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Find out how regulations from CMS including the Medicare Physician Fee Schedule affect the specialty of otolaryngology - head and neck surgery and read our comments letters to CMS to address these policies. View advocacy letters that the Academy has sent in conjunction with other national medical associations.

Medicare Resources

What’s New: Medicare Updates

Important Notice: Physician Billing and Medicare for April 1, 2014 – Mid-April (3/30/2015)
The current Sustainable Growth Rate (SGR) payment patch expires on April 1, long before Congress reconvenes and the Senate votes on the H.R. 2. As members likely know, last week, the U.S. House of Representatives, in a rare demonstration of bipartisanship, voted 392-37 to pass H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The Senate is expected to vote on the measure in mid-April following a two-week recess. After 14 years and 17 short-term patches, H.R. 2 – which is strongly supported by the AAO-HNS – will provide much-needed stability for physicians and their patients by permanently repealing the flawed SGR formula used to determine Medicare payments. Until the Senate votes, all physician services provided on or after April 1 will be subject to a cut of 21 percent.

The Centers for Medicare & Medicaid Services (CMS) is instructing its carriers to "hold" for 10 business days any claims for services provided on April 1 and beyond, until legislation can be passed and signed into law that reverses the 21 percent cut. The 10-business-day hold means that April claims will be held through Tuesday, April 14. Since no claims by law can be paid sooner than 14 calendar days from their receipt, this hold should have little practical impact on Medicare remittance in the short-term, although billing for copayments and claims reconciliation will be more complicated. By law, Medicare is required to pay physicians the lesser of the submitted charge or the Medicare approved amount.

For this reason, the AMA is advising against submitting claims with reduced amounts reflecting the 21 percent cut. Instead, the AMA recommends physicians either continue charging the current 2015 rates for April dates of service or defer submitting claims until after final action on the legislation. In the unexpected event that Congress allows the 21 percent cut to take effect, Medicare would pay physicians at the reduced amount no matter what the physician billed and no further action would be necessary. However, non-participating physicians who have collected balance billing amounts for unassigned claims based on the currently-allowed amount could be required to make refunds to their patients based on new, lower balance billing limits.

Health Policy Attends December MedPAC Meeting (1/13/2015)
As members know, the Medicare Payment Advisory Commission (MedPAC) is the independent commission charged with annually reviewing Medicare payment policies and making recommendations to Congress based on its review and findings. MEDPAC held meetings on December 18 and 19th to discuss preliminary draft recommendations to Congress that it will revisit in March when it drafts its annual report.  Health Policy staff were in attendance and have summarized relevant topics discussed. Click here to view the summary.

Summaries of Regulations and Comment Letters
Sign-on Letters

Academy Joins Effort Demanding Change to MU (1/21/2015)
Earlier this month, the Academy signed on to an AMA letter calling for changes to the Electronic Health Records (EHR) Meaningful Use (MU) certification process. The letter addresses issues related to interoperability, security, and usability. To read the letter, click here.

Academy Signs on to PARTNERS Coalition Letter Calling for Increased Regulation of Cigarettes (3/27/2014)
On March 27, the Academy signed onto a letter calling for FDA regulation of the design and composition of cigarettes, essentially in effort to reverse harmful effects created through the evolution of design and composition of cigarettes.  View the letter here

Academy Urges CMS to Revisit Onerous 90-Day Grace Period Policy (3/13/2014)
Under the ACA, consumers who purchase certain health insurance plans are allowed a three-month grace period if they miss a monthly premium payment. During the last two months of this grace provision, insurers are allowed to pend and/or deny claims submitted during this time frame. In other words, insurers are able to unfairly shift the burden and risk of potential loss for patient non-payment to physicians by having physicians bear the cost of the services provided. In an effort to protect members from this onerous policy, the Academy joined an AMA letter urging CMS to require insurers to notify providers of a patient’s grace period status as part of the insurance eligibility verification process. The Academy will continue to call on CMS to revisit this policy and will keep members apprised of all pertinent information via eNews, HP Update and other outreach media. View the sign-on letter here.  

MedPAC Meeting Summaries

Health Policy Attends December MedPAC Meeting (1/13/2015)
As members know, the Medicare Payment Advisory Commission (MedPAC) is the independent commission charged with annually reviewing Medicare payment policies and making recommendations to Congress based on its review and findings. MEDPAC held meetings on December 18 and 19th to discuss preliminary draft recommendations to Congress that it will revisit in March when it drafts its annual report.  Health Policy staff were in attendance and have summarized relevant topics discussed. Click here to view the summary.

Medicare Enrollment

Provider Enrollment Update
CMS has added a report containing the names of physicians with pending Provider Enrollment, Chain, and Ownership System (PECOS) applications. You may check this report to find out if your Medicare contractor is still processing your PECOS application. CMS plans to update this report twice a week. CMS has also provided enrollment guidance for physicians who infrequently receive payments from Medicare.

Provider Participation in the Medicare Program
Provides an overview of participation status options for providers in the Medicare program.

Internet Based Provider Enrollment, Chain and Enrollment System (Internet PECOS)
Provides a summary of the Internet PECOS 

Internet Based PECOS-Getting Started
Provides instructions on creating or updating your enrollment record in PECOS. 

Do you have an Enrollment Record in PECOS that contains your NPI?
Regarding Change Requests 6417 and 6421,  CMS has made available a file that contains the National Provider Identifier (NPI) and the first and last names of all physicians and non-physician practitioners who are eligible to order and refer (in the Medicare program) and who have current enrollment records in Medicare (i.e., they have enrollment records in Internet-based Provider Enrollment, Chain and Ownership System (PECOS) that contain an NPI). You can check this file to ensure that you are enrolled in PECOS and enroll in PECOs if you aren’t. 

Change in Provider Enrollment Timeliness Standards for Certain Paper Applications
Effective June 21, 2010 Medicare will change the timeliness standards for provider enrollment processing for the CMS-855I and 855B initial applications, change requests and reassignments.

NPI Basics
The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA.

Viewing, Accessing or Maintaining your NPPES Account Information
CMS recommends that health care providers that have obtained their NPI know and maintain National Plan and Provider Enumeration System (NPPES) User Ids and passwords, reset NPPES passwords at least once a year and review NPPES records to ensure the accuracy of the information.

NPI Registry
The NPI Registry enables you to search for a provider's NPPES information. All information produced by the NPI Registry is provided in accordance with the NPPES Data Dissemination Notice. You may run simple queries to retrieve this read-only data. For example, users may search for a provider by the NPI or Legal Business Name. There is no charge to use the NPI Registry.

Medicare Forms
Medicare Provider Enrollment forms, Provider Participation Application forms, Appeal forms, and Advance Beneficiary Notice Forms.

Medicare Administrative Contractors (MAC)

Implementation of the Medicare Administrative Contractors (MAC)

With the new MAC structure, there are 15 contractors by jurisdiction responsible for processing Part A and B claims. Four of the A/B MAC providers will overlap responsibility for handling Home Health and Hospice claims. The final four MAC plans will be the Durable Medical Equipment contractors.

A/B MAC Jurisdictions Maps

A map illustrating the current Medicare Administrative Contrator Jurisdictions

Websites for the Medicare Administrative Contractors (MAC)

Website links to your MACs. Obtain information on active LCDs and other billing and coding updates

Carrier Advisory Committee (CAC)

The CAC acts as a formal mechanism for physicians in the state to be informed about and to participate in the development of Local Coverage Determinations (LCD) in an advisory capacity, a mechanism to discuss and improve administrative policies
that are within carrier discretion and a forum for information exchange between carriers and physicians. To view a current list of ENT CACs. To obtain contact information for your CAC, contact the Health Policy team

Medicare Archives

CMS Issues 2015 Final Rule for the Medicare Physician Fee Schedule (11/13/2014)
On October 31, the Centers for Medicare & Medicaid Services (CMS) released the 2015 Medicare Physician Fee Schedule (MPFS) final rule. Key provisions include: transitioning global codes, identifying increased values for several esophagoscopy codes, affirming the RUC recommended values for endoscopic Zenker's and VNG codes, and finalizing several changes to CMS quality initiatives, including two new PQRS measures groups for AOE and sinusitis. The Academy will provide a detailed summary in the coming weeks. View the final rule here

CMS Issues  2015 Proposed Rules for the Medicare Physician Fee Schedule and Hospital Outpatient/Ambulatory Surgical Centers
Last week, CMS released the proposed 2015 Medicare Physician Fee Schedule (MPFS) and 2015 Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Centers (ASCs) proposed rules. In its 2015 MPFS Proposed Rule, CMS is proposing a new  more transparent process for establishing Dir=descending PFS payment rates that will allow for more public input prior to finalizing rates.  Under the new process, payment changes will go through notice and comment rulemaking before being adopted beginning for 2016  In addition, CMS is proposing changes to several quality reporting initiatives, changes to the Physician Compare Website and to continue phasing in of the Value Based Payment Modifier.  For more on the proposed rule, see the CMS Fact Sheet on the Rule

Under its 2015 Proposed Rule for the HOPPS and ASC payment systems, CMS is proposing to move forward with its comprehensive APC policy which was delayed until 2015, to begin collecting data on off-campus provider-based departments by requiring use of a modifier for these services, and to modify quality measures used for reporting in the ASC and outpatient settings . For more, see the CMS Fact Sheet on the Rule.

CMS Announces Release of Unprecedented Public Access to Data (4/8/2014)
Recently, the Centers for Medicare & Medicaid Services (CMS) stated it would allow public access to physicians’ Medicare Part B 2012 data, including access to the number and type of health care services, number of unique beneficiaries, average submitted charges, and average amount of money paid by Medicare for those services. While the Academy, along with other specialties, support the concept of transparency related to data, we cautioned that providers should have the opportunity to review their data prior to be in becoming public.  

Coding Update:  New CMS G-Code/Modifier Requirements for Therapy Services (3/13/2014)
Last year, CMS finalized several key changes to reporting requirements regarding therapy services. Specifically, CMS implemented a claims-based data collection strategy to collect data on patient function, which impacts key services provided by Otolaryngologists. CMS defines “therapists” as all practitioners who furnish outpatient therapy services. Under this policy, claims for therapy services must now include non-payable G-codes and modifiers, which will allow the agency to capture data on the beneficiary’s functional limitations at various points during the provision of therapy. For therapy services being furnished that are not intended to treat a functional limitation, the therapist should use the G-code for “other” and the modifier representing zero.  For a full summary of the issue, click here.