The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS
The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS
BackgroundIn accordance with the Social Security Act (Section 1833(f) athttp://www.ssa.gov/OP_Home/ssact/title18/1833.htm on the Internet), the Centers for Medicare &Medicaid Services (CMS) is increasing the calendar year (CY) payment rates for Rural Health Clinics(RHCs) and Federally Qualified Health Centers (FQHCs) effective for services on or after January 3, 2011,through December 31, 2011 (i.e., CY 2011) as follows:• The Rural Health Clinic (RHC) upper payment limit per visit is increased from $77.76 to $77.99effective January 3, 2011, through December 31, 2011 (i.e., CY 2011). The 2011 rate reflects a 0.3percent increase over the 2010 payment limit in accordance with the rate of increase in the MedicareEconomic Index (MEI).• The Federally Qualified Health Center (FQHC) upper payment limit per visit for urban FQHCs isincreased from $125.72 to $126.10 effective January 3, 2011, through December 31, 2011 (i.e., CY 2011);and the maximum Medicare payment limit per visit for rural FQHCs is increased from $108.81 to$109.14 effective January 3, 2011, through December 31, 2011. The 2011 FQHC rates reflect a 0.3percent increase over the 2010 rates in accordance with the rate of increase in the MEI.Medicare contractors will not retroactively adjust individual RHC/FQHC bills paid at previous upperpayment limits. However, they have the discretion to make adjustments to the interim payment rate or alump sum adjustment to total payments already made to take into account any excess or deficiency inpayments to date.Additional InformationThe official instruction, CR 7101, issued to your FI or MAC regarding this change may be viewed athttp://www.cms.gov/Transmittals/downloads/R2063CP.pdf on the CMS Web site. If you have anyquestions, please contact your FI or MAC at their toll-free number, which may be found athttp://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.News Flash - It’s a Busy Time of Year. Make each office visit an opportunity to talk with your patientsabout the importance of getting the seasonal flu vaccination and a one-time pneumococcal vaccination.Remember, Medicare pays for these vaccinations for all beneficiaries with no co-pay or deductible. Theseasonal flu and invasive pneumococcal disease kill thousands of people in the United States each year,most of them 65 years of age or older. The Centers for Disease Control and Prevention (CDC) alsorecommends that health care workers and caregivers be vaccinated against the seasonal flu. Protect yourpatients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu. Remember – Influenzavaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part Dcovered drug. For information about Medicare’s coverage of the influenza vaccine and its administration,as well as related educational resources for health care professionals and their staff, please visithttp://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf andhttp://www.cms.gov/AdultImmunizations on the Centers for Medicare & Medicaid Services(CMS) Web site.DisclaimerThis article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links tostatutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of eitherthe written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statementof their contents.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 80 MMR 2011-01, January 2011
News Flash – A revised Medicare Learning Network® publication titled “Rural Health Clinic”(September 2010), which provides information about Rural Health Clinic (RHC) services, Medicarecertification as a RHC, RHC visits, RHC payments, cost reports, and annual reconciliation, is nowavailable in print format. To place your order, visit http://www.cms.gov/MLNGenInfo , scroll down to“Related Links Inside CMS” and select “MLN Product Ordering Page”.Centers for Medicare & Medicaid Services Articles for Part B ProvidersEnd-Stage Renal Disease Home Dialysis Monthly Capitation PaymentMLN Matters® Number: MM7003Related Change Request (CR) #: 7003Related CR Release Date: July 9, 2010Effective Date: January 1, 2011Related CR Transmittal #: R1999CPImplementation Date: January 3, 2011Provider Types AffectedThis article is for physicians and providers submitting claims to Medicare contractors (carriers and/or A/BMedicare administrative contractors [A/B MACs]) for home dialysis monthly capitation payment (MCP)services provided to Medicare ESRD beneficiaries.Provider Action NeededImpact to YouThis article is based on Change Request (CR) 7003 which instructs that, effective January 1, 2011, themonthly capitation payment (MCP) physician (or practitioner) must furnish at least one face-to-facepatient visit per month for the home dialysis MCP service as described by current procedure terminology(CPT) codes 90963, 90964, 90965, and 90966.What You Need to KnowPhysicians and practitioners managing Medicare beneficiaries with end-stage renal disease (ESRD) whodialyze at home are paid a single monthly rate based on the age of the beneficiary, and currently, theCenters for Medicare & Medicaid Services (CMS) does not require a frequency of required visits for thehome dialysis monthly capitation payment (MCP) service. CR 7003 instructs that, effective January 1,2011, the MCP physician (or practitioner) must furnish at least one face-to-face patient visit per month forthe home dialysis MCP service. In addition, documentation by the MCP physician (or practitioner)should support at least one face-to-face encounter per month with the home dialysis patient. However,Medicare contractors may waive the requirement for a monthly face-to-face visit for the home dialysisMCP service on a case by case basis; for example, when the nephrologist’s notes indicate that thephysician actively and adequately managed the care of the home dialysis patient throughout the month.The management of home dialysis patients who remain a home dialysis patient the entire month shouldbe coded using the ESRD-related services for home dialysis patients Healthcare Common ProcedureCoding System (HCPCS) codes.What You Need to DoSee the Background and Additional Information Sections of this article for further details regarding thesechanges.CPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 81 MMR 2011-01, January 2011
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News Flash – A revised <strong>Medicare</strong> Learning Network® publication titled “Rural Health Clinic”(September 2<strong>01</strong>0), which provides information about Rural Health Clinic (RHC) services, <strong>Medicare</strong>certification as a RHC, RHC visits, RHC payments, cost reports, and annual reconciliation, is nowavailable in print format. To place your order, visit http://www.cms.gov/MLNGenInfo , scroll down to“Related Links Inside CMS” and select “MLN Product Ordering Page”.Centers for <strong>Medicare</strong> & Medicaid Services Articles for Part B ProvidersEnd-Stage Renal Disease Home Dialysis <strong>Monthly</strong> Capitation PaymentMLN Matters® Number: MM7003Related Change Request (CR) #: 7003Related CR Release Date: July 9, 2<strong>01</strong>0Effective Date: <strong>January</strong> 1, <strong>2<strong>01</strong>1</strong>Related CR Transmittal #: R1999CPImplementation Date: <strong>January</strong> 3, <strong>2<strong>01</strong>1</strong>Provider Types AffectedThis article is for physicians and providers submitting claims to <strong>Medicare</strong> contractors (carriers and/or A/B<strong>Medicare</strong> administrative contractors [A/B MACs]) for home dialysis monthly capitation payment (MCP)services provided to <strong>Medicare</strong> ESRD beneficiaries.Provider Action NeededImpact to YouThis article is based on Change Request (CR) 7003 which instructs that, effective <strong>January</strong> 1, <strong>2<strong>01</strong>1</strong>, themonthly capitation payment (MCP) physician (or practitioner) must furnish at least one face-to-facepatient visit per month for the home dialysis MCP service as described by current procedure terminology(CPT) codes 90963, 90964, 90965, and 90966.What You Need to KnowPhysicians and practitioners managing <strong>Medicare</strong> beneficiaries with end-stage renal disease (ESRD) whodialyze at home are paid a single monthly rate based on the age of the beneficiary, and currently, theCenters for <strong>Medicare</strong> & Medicaid Services (CMS) does not require a frequency of required visits for thehome dialysis monthly capitation payment (MCP) service. CR 7003 instructs that, effective <strong>January</strong> 1,<strong>2<strong>01</strong>1</strong>, the MCP physician (or practitioner) must furnish at least one face-to-face patient visit per month forthe home dialysis MCP service. In addition, documentation by the MCP physician (or practitioner)should support at least one face-to-face encounter per month with the home dialysis patient. However,<strong>Medicare</strong> contractors may waive the requirement for a monthly face-to-face visit for the home dialysisMCP service on a case by case basis; for example, when the nephrologist’s notes indicate that thephysician actively and adequately managed the care of the home dialysis patient throughout the month.<strong>The</strong> management of home dialysis patients who remain a home dialysis patient the entire month shouldbe coded using the ESRD-related services for home dialysis patients Healthcare Common ProcedureCoding System (HCPCS) codes.What You Need to DoSee the Background and Additional Information Sections of this article for further details regarding thesechanges.CPT codes and descriptors are only copyright 2<strong>01</strong>0 American Medical Association (or such other date publication of CPT)<strong>The</strong> <strong>Medicare</strong> <strong>Monthly</strong> <strong>Review</strong> 81 <strong>MMR</strong> <strong>2<strong>01</strong>1</strong>-<strong>01</strong>, <strong>January</strong> <strong>2<strong>01</strong>1</strong>
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