Changes in Flu Shot Codes When Billing On/After January 1, 2011

by Mary Pat Whaley http://www.managemypractice.com/

CMS has created specific HCPCS codes and payment allowances to replace CPT code 90658 for Medicare billing purposes for the 2010-2011 influenza season. Note that these HCPCS codes will not be recognized by the Medicare claims processing systems until January 1, 2011, when CPT code 90658 will no longer be recognized.

• Q2035 (locally priced)
• Afluria vacc, 3 yrs & >, im
• Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Afluria)
• Q2036 ($7.439 national allowable)
• Flulaval vacc, 3 yrs & >, im
• Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Flulaval)
• Q2037 ($13.253 national allowable)
• Fluvirin vacc, 3 yrs & >,im
• Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluvirin)
• Q2038 ($12.593 national allowable)
• Fluzone vacc, 3 yrs & >, im
• Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Fluzone)
• Q2039 (locally priced)
• NOS flu vacc, 3 yrs & >, im
• Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (Not Otherwise Specified)

Other information:

• For dates of service between October 1, 2010 and December 31, 2010, the CPT 90658 and the Q-codes will be valid for billing; however, providers may not bill Medicare for both the CPT 90658 and any of the Q-codes for the same patient for the same date of service. Thus, if a provider vaccinates a beneficiary on any date between October 1, 2010 and December 31, 2010, the provider may either bill Medicare immediately using CPT 90658, or hold the claim and wait until January 1, 2011 to bill Medicare using the most appropriate Q-code. If a claim has already been submitted and processed using CPT 90658, then there is no need to use the Q-code for that same service. For dates of service on or after January 1, 2011, providers may only bill Medicare for one of the HCPCS codes that appropriately describes the specific vaccine product administered.
• For dates of service on or after September 1, 2010, the corrected Medicare Part B payment allowance for CPT 90655 is $14.858.
• Annual Part B deductible and coinsurance amounts do not apply to these vaccines. All physicians, non-physician practitioners and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine.
• Be aware that Medicare contractors will not search their files to adjust payment on claims paid incorrectly prior to implementing CR7324. However, they will adjust such claims that you bring to their attention.

For additional information on providing the flu shot, see my previous post here.

Physicians Have Something to Celebrate as the Medicare Cut is Delayed One Year and Physicians Are Exempt From the Red Flags Rules

by Mary Pat Whaley http://www.managemypractice.com/

Two milestone Acts were approved by Congress this week and both will be presented to President Obama for his signature shortly.

What he will be signing:

1. The “Medicare and Medicaid Extenders Act of 2010″ This legislation freezes Medicare physician payments at current rates through the end of 2011. The Act also includes funds for Medicare contractors to pay claims for physician services affected by provisions of the Patient Protection and Affordable Care Act passed last spring. The bill, estimated to cost $19.3 billion over 10 years, will be paid for by changing a provision of the health reform act that provides tax credits for people who buy coverage. President Obama released a statement saying: “It’s time for a permanent solution that seniors and their doctors can depend on and I look forward to working with Congress to address this matter once and for all in the coming year.

2. “Red Flag Program Clarification Act of 2010“ changes the Red Flags Rule’s definition of “creditor” and relieves doctors from complying with the Federal Trade Commission’s identity theft prevention law.

Related posts:

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2. Medicare Cuts Delayed Again, This Time Until June 1, 2010 UPDATE: On June 24, 2010 the House and Senate passed...

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**Congress approves Medicare physician payment fix**

**Special Update**

The House of Representatives passed legislation this morning that averts a 24.9 percent Medicare payment cut to physicians that was scheduled to take effect on Jan. 1. The measure passed the Senate Wednesday evening by unanimous consent. To pay for the legislation, the bill changes policy regarding overpayments of the healthcare affordability tax credit. President Obama supports the bill and is anticipated to sign it into law shortly.

Congress reacted to the thousands of phone calls and e-mails sent by MGMA members and took swift action. MGMA is pleased that Congress was able to stop the pending cut for a year to give lawmakers time to find a permanent solution.

The Benefits and Drawbacks of Managing a Private Practice vs. Managing a Hospital-Owned Practice

by Mary Pat Whaley http://www.managemypractice.com/

Ownership

Private practices are organized in a corporate model where the physicians are shareholders, or where one or more physicians own the practice and employ other physicians or providers. Private practices are almost exclusively for-profit. Physician practices are organized into corporations for the tax benefits as well as protecting the owners from liability judgments.

Hospitals can be for-profit, not-for-profit or government-owned. For-profit hospitals make up less than 20% of the total hospitals in the United States.

Financial Models

Private practice owners take a salary draw, split any receipts after all expenses are paid, and generally distribute receipts monthly or quarterly. This leaves very little at year end to be taxed through the corporation.

Hospitals that employ physicians typically guarantee a salary and offer an incentive plan where the physicians earn more for seeing more patients and/or being more productive based on work Relative Value Units (wRVUs). Hospitals may or may not use a practice expense and revenue model to measure the margin.

Benefits of Managing a Private Practice

1. You get to do everything, so if you like or want to learn about HR, marketing, finance, IT, contract negotiation, revenue cycle management, facility management, and lots of other stuff, you’ll get to do it in a private practice.

2. You are the top position in the practice, so you get to put your imprint on the practice. You can often be more creative.

3. Physicians can be very laid-back and practices can maintain a more relaxed, family-like atmosphere.

4. Decision-making can be straightforward and swift, so you can help your practice to be nimble in response to news events, trends and new ideas. If your practice decides to become a concierge practice or stop or start taking a particular payer, so be it!

5. You may find it easier to get a foot in the door and start your management career in a private practice as physicians don’t always hire managers using traditional means. A recommendation from another manager, a consultant or a physician may be enough to get you started.

Drawbacks of Managing a Private Practice

1. You report to the physicians who may not have business expertise and may fight you on your well-founded recommendations.

2. There is no internal career path – you’re at the top in the practice.

3. Physicians will make less money every time a new non-revenue generating position is added or any time equipment needs to be replaced – expect them to be generally slow to respond to capital expenditure needs, especially if they cannot see that any new revenue will come from the expense.

4. When physicians “eat what they kill”, taking home the dollars they personally earn less their expenses, they can be pitted against each other and have conflicting priorities.

5. Your practice could be purchased by a hospital and you could find yourself out of a job, or your job radically changed.

Benefits of Managing a Hospital-Owned Practice

1. You report to a management professional who should understand the business and be supportive of your well-founded recommendations.

2. You will receive support from other hospital departments: the Human Resources department will screen, orient and provide benefit support to your staff; the Information Systems department will provide and maintain your practice management system, EMR system and other hardware and software; and the Accounting department will pay the bills and write the payroll.

3. You may be able to climb the career ladder and manage multiple practices, or become the Vice President of Physician Practices, or the COO, CFO or CEO of the hospital.

4. You will get to interact with managers of other departments and broaden your hospital knowledge and understanding of the care continuum.

5. You can learn a lot from the process of preparing for and living through a JCAHO (a.k.a. “The Joint Commission”) visit.

Drawbacks of Managing a Hospital-Owned Practice

1. Hospitals use different terminology for charges, adjustments and receipts and work on the accrual system instead of the cash system, which most private practices use. It takes time to understand and distinguishes the terminology and process differences.

2. The entire system will be in a tizzy on a regular basis getting ready for a JCAHO (a.k.a. “The Joint Commission”) visit.

3. You can expect to have much less autonomy in a hospital system and there may be more red tape involved in getting even simple requests filled.

4. Hospital administration may find it difficult to relate to the perspective of the hourly staff and it could be frustrating to balance the needs of the staff and the needs of the organization.

5. Because the hospital is the big-dollar earner, the needs of the clinics may be second, third or fourth down the line in importance.

What do you see as the benefits or drawbacks of your private practice or hospital practice job?

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