 eRx Incentive Payment [PDF 57 KB]

43. 43 2011 3 rd Party Update HIPAA HIPAA Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

44. 44 Nursing Home Coding 1. Make sure there is a justifiable medical reason for the visit. 2. If using E&M coding, make sure your documentation justifies your 99307, 99308, or 99309 claim. 3. Don’t let your documentation look “cookie-cutter”. If all your documentation looks alike, it raises question of authenticity. 4. 3. The AOA says an OD can use the 92xxx exam codes when making nursing home visits, using the place of service codes of 31 (skilled nursing facility) or, more likely, 32 (nursing facility).

45. 45 Final Code must be Reasonable and Necessary Considering Chief Complaint/ Reason for visit / Presenting Problem Chief Complaint/ Reason for visit / Presenting Problem History History Clinical findings Clinical findings Decision Making Required Decision Making Required

46. 46 Must Sign Written Order for Testing WPS Medicare's Comprehensive Error Rate Testing (CERT) error findings for insufficient documentation accounted for 50% of all errors assessed. The majority of these errors were due to the LACK OF A VALID PHYSICIAN ORDER for diagnostic services.

47. 47 CHANGES IN THE WPS OPTOMETRY LCD, EFFECTIVE JANUARY 1, 2011 The following CPT codes have been added to Table I for All Optometrists; 76513 82962 83516 83520 92541 92542 92544 99221-99223 99231-99233 99281-99283 99350 99354 99355 99356 99357 92018 92019 92260 92270 92287

48. 48 CHANGES IN THE WPS OPTOMETRY LCD, EFFECTIVE JANUARY 1, 2011 The following Codes have been added to Table II for Optometrists with a therapeutic license; The following Codes have been added to Table II for Optometrists with a therapeutic license; 65272 65275 65286 65600 67825 67850 82785 87070 87081 87205 87809 87809. 68020 98020 68530 68810 68840 76529

49. 49 CHANGES IN THE WPS OPTOMETRY LCD, EFFECTIVE JANUARY 1, 2011 The following CPT codes, found in Table II, no longer require a -55 modifier; 67820 67938 68040 68761 68801

50. 50 2011 3 rd Party Update HIPAA HIPAA Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

51. 51 Consolidated Billing Medicare’s Consolidated Billing is when you bill the patient's SNF for materials, and some services, rather than Noridian or WPS. Applies when the patient Had an inpatient hospital stay of 3 consecutive days or more. Has remaining Medicare Part A benefits His/her doctor decided daily skilled care is needed. The SNF has been certified by Medicare. The skilled services are needed due to hospital stay.

52. 52 Consolidated Billing Whenever you have a scheduled patient who is residing in a SNF, prior to examination you should always ask the SNF if the patient is currently covered under Medicare A. If so, you need to explain to the SNF about consolidated billing, since most are unfamiliar with the term or its consequences.

53. 53 Consolidated Billing All post-op DME billing that would normally go to Noridian must now go to the SNF. All post-op DME billing that would normally go to Noridian must now go to the SNF. The technical component of most ancillary testing must also go to the SNF. The technical component of most ancillary testing must also go to the SNF.

54. 54 Consolidated Billing Technical component of the following codes must be billed to the SNF 92060 SPEC’L EYE EVAL. 92065 ORTHOPTICS 92081 VISUAL FIELDS 92082 VISUAL FIELDS 92083 VISUAL FIELDS 92133-4 DX IMAGING 92136 OPHTHALMIC BIOMETRY 92235 EYE EXAM WITH PHOTOS 92240 ICG ANGIOGRAPHY 92250 EYE EXAM WITH PHOTOS 92265 EYE MUSCLE EVALUATION 92270 ELECTRO-OCULOGRAPHY 92275 ELECTRORETINOGRAPHY 92283 COLOR VISION 92284 DARK ADAPTATION EYE 92285 EYE PHOTOGRAPHY 92286 INTERNAL EYE PHOTO Excerpted From http://cms.hhs.gov/medlearn/file2pctc1. http://cms.hhs.gov/medlearn/file2pctc1.

55. 55 Consolidated Billing It is important that you work cooperatively with the SNF in these matters. If either you or the SNF have questions about consolidated billing, you can find further information at the CMS website on consolidated billing: http://www.cms.hhs.gov/medlearn/snfcode.asp. http://www.cms.hhs.gov/medlearn/snfcode.asp.

56. 56 Non-Participating Medicare Providers Cannot Bill or Charge Usual and Customary Fees. The rules are…. You do not have to see Medicare patients. You do not have to see Medicare patients. But, if you see ANY Medicare patients, federal law requires you to follow Medicare guidelines. But, if you see ANY Medicare patients, federal law requires you to follow Medicare guidelines. Non-Par providers must file claims for their Medicare Patients. Non-Par providers must file claims for their Medicare Patients. Medicare Limiting Charge

57. 57 Non-Par providers must not bill more than the Medicare limiting charge (last column on Medicare Fee Schedule), under penalty of federal law. Non-Par providers must not bill more than the Medicare limiting charge (last column on Medicare Fee Schedule), under penalty of federal law. Non-par Providers Cannot Collect From Medicare Patients & Medigap &/or Patient a Total $ Amount More Than The Medicare Limiting Charge Non-par Providers Cannot Collect From Medicare Patients & Medigap &/or Patient a Total $ Amount More Than The Medicare Limiting Charge Excessive billing or failure to file claims will incur severe fines. Excessive billing or failure to file claims will incur severe fines. Medicare Limiting Charge

58. 58 Medicare Limiting Charge

59. 59 A provider who violates the limiting charge is subject to Assessments of up to $10,000 per violation plus Assessments of up to $10,000 per violation plus Triple the amount of the charges in violation, and Triple the amount of the charges in violation, and Possible exclusion from the Medicare program. Possible exclusion from the Medicare program. Medicare Limiting Charge

60. 60 Medicare Fees You Cannot Charge Medicare Patients Extra Fees such as A Finance Charge A Finance Charge Interest Interest Other Similar Types Of Charges. Other Similar Types Of Charges.

61. 61 New ABN Required November 1st release date of 3/2011 printed in lower left hand corner https://www.noridianmedicare.com/dme/forms/docs/cms-r-131.pdf

62. 62 2011 3 rd Party Update HIPAA HIPAA Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

63. 63 Medicare DME Enrollment DME Suppliers Must Now Pay $500+ To Enroll Or To Re-Enroll DME Suppliers Must Now Pay $500+ To Enroll Or To Re-Enroll DME Suppliers Must Re-Enroll Every 3 Years. DME Suppliers Must Re-Enroll Every 3 Years. CMS requires that all DMEPOS suppliers re-enroll every three years with the NSC CMS requires that all DMEPOS suppliers re-enroll every three years with the NSC Requires application fee of $505 in 2011 as part of the enrollment process Requires application fee of $505 in 2011 as part of the enrollment process http://www.cms.gov/MLNMattersArticles/downloads/MM7350.pdf http://www.cms.gov/MedicareProviderSupEnroll/

64. 64 DME Supplier Standards Medicare standards a supplier of DME must meet The supplier must certify it meets the standards. The supplier standards can be found in 424 CFR Section 424.57 http://nebraska.aoa.org/documents/ne/2010-12-3RD-PARTY-NEWLSETTER.pdf

65. 65 DME Electronic Claims: Annual CEDI Recertification CEDI Recertification Now Required Annually Beginning in 2011, CEDI is requiring all Trading Partners to recertify their user access on an annual basis. Beginning in 2011, CEDI is requiring all Trading Partners to recertify their user access on an annual basis. If you have your own submitter ID that contains A08, B08, C08, or D08, you are a "trading partner”. DO IT NOW. If you have your own submitter ID that contains A08, B08, C08, or D08, you are a "trading partner”. DO IT NOW. http://www.ngscedi.com/forms/formsindex.htm

66. 66 2011 3 rd Party Update HIPAA HIPAA Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

67. 67 Medicaid Managed Care At the behest of the Unicameral, Medicaid managed care will go state wide in July (?) of 2012. At the behest of the Unicameral, Medicaid managed care will go state wide in July (?) of 2012. No one yet knows which insurers will be approved as MCOs in the newly affected areas of the state. No one yet knows which insurers will be approved as MCOs in the newly affected areas of the state.

68. 68 Medicaid Managed Care MCOs authorize, arrange, provide, and pay for the delivery of health care services to enrolled clients. Cover all Medicaid recipients except Those also covered by Medicare, Residents of nursing or intermediate care facilities Certain other narrow exclusions.

69. 69 Medicaid Managed Care If the MCOs currently serving eastern Nebraska are approved for out-state, and If the MCOs currently serving eastern Nebraska are approved for out-state, and If they handle the situation the same as they have in the eastern 10 counties, If they handle the situation the same as they have in the eastern 10 counties, Then Nebraska ODs will need to be a Block Vision provider to see routine care Medicaid patients, and Then Nebraska ODs will need to be a Block Vision provider to see routine care Medicaid patients, and Will need to be a Share Advantage and a Coventry Nebraska provider to see medical diagnosis patients. Will need to be a Share Advantage and a Coventry Nebraska provider to see medical diagnosis patients. However BCBS should also be a strong contender. However BCBS should also be a strong contender.

70. 70 2011 3 rd Party Update HIPAA HIPAA Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

71. 71 WPS: 92004 Dilation WPS Q & A on 92004 Eye Exams CERT [Comprehensive Error Rate Testing] states that 92004 must include initiation of diagnostic and treatment services, and should include dilation, unless documentation show contraindication CERT [Comprehensive Error Rate Testing] states that 92004 must include initiation of diagnostic and treatment services, and should include dilation, unless documentation show contraindication

72. 72 Medicare Coverage VEP And Tear Osmolarity Not Covered By Medicare Make sure you have a ABN signed if you plan to perform either test on Medicare patients. Make sure you have a ABN signed if you plan to perform either test on Medicare patients.

73. 73 Medicare Coverage Diabetic Examinations Despite HHS and CMS ostensibly advocating preventative medicine, 250.0x by itself is no longer reimbursable by Medicare.

74. 74

75. 75 Medicare Probe Results for CPT 99213 - Optometry Of all the specialties checked by WPS and displayed on their website, optometry was the only profession that had Of all the specialties checked by WPS and displayed on their website, optometry was the only profession that had More 99214 claims than the national average More 99214 claims than the national average Less 99213 claims than the national average Less 99213 claims than the national average Make sure your documentation shows justification for the level billed Make sure your documentation shows justification for the level billed

76. 76 Billing Punctal Plugs to Medicare The bottom line: ignore the 50 modifier and all the fancy coding; The bottom line: ignore the 50 modifier and all the fancy coding; Just vary the number of units. 3 plugs, three units. 4 plugs, 4 units. Just vary the number of units. 3 plugs, three units. 4 plugs, 4 units.

77. 77 Ordering/Referring Physicians Must Be in Capital Letters Medicare Providers who order health care products for Medicare beneficiaries or order health care products for Medicare beneficiaries or refer Medicare beneficiaries for health care services refer Medicare beneficiaries for health care services must be identified entirely in capital letters on Medicare claims

78. 78 2011 3 rd Party Update HIPAA HIPAA Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

79. 79 From the AOA: Forget The S Codes! Optometrists play an ever increasing role as members of the primary health care team and Optometrists play an ever increasing role as members of the primary health care team and Using S Codes poses many risks for access to the full range of optometric services. Using S Codes poses many risks for access to the full range of optometric services.

80. 80 Pay for Performance, Not for Procedures From the AOA: National Strategy for Quality Improvement in Health Care- Business as usual, including basing payment on procedures performed, is going by the wayside. Business as usual, including basing payment on procedures performed, is going by the wayside. Diagnosis related groups (Hospitals) Diagnosis related groups (Hospitals) Acute Care Episode (cardiac, orthopedic A & B) Acute Care Episode (cardiac, orthopedic A & B) Episode of Care (Home Health) Episode of Care (Home Health)

81. 81 2011 3 rd Party Update HIPAA HIPAA Claim Format Claim Format ICD-10-CM ICD-10-CM Privacy Privacy EHR EHR PQRS PQRS eRx eRx WPS WPS CMS CMS Noridian Noridian CEDI Medicaid Medicaid Coding Coding AOA AOA Potpourri Potpourri

82. 82 FTC Red Flags Rule Most Optometrists Exempt From Red Flags Rule Applies only when 1) Using credit reports in the ordinary course of business 2) Furnishing information to credit reporting companies 3) Loaning money

83. 83 Review Insurance Agreements October is a great time to launch your 'annual' review of all the agreements you've signed with HMOs, medical insurers, and vision plans. October is a great time to launch your 'annual' review of all the agreements you've signed with HMOs, medical insurers, and vision plans.

84. 84 The Medical Home The Medical Home: Communicate with Your Patient's PCP --- In order for an optometrist to be considered a player in the upcoming medical home scenario, the OD must communicate significant findings to the patient's PCP on a regular basis. 11p4 In order for an optometrist to be considered a player in the upcoming medical home scenario, the OD must communicate significant findings to the patient's PCP on a regular basis. 11p4