RCM eNews – December 2022

CMS has announced a change to the incident-to billing guidelines for behavioral health services to address the need for improved access to these services in the 2023 Medicare Physician Fee Schedule Final Rule. This rule creates an exception to the direct supervision requirement of incident-to billing to allow for general supervision for these services.

This will eliminate the need for a physician or NPP to be on site, while still allowing certain mental health providers to be reimbursed at 100% of the fee schedule if they have a provider available to provide general supervision.

The final rule states: CMS has finalized the proposal to add an exception to the direct supervision requirement under the “incident to” regulation at 42 CFR 410.26 to allow behavioral health services to be provided under the general supervision of a physician or non-physician practitioner (NPP), rather than under direct supervision, when these services or supplies are furnished by auxiliary personnel, such as Licensed Professional Counselors (LPCs) and Licensed Marriage and Family Therapists( LMFTs), incident to the services of a physician (or NPP). CMS is also clarifying that any service furnished primarily for the diagnosis and treatment of a mental health or substance use disorder can be furnished by auxiliary personnel under the general supervision of a physician or NPP who is authorized to furnish and bill for services provided incident to their own professional services.

CMS believes that this change will facilitate access and extend the reach of behavioral health services. Finally, CMS indicated in the final rule that we intend to address payment for new codes that describe caregiver behavioral management training in CY 2024 rulemaking.

As a reminder, incident-to services are services performed in a non-facility setting by non-physician practitioners. All other specialties will still follow the direct supervision requirement of incident-to billing.

CMS has finalized their policy for split/shared services in 2023 to determine which professional should bill for a shared service by defining the “substantive portion” as more than half of the total time.

Therefore, for CY 2023, as in CY 2022, the substantive portion of a visit is comprised of any of the following elements:

As finalized, clinicians who furnish split (or shared) visits will continue to have a choice of history, or physical exam, or medical decision making, or more than half of the total practitioner time spent to define the “substantive portion” instead of using total time to determine the substantive portion, until CY 2024.

Driven by the pressing need to reduce healthcare’s excessive administrative costs and the rapid expansion of digital solutions amid the pandemic, major payers are accelerating the transition toward electronic payments for provider reimbursement.

UnitedHealthcare, the nation’s largest health insurance company with 49.5 million covered lives, last year began phasing out paper checks and accompanying provider remittance advices (PRA) for medical payments to more than 1.3 million network physicians and care professionals.
Aetna—the third largest carrier with 39 million covered lives— similarly announced in September 2021 that it would begin transitioning to an all-electronic payment and remittance process for participating and non-participating providers by September 2022.

Click here to read more.

Certificates of Medical Necessity and DME Information forms are no longer required after January 1, 2023. Electronic and paper claims that include these forms will be rejected for dates of service January 1, 2023, and after. Electronic and paper claims will still require these forms for dates of service prior to January 1, 2023.

Effective February 1, 2023, Excellus will require preventive vaccines to be billed through the TransactRx billing tool when Medicare Part D vaccines are administered in your office to Medicare Advantage members.

TransactRx is an independent company that offers a free, real time, and efficient online tool for providers to bill Part D vaccine claims administered in the office. The tool also allows providers to determine:

Vaccines for preventive purposes are required to be billed to Part D through TransactRx effective February 1, 2023. These vaccines include, but are not limited to:

Failure to submit claims for Medicare Part D vaccines through TransactRx with dates of service on or after February 1, 2023, will result in a denial and the provider will be held liable. Members cannot be billed for the vaccine.

Enroll with TransactRx prior to February 1 to avoid any interruption in reimbursement. Visit the TransactRx website to learn more, enroll, or to register for a TransactRx demonstration free of charge.

If you opt not to use the tool, it is recommended that you direct the Medicare Advantage members to obtain Part D vaccines at their local in-network pharmacy.

Integrated Benefits for Duals (IB-DUAL) is a Medicaid Managed Care Program designed for individuals who are eligible for both Medicare and Medicaid. It provides a more complete set of benefits and services for dual-eligible beneficiaries not in need of long-term services and supports.

Medicaid Advantage Plus (MAP) is a Medicaid Managed Care Program designed for individuals who are eligible for both Medicare and Medicaid but who require more than 120 days of community-based long-term care services.

IB-DUAL and MAP allow dual-eligible beneficiaries who meet criteria to enroll in the same health plan for most of their Medicare and Medicaid benefits. Enrollment is voluntary.

Providers currently participating in the Excellus Medicaid Managed Care line of business will be considered in-network for IB-DUAL and MAP.

Medicare Interactive published a helpful factsheet outlining Medicaid Advantage Plus plans, with information regarding eligibility, care coordination, costs, enrollment, and helpful questions to ask.

A Medicaid Advantage Plus (MAP) plan is a type of integrated Dual-eligible Special Needs Plan (D-SNP) combined with a type of Medicaid managed long-term care (MLTC) plan offered through the same insurance company. MAP plans are offered in certain New York State counties and provide managed care if you are eligible for (and enrolled in) Medicare and Medicaid (dually eligible) and in need of a certain amount of long-term care.

In MAP, one private plan administers your Medicare, Medicaid, long-term care benefits, and drug coverage. MAP plans cover doctor office visits, hospital stays, Part D benefits, home health aides, adult day health care, certain behavioral health care, dental care, and nursing home care. Some services not covered by MAP, including certain behavioral health services, may be covered under your traditional fee-for-service (FFS) Medicaid benefit.

Click here to read the factsheet.

National Government Services is always looking for ways to assist providers to get their claims processed and paid correctly the first time. Claim denials and rejects very often require the provider to submit an appeal of the denied/rejected claims. This can be time consuming and costly for you.

In reviewing their claim submission data along with appeals submissions, they have found a large volume of podiatry claims that were denied/rejected because the Local Coverage Determinations (LCD) was not applied on the claim submissions, as well as missing claim criteria (modifiers, class findings).

The NGS Provider Outreach Team will be conducting a webinar on Tuesday, December 13, 2022 from 10:00AM to 11:15AM (EST), on the LCDs and billing requirements to assist providers with submitting claims correctly the first time to get paid and avoid time consuming and costly appeals.

While the Medicare Program generally excludes routine foot care services from coverage, there are specific indications or exceptions under which there are Program benefits. Medicare payment may be made for routine foot care when the patient has a systemic disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk. During this webinar, they will review the LCD policy for Routine Foot Care and Debridement of Nails (L33636) and the related local coverage article (A57759).

Click here to register.

Starting November 20, 2022, the PEAR portal will have a new look. The web address (pearprovider.com) remains the same; however, the login process is changing.

You will see new screens when prompted to enter your existing PEAR username and password. Additionally, when you log in for the first time after this date, you will be required to answer three new security questions. These changes will help to further increase our site security.

Follow these steps when logging into PEAR on or after November 20, 2022:

If you need further assistance, access the PEAR Help Center, or contact PEAR Support at 1-833-444-PEAR (1-833-444-7327).

United Healthcare Community Plan considers any CPT and HCPCS codes that are not on a state Medicaid fee schedule as not covered for that state’s Medicaid market unless there are benefit and/or contractual agreements with negotiated rates.

Any CPT and HCPCS codes that are not on the CMS NPFS but are on the state fee schedule will be covered for that state’s Medicaid market. All covered services are subject to all UnitedHealthcare Community Plan Reimbursement Policies and, although they will not deny as not covered services, may deny based on another policy.

Any CPT and/or HCPCS codes that are not on the CMS NPFS, nor on an individual state fee schedule will deny as not covered in that state unless there are benefit and/or contractual agreements with negotiated rates. Any code that is not covered in any UnitedHealthcare Community Plan market will be on the UnitedHealthcare Community Plan Non-Covered Codes List.

For New York State, click here for the list of non-covered CPT/HCPCS codes. To read the entire policy and to view other states non-Covered code list, click here.

Beginning Feb 1, 2023, United Healthcare is requiring claim reconsiderations and post-service appeals to be submitted electronically.

This change affects most network health care professionals (primary and ancillary) and facilities that provide services to commercial and UnitedHealthcare® Medicare Advantage plan members. This does not affect pre-service clinical appeals.

UHC offers a 2-step process for claim denials: Step 1 is to file a claim reconsideration request, and Step 2 is to file an appeal if you disagree with the outcome of the claim reconsideration decision. The 2-step process allows for a total of 12 months for timely submission of both steps.

Later in 2023, more functions will move to a digital process including claim submission and claim attachments.

Click here for details on electronically submission options and click here for an interactive guide for claim follow-up.