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How is the Therapy Progress Report different than the Treatment Encounter Note and what information should ...
- The Progress Report provides justification for the medical necessity of treatment. For Medicare payment purposes, inform... (more)
- The Progress Report provides justification for the medical necessity of treatment. For Medicare payment purposes, information required in Progress Reports should be provided at least once every 10 treatment days, or once during the treatment interval of 1 month or 30 calendar days, whichever is less. Objective measures of progress should be included when available. A treatment note justifies the billing for each treatment day. See FAQ ID#7102. It may also (at the clinician’s option) include information required for the Progress Report. Note: Documentation requirements apply to all outpatient therapy services regardless of therapy caps.
If the Treatment Notes completed during the Progress Report period are have sufficient information to fulfill the requirements of the Progress Report, that information does not have to be re-written into a Progress Report at the end of the reporting period.
(FAQ2003)
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What is Revalidation?
- Revalidation is the process by which CMS or its contractor requires a provider or supplier to certify the accuracy of th... (more)
- Revalidation is the process by which CMS or its contractor requires a provider or supplier to certify the accuracy of their existing enrollment information with Medicare.
(FAQ2081)
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How do I obtain the Correct Coding Initiative (CCI) Edits Manual?
- The Correct Coding Initiative (CCI) Edits Manual may be obtained in two ways. The first is through the CMS website at ... (more)
- The Correct Coding Initiative (CCI) Edits Manual may be obtained in two ways. The first is through the CMS website at http://www.cms.hhs.gov/NationalCorrectCodInitEd/. The CMS website contains a listing of the CCI edits, by specific CPT sections, and is available free for downloading to the public.
Secondly, the CCI Edits Manual may be obtained by purchasing the manual, or sections of the manual, from the National Technical Information Service (NTIS) website at http://www.ntis.gov/products/families/cci/, or by contacting NTIS at 1-800-363-2068 or 703-605-6060. You may purchase an electronic version of the CCI Edits Manual from NTIS. Please contact NTIS for further information on the electronic version of the CCI edits. (FAQ1877)
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What does the physician referral law prohibit?
- The physician referral law (section 1877 of the Social Security Act) prohibits a physician from referring patients to an... (more)
- The physician referral law (section 1877 of the Social Security Act) prohibits a physician from referring patients to an entity for a designated health service (DHS), if the physician or a member of his or her immediate family has a financial relationship with the entity, unless an exception applies. (The exceptions are specified in 42 CFR Part 411, Subpart J.) The law also prohibits an entity from presenting a claim to Medicare or to any person or other entity for DHS provided under a prohibited referral. No Medicare payment may be made for DHS rendered as a result of a prohibited referral, and an entity must timely refund any amounts collected for DHS performed under a prohibited referral. Civil money penalties and other remedies may also apply under some circumstances. Additional information is available at www.cms.hhs.gov/PhysicianSelfReferral/01_overview.asp#TopOfPage
(FAQ1803)
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[EHR Incentive Programs] How and when will incentive payments for the Medicare Electronic Health Record (EH...
- For eligible professionals (EPs), incentive payments for the Medicare EHR Incentive Program will be made approximatel... (more)
For eligible professionals (EPs), incentive payments for the Medicare EHR Incentive Program will be made approximately four to eight weeks after an EP successfully attests that they have demonstrated meaningful use of certified EHR technology. However, EPs will not receive incentive payments within that timeframe if they have not yet met the threshold for allowed charges for covered professional services furnished by the EP during the year. Payments will be held until the EP meets the threshold in allowed charges for the calendar year ($24,000 in the EP's first year) in order to maximize the amount of the EHR incentive payment they receive. Medicare EHR incentive payments are based on 75% of the estimated allowed charges for covered professional services furnished by the EP during the entire calendar year. If the EP has not met the threshold in allowed charges by the end of calendar year, CMS expects to issue an incentive payment for the EP in March of the following year (allowing two months after the end of the calendar year for all pending claims to be processed).
Payments to Medicare EPs will be made to the taxpayer identification number (TIN) selected at the time of registration, through the same channels their claims payments are made. The form of payment (electronic funds transfer or check) will be the same as claims payments.
Bonus payments for EPs who practice predominantly in a geographic Health Professional Shortage Area (HPSA) will be made as separate lump-sum payments no later than the end of the calendar year following the year in which the EP was eligible for the bonus payment.
Medicare EHR incentive payments to eligible hospitals and critical access hospitals (CAHs) will also be made approximately four to eight weeks after the eligible hospital or CAH successfully attests to having demonstrated meaningful use of certified EHR technology. Eligible hospitals and CAHs will receive an initial payment and a final payment. Final payment will be determined at the time of settling the hospital cost report. CAHs will be paid after they submit their reasonable cost data to their Medicare Administrative Contractor (MAC).
Please note that the Medicaid incentives will be paid by the States, but the timing will vary according to State. Please contact your State Medicaid Agency for more details about payment.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10160
(FAQ2899)
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How can a health care provider apply for and obtain a National Provider Identifier (NPI)?
- A health care provider may apply for an NPI in one of three ways:
1. Apply through a web-based application ... (more)
- A health care provider may apply for an NPI in one of three ways:
1. Apply through a web-based application process. The web address to the National Plan and Provider Enumeration System (NPPES) is https://nppes.cms.hhs.gov.
2. If requested, give permission to have an Electronic File Interchange Organization (EFIO) submit the application data on behalf of the health care provider (i.e., through a bulk enumeration process). If a health care provider agrees to permit an EFIO to apply for the NPI, the EFIO will provide instructions regarding the information that is required to complete the process.
3. Fill out and mail a paper application form to the NPI Enumerator. Health care providers may wish to obtain a copy of the paper NPI Application/Update Form (CMS-10114) and mail the completed, signed application to the NPI Enumerator located in Fargo, ND, whereby staff at the NPI Enumerator will enter the application data into NPPES. This form is now available for download from the CMS website (http://www.cms.gov/cmsforms/downloads/CMS10114.pdf) or by request from the NPI Enumerator. Health care providers who wish to obtain a copy of this form from the NPI Enumerator may do so in any of these ways:
Phone: 1-800-465-3203 or TTY 1-800-692-2326
E-mail: customerservice@npienumerator.com
Mail:
NPI Enumerator
P.O. Box 6059
Fargo, ND 58108-6059
(FAQ1855)
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What is CMS?
- The Centers for Medicare & Medicaid Services (CMS) is a branch of the U.S. Department of Health and Human Services. ... (more)
- The Centers for Medicare & Medicaid Services (CMS) is a branch of the U.S. Department of Health and Human Services. CMS is the federal agency which administers Medicare, Medicaid, and the Children's Health Insurance Program. Provides information for health professionals, regional governments, and consumers. Additional information regarding CMS and it’s programs is available at http://www.cms.hhs.gov/.
(FAQ1779)
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What are Therapy Caps?
- Therapy caps are congressionally-mandated financial limitations on outpatient occupational therapy, physical therapy, an... (more)
- Therapy caps are congressionally-mandated financial limitations on outpatient occupational therapy, physical therapy, and speech-language pathology services, except for those services provided in the hospital outpatient setting. Financial limitations of therapy services (therapy caps) were initiated in 4541(c) of the Balanced Budget Act (BBA) of 1997 and were implemented in 1999 and for a short time in 2003. Congress placed moratoria on the limits for 2004 and 2005. The moratoria have expired and, effective January 1, 2006, therapy caps were again in effect. The Tax Relief and Healthcare Act of 2006 has extended the exceptions process (implemented by The Deficit Reduction Act for calendar year 2006) to allow medically necessary services above the cap to be paid for by Medicare during calendar year 2007, and has been extended at least through June, 2008. The transmittals that explain therapy caps and exceptions are part of the following Medicare manuals located at http://www.cms.hhs.gov/Manuals/IOM/list.asp:
Pub. 100-02, chapter 15, section 220 and 230,
Pub. 100-04, chapter 5, section 10.2, and
Pub. 100-08, Chapter 3, chapter 13, section 13.5.1.
For further details see FAQ ID#7070. How do caps apply to outpatient therapy? For the transmittals related to the change request 5478, containing the policies changed for 2007, see the following: http://www.cms.hhs.gov/transmittals/downloads/R63BP.pdf http://www.cms.hhs.gov/transmittals/downloads/R181PI.pdf
http://www.cms.hhs.gov/transmittals/downloads/R1145CP.pdf
You can also call your Medicare contractor at their toll free numbers, which are available at http://www.cms.hhs.gov/apps/contacts/ (FAQ2001)
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When are providers and suppliers required to revalidate?
- Providers and suppliers, including physicians, are required to revalidate their information every five years, while cert... (more)
- Providers and suppliers, including physicians, are required to revalidate their information every five years, while certain suppliers, including physicians who furnish durable medical equipment (DME), are required to revalidate their information every three years. CMS is currently undertaking an "off-cycle" revalidation process now for all providers, meaning a revalidation request could happen sooner than five years.
Providers and suppliers should take action to revalidate their enrolment when requested to do so by their Medicare Administrative Contractor. (FAQ3687)
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How do physicians join or leave a group?
- If both the physician and the group are already enrolled with the same carrier, the physician and the group together are... (more)
- If both the physician and the group are already enrolled with the same carrier, the physician and the group together are required to complete a CMS 855R showing the date the physician joined the group and reassigned benefits to the group. If a physician leaves a group, the physician or the group should complete the CMS 855R, showing the date the physician left the group. When leaving the group, the CMS 855R does not need to be signed by both the physician and the group.
If either the physician or the group have not enrolled with the carrier, they must first complete the appropriate CMS 855 for either an individual (CMS 855I) or group (CMS 855B) before the reassignment can be effective.
(FAQ1983)
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Why do I have to pay a Medicare enrollment application fee?
- Section 6401(a) of the Affordable Care Act (ACA) requires the Secretary to impose a fee on each "institutional provid... (more)
Section 6401(a) of the Affordable Care Act (ACA) requires the Secretary to impose a fee on each "institutional provider of medical or other items or services and suppliers." The fee is to be used by the Secretary to cover the cost of program integrity efforts including the cost of screening associated with provider enrollment processes, including those under section 1866(j) and section 1128J of the Social Security Act. The application fee is currently $505 for CY2011; however, based upon provisions of the ACA this fee will vary from year-to-year based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CPI-U). The application fee for CY 2012 is $523. The application fee for CY 2013 is $532. The application fee is to be imposed on institutional providers that are newly-enrolling, re-enrolling/re-validating, or adding a new practice location - for applications received on and after March 25, 2011.
CMS has defined "institutional provider" to mean any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS-855S or associated Internet-based PECOS enrollment application.
(FAQ3131)
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[EHR Incentive Programs] When eligible professionals work at more than one clinical site of practice, are t...
- CMS considers these two separate, but related issues.Meaningful use: Any eligible professional demonstrating mean... (more)
CMS considers these two separate, but related issues. Meaningful use: Any eligible professional demonstrating meaningful use must have at least 50% of their of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology capable of meeting all of the meaningful use objectives. Therefore, States should collect information on meaningful users' practice locations in order to validate this requirement in an audit.
Patient volume: Eligible professionals may choose one (or more) clinical sites of practice in order to calculate their patient volume. This calculation does not need to be across all of an eligible professional's sites of practice. However, at least one of the locations where the eligible professional is adopting or meaningfully using certified EHR technology should be included in the patient volume. In other words, if an eligible professional practices in two locations, one with certified EHR technology and one without, the eligible professional should include the patient volume at least at the site that includes the certified EHR technology. When making an individual patient volume calculation (i.e., not using the group/clinic proxy option), a professional may calculate across all practice sites, or just at the one site. For more information on applying the group/clinic proxy option, see FAQ #10362 or click here.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10416 (FAQ3015)
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What simple steps can I take to submit Physician Quality Reporting System (PQRI) quality measures data on c...
- Take the following steps to begin claims-based reporting for Physician Quality Reporting: 1). Use the measure specificat... (more)
- Take the following steps to begin claims-based reporting for Physician Quality Reporting: 1). Use the measure specifications to identify measures applicable for professional services you routinely provide. 2). Select those measures that make sense based upon prevalence and volume in your practice as well as your individual or practice performance analysis and improvement priorities. 3). Review the measures that you have selected to become familiar with how to apply and correctly code the measures. 4). Refer to the Physician Quality Reporting System Implementation Guide for more detailed information and reporting tips at http://www.cms.gov/PQRS/15_MeasuresCodes.asp. 5). Access data collection worksheets on the American Medical Association's (AMA) website (http://www.ama-assn.org/ama) to help you implement Physician Quality Reporting in your practice. 6) Ensure that your billing software and clearinghouse can correctly submit Physician Quality Reporting quality-data codes (QDCs) on your behalf to the carrier. 7) Regularly review the Remittance Advice Notice you receive from the Carrier/Medicare Administrative Contractor (MAC) to ensure the denial remark code N365 is listed for each QDC submitted.
Reference: http://www.cms.gov/PQRS/30_EducationalResources.asp (FAQ2235)
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I recently hired a new office manager. In addition, we will be moving next week. Should I submit that infor...
- There have been no changes to Medicare enrollment update filing timelines. Providers and suppliers should continue to su... (more)
- There have been no changes to Medicare enrollment update filing timelines. Providers and suppliers should continue to submit routine changes-address updates, reassignments, additions to practices, changes in authorized officials, information updates and similar changes to their office or group practices-- as they always have done and in a timely manner. Providers and suppliers may continue to submit changes like address changes to Medicare no sooner than 30 days from when they expect to start billing at a new location. If the provider also receives a request for revalidation from the Medicare Administrative Contractor (MAC), the provider should separately respond to that request. If the provider or supplier has any questions about the need to complete the revalidation application, the provider or supplier should contact their Medicare Administrative Contractor (MAC).
(FAQ3765)
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Who is the Administrator and what is the mailing address?
- For the latest information, please visit:
... (more)
- For the latest information, please visit:
http://www.cms.hhs.gov/CMSLeadership/08_Office_OA.asp (FAQ1781)
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What is the mutually exclusive edit table?
- The mutually exclusive edit table contains edits consisting of two codes (procedures) which cannot reasonably be perform... (more)
- The mutually exclusive edit table contains edits consisting of two codes (procedures) which cannot reasonably be performed together based on the code definitions or anatomic considerations. Each edit consists of a column 1 and column 2 code. If the two codes of an edit are billed by the same provider for the same beneficiary for the same date of service without an appropriate modifier, the column 1 code is paid. If clinical circumstances justify appending a CCI-associated modifier to the column 2 code of a code pair edit, payment of both codes may be allowed (see section entitled "CCI Modifiers").
(FAQ1887)
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[EHR Incentive Programs] For the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, i...
- In most cases, an eligible professional or eligible hospital is not limited to demonstrating meaningful use to the ex... (more)
In most cases, an eligible professional or eligible hospital is not limited to demonstrating meaningful use to the exact way in which the Complete EHR or EHR Module was tested and certified. As long as an eligible professional or eligible hospital uses the certified Complete EHR or certified EHR Module's capabilities and, where applicable, the associated standard(s) and implementation specifications that correlate with the respective meaningful use objective and measure, they can successfully demonstrate meaningful use even if their exact method differs from the way in which the Complete EHR or EHR Module was tested and certified.
It is important to remember the purpose of certification. Certification is intended to provide assurance that a Complete EHR or EHR Module will properly perform a capability or capabilities according to the adopted certification criterion or criteria to which it was tested and certified (and according to the applicable adopted standard(s) and implementation specifications, if any). The Temporary Certification Program and Permanent Certification Program Final Rules (75 FR 36188 and 76 FR 1301, respectively), published by the Office of the National Coordinator for Health IT (ONC), acknowledged that eligible professionals and eligible hospitals could, where appropriate, modify their certified Complete EHR or certified EHR Module to meet local health care delivery needs and to take full advantage of the capabilities that the certified Complete EHR or certified EHR Module includes.
These rules also cautioned that modifications made to a Complete EHR or EHR Module post-certification have the potential to adversely affect the technology's capabilities such that it no longer performs as it did when it was tested and certified, which could ultimately compromise an eligible professional or eligible hospital's ability to successfully demonstrate meaningful use.
In instances where a certification criterion expresses a capability which could potentially be added to or enhanced by an eligible professional or eligible hospital, the way in which EHR technology was tested and certified generally would not limit a provider's ability to modify the EHR technology in an effort to maximize the utility of that capability. Examples of this could include adding clinical decision support rules, adjusting or adding drug-drug notifications, or generating patient lists or patient reminders based on additional data elements beyond those that were initially required for certification. Modifications that adversely affect the EHR technology's capability to perform in accordance with the relevant certification criterion could, however, ultimately compromise an eligible professional or eligible hospital's ability to successfully demonstrate meaningful use.
In instances where the EHR technology was tested and certified using a sample workflow and/or generic forms/templates, an eligible professional or eligible hospital generally is not limited to using that sample workflow and/or those generic forms/templates. In this context, the "workflow" would constitute the specific steps, methods, processes, or tasks an eligible professional or eligible hospital would follow when using one or more capabilities of the certified Complete EHR or certified EHR Module to meet meaningful use objectives and associated measures. An eligible health care provider could use a different workflow and/or substitute different forms/templates for those that are included in the certified Compete EHR or certified EHR Module. Again, care should be taken to ensure that such actions do not adversely affect the Complete EHR's or EHR Module's performance of the capabilities for which it was tested and certified, which could ultimately compromise an eligible professional or eligible hospital's ability to successfully demonstrate meaningful use.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10473 (FAQ3073)
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[EHR Incentive Programs] Who can enter medication orders in order to meet the measure for the computerized ...
- Any licensed healthcare professional can enter orders into the medical record for purposes of including the order in the... (more)
- Any licensed healthcare professional can enter orders into the medical record for purposes of including the order in the numerator for the measure of the CPOE objective if they can enter the order per state, local, and professional guidelines. The order must be entered by someone who could exercise clinical judgment in the case that the entry generates any alerts about possible interactions or other clinical decision support aides. This necessitates that CPOE occurs when the order first becomes part of the patient's medical record and before any action can be taken on the order. Each provider will have to evaluate on a case-by-case basis whether a given situation is entered according to state, local, and professional guidelines, allows for clinical judgment before the medication is given, and is the first time the order becomes part of the patient's medical record.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10134 (FAQ2851)
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[EHR Incentive Programs] What do the numerators and denominators mean in measures that are required to demo...
- There are 15 measures for EPs and 14 measures for eligible hospitals that require the collection of data to calculate a ... (more)
- There are 15 measures for EPs and 14 measures for eligible hospitals that require the collection of data to calculate a percentage, which will be the basis for determining if the Meaningful Use objective was met according to a minimum threshold for that objective.
Objectives requiring a numerator and denominator to generate this calculation are divided into two groups: one where the denominator is based on patients seen or admitted during the EHR reporting period, regardless of whether their records are maintained using certified EHR technology; and a second group where the objective is not relevant to all patients either due to limitations (e.g., recording tobacco use for all patients 13 and older) or because the action related to the objective is not relevant (e.g., transmitting prescriptions electronically). For these objectives, the denominator is based on actions related to patients whose records are maintained using certified EHR technology. This grouping is designed to reduce the burden on providers. Table 3 in the Medicare and Medicaid EHR Incentive programs final rule (FR 75 44376 - 44380) lists measures sorted by the method of measure calculation. To view the final rule, please visit: http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10095 (FAQ2813)
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What hard-copy documentation must accompany the revalidation enrollment application?
- The documents that must accompany the 855 enrollment application or the internet based PECOS application form are specif... (more)
- The documents that must accompany the 855 enrollment application or the internet based PECOS application form are specified within each application and may vary based on your provider or supplier type. However, for purposes of revalidation effort, CMS is moving away from requiring providers and suppliers to submit paperwork that has previously been submitted to the Medicare contractors if the information has not changed. For example a number of have previously submitted the CP-575 form. If nothing on this form has changed since it was last submitted to the Medicare contractor, the provider or supplier need not submit this information again with the revalidation application. However, if you are requested to do so by the Medicare contractor you should comply with that request. The contractor has the right to later ask for any information required, including previously submitted documents as needed to process the revalidation request.
(FAQ3693)
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[EHR Incentive Programs] In order to receive payments under the Medicare and Medicaid Electronic Health Rec...
- In order to receive Medicare EHR incentive payments, EPs, eligible hospitals, and critical access hospitals must have... (more)
In order to receive Medicare EHR incentive payments, EPs, eligible hospitals, and critical access hospitals must have an enrollment record in PECOS with an APPROVED status. Medicaid EPs do not have to be in PECOS. It is possible to receive payment for Medicare claims and not be in approved status. We encourage all providers to verify their status as soon as possible.
There are three ways to verify that you have an enrollment record in PECOS:
1. Check the Ordering Referring Report on the CMS website. If you are on that report, you have a current enrollment record in PECOS. Go to http://www.cms.gov/MedicareProviderSupEnroll/, click on "Ordering Referring Report" on the left.
2. Use Internet-based PECOS to look for your PECOS enrollment record. If no record is displayed, you do not have an enrollment record in PECOS. Go to http://www.cms.gov/MedicareProviderSupEnroll/, click on "Internet-based PECOS" on the left.
3. Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in PECOS. Go to http://www.cms.gov/MedicareProviderSupEnroll/, click on "Medicare Fee-For-Service Contact Information" under "Downloads."
If you are not in PECOS, the best way to submit your application is through internet-based PECOS. For more information go to: http://questions.cms.hhs.gov/app/answers/detail/a_id/10038/kw/pecos/session/L3NpZC9qeG1GdDliaw%3D%3D
Indian Health Service (IHS) providers who submit a paper CMS-855 will have their enrollment information entered into PECOS.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10154 (FAQ2887)
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What is an IRS Form CP 575?
- The IRS Form CP 575 is an Internal Revenue Service generated letter you receive from the IRS granting your Employer Iden... (more)
- The IRS Form CP 575 is an Internal Revenue Service generated letter you receive from the IRS granting your Employer Identification Number (EIN). A copy of your CP 575 may be required by the Medicare contractor to verify the provider or supplier’s legal business name and EIN.
(FAQ2009)
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[EHR Incentive Program] I am an eligible professional (EP) who has successfully attested for the Medicare E...
- For EPs, incentive payments for the Medicare EHR Incentive Program will be made approximately four to eight weeks aft... (more)
For EPs, incentive payments for the Medicare EHR Incentive Program will be made approximately four to eight weeks after an EP successfully attests that they have demonstrated meaningful use of certified EHR technology. However, EPs will not receive incentive payments within that timeframe if they have not yet met the threshold for allowed charges for covered professional services furnished by the EP during the year.
The Medicare EHR incentive payments to EPs are based on 75% of the estimated allowed charges for covered professional services furnished by the EP during the entire payment year. Therefore, to receive the maximum incentive payment of $18,000 for the first year of participation in 2011 or 2012, the EP must accumulate $24,000 in allowed charges. If the EP has not met the $24,000 threshold in allowed charges at the time of attestation, CMS will hold the incentive payment until l the EP meets the $24,000 threshold in order to maximize the amount of the EHR incentive payment the EP receives. If the EP still has not met the $24,000 threshold in allowed charges by the end of calendar year, CMS expects to issue an incentive payment for the EP in March 2012 (allowing 60 days after the end of the 2011 calendar year for all pending claims to be processed).
Payments to Medicare EPs will be made to the taxpayer identification number (TIN) selected at the time of registration, through the same channels their claims payments are made. The form of payment (electronic funds transfer or check) will be the same as claims payments.
Bonus payments for EPs who practice predominantly in a geographic Health Professional Shortage Area (HPSA) will be made as separate lump-sum payments no later than the end of the calendar year following the year in which the EP was eligible for the bonus payment.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10692 (FAQ3361)
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How do you make changes to the provider enrollment information on file with your fee-for-service contractor?
- Providers and suppliers should report changes using the applicable provider enrollment application (CMS-855) for your pr... (more)
- Providers and suppliers should report changes using the applicable provider enrollment application (CMS-855) for your provider/supplier type and/or submit an electronic application using Internet-Based PECOS.
Reference: http://www.cms.gov/MedicareProviderSupEnroll (FAQ1905)
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Who is affected by the transition to ICD-10? If I don't deal with Medicare claims, will I have to transition?
- Everyone covered by the Health Insurance Portability and Accountability Act (HIPAA) must transition to ICD-10. &nbs... (more)
- Everyone covered by the Health Insurance Portability and Accountability Act (HIPAA) must transition to ICD-10. This includes providers and payers who do not deal with Medicare claims.
(FAQ3407)
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If I am joining a Group, will I need to submit the Group’s National Provider Identifier (NPI) in section 4B...
- In Section 4B of the CMS-855I, the NPI of the Group should be entered if it has been issued to the Group. If you are jo... (more)
- In Section 4B of the CMS-855I, the NPI of the Group should be entered if it has been issued to the Group. If you are joining a group, the group is responsible for providing you with their current Provider Identification Number (PIN) and the NPI, if they have been issued.
(FAQ2011)
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What are the hours and contact information for the HETS Help Desk?
- The operational hours for the MCARE Help Desk have changed.
Effective February 1, 2012 the Help Desk ... (more)
- The operational hours for the MCARE Help Desk have changed.
Effective February 1, 2012 the Help Desk will be open from 7:00 AM - 7:00 PM ET Monday - Friday (with the exception of selected holidays).
HETS submitters who contact the Help Desk outside of business hours have an opportunity to leave a voicemail for urgent issues. Messages are monitored 24 hours a day - depending on the severity of the issue, calls may be returned the next business day.
Please contact the Help Desk if you have any questions.
You can also email the help desk at mcare@cms.hhs.gov. This email address is monitored Monday - Friday 7AM - 7PM ET. Emails are typically answered within 1 business day. (FAQ2157)
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If an eligible professional (EP) is unable to meet the measure of a Meaningful Use objective because it is ...
- Some Meaningful Use objectives provide exclusions and others do not. Exclusions are available only when our regulations ... (more)
- Some Meaningful Use objectives provide exclusions and others do not. Exclusions are available only when our regulations specifically provide for an exclusion. EPs may be excluded from meeting an objective if they meet the circumstances of the exclusion. If an EP is unable to meet a Meaningful Use objective for which no exclusion is available, then that EP would not be able to successfully demonstrate Meaningful Use and would not receive incentive payments under the Medicare and Medicaid EHR Incentive Programs.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10151 (FAQ2883)
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[EHR Incentive Programs] What information must an eligible professional provide in order to meet the measur...
- In our final rule, we defined "clinical summary" as: an after-visit summary that provides a patient with relevant and ac... (more)
- In our final rule, we defined "clinical summary" as: an after-visit summary that provides a patient with relevant and actionable information and instructions containing, but not limited to, the patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms.
The EP must include all of the above that can be populated into the clinical summary by certified EHR technology. If the EP’s certified EHR technology cannot populate all of the above fields, then at a minimum the EP must provide in a clinical summary the data elements for which all EHR technology is certified for the purposes of this program (according to §170.304(h)):
• Problem List • Diagnostic Test Results • Medication List • Medication Allergy List
This answer applies to clinical summaries generated by certified EHR technology for electronic or paper dissemination. Also, if one form of dissemination (paper or electronic) has a more limited set of fields than the other, this does not serve as a limit on the other form. For example, certified EHR technology may be capable of populating a clinical summary with a greater number of data elements when the clinical summary is provided to the patient electronically than when the clinical summary is printed on paper. When the clinical summary in this example is provided electronically, it should include all of the above elements that can be populated by the certified EHR technology. The clinical summary would not be limited by the data elements that are capable of being displayed on a paper printout.
Keywords: FAQ10558 (FAQ5989)
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Can you explain the term 'skilled service?'
- Skilled services covered by the Medicare home health benefit are discussed in the Home Health Manual, CMS Publication 11... (more)
- Skilled services covered by the Medicare home health benefit are discussed in the Home Health Manual, CMS Publication 11, Chapter II - Coverage of Home Health Services in section 205. This publication can be found on our website at: http://www.cms.hhs.gov/manuals
(FAQ1783)
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[EHR Incentive Programs] My practice does not typically collect information on any of the core, alternate c...
- EPs are not excluded from reporting clinical quality measures, but zero is an acceptable value for the CQM denominato... (more)
EPs are not excluded from reporting clinical quality measures, but zero is an acceptable value for the CQM denominator. If there were no patients who met the denominator population for a CQM, then the EP would report a zero for the denominator and a zero for the numerator. For the core measures, if the EP reports a zero for the core measure denominator, then the EP must report results for up to three alternate core measures (potentially reporting on all 6 core/alternate core measures). For the menu-set measures, we expect the EP to report on measures which do not have a denominator of zero. If none of the measures in the menu set applies to the EP, then the EP must report on three of such measures, reporting a denominator of zero, and then attest that the remainder of the menu-set measures have a value of zero in the denominator. As we stated in the final rule (75 FR 44409-10): "The expectation is that the EHR will automatically report on each core clinical quality measure, and when one or more of the core measures has a denominator of zero then the alternate core measure(s) will be reported. If all six of the clinical quality measures in Table 7 have zeros for the denominators (this would imply that the EPs patient population is not addressed by these measures), then the EP is still required to report on three additional clinical measures of their choosing from Table 6 in this final rule. In regard to the three additional clinical quality measures, if the EP reports zero values, then for the remaining clinical quality measures in Table 6 (other than the core and alternate core measures) the EP will have to attest that all of the other clinical quality measures calculated by the certified EHR technology have a value of zero in the denominator, if the EP is to be exempt from reporting any of the additional clinical quality measures (other than the core and alternate core measures) in Table 6."
To view the final rule, please visit: http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10072 (FAQ2773)
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[EHR Incentive Programs] For the Medicare and Medicaid Electronic Health Record (EHR) Incentive Progr...
- The attestation system only allows the selection of 5 menu objectives. If an EP practices in multiple locations that ... (more)
The attestation system only allows the selection of 5 menu objectives. If an EP practices in multiple locations that choose to implement the same menu objectives, the EP should combine the data for menu objectives for attestation. For menu objectives that are not shared across multiple locations, the EP should attest to the menu objectives implemented at the location where they have the greatest number of their patient encounters.
The attestation system only allows the selection of 6 additional clinical quality measures. If an EP practices in multiple locations that choose to implement the same quality measures, the EP should combine the data for quality measures for attestation. For clinical quality measures that are not shared across multiple locations, the EP should attest to the clinical quality measures implemented at the location where they have the greatest number of their patient encounters.
For information on how to calculate the objectives and clinical quality measures that are the same at multiple locations please refer to FAQ #3609.
(FAQ7779)
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Can I fax a copy of the provider enrollment application to the Medicare contractor?
- No. Since the enrollment application must contain an original signature, you cannot fax an enrollment application to a ... (more)
- No. Since the enrollment application must contain an original signature, you cannot fax an enrollment application to a Medicare contractor.
(FAQ1903)
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[EHR Incentive Programs] What are the specific medical specialty codes associated with anesthesiology...
- The included Medicare Specialty Codes are diagnostic radiology (30), nuclear medicine (36), interventional radiology ... (more)
The included Medicare Specialty Codes are diagnostic radiology (30), nuclear medicine (36), interventional radiology (94), anesthesiology (05), and pathology (22).
We note that current practice guidelines issued by the American College of Radiology for interventional radiology (94) indicate that both face-to-face patient contact (pre and post procedure) and follow-up care (longitudinal care) are expected as part of the scope of practice, and we may need to revisit this issue in future rulemaking.
Radiation oncology, together with surgical and medical oncology, is one of the 3 primary disciplines involved in cancer treatment according to the American College of Radiology practice guidelines. Radiation oncologists are therefore specialized oncologists as opposed to specialized radiologists and are not eligible for the specialty-based exception. If a radiation oncologist believes they meet the hardship exception criteria for lack of face-to-face patient interaction and lack of need for follow-up care they may apply for that exception, as can any eligible professional regardless of specialty. (FAQ7731)
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[EHR Incentive Programs] After successfully demonstrating meaningful use for the Medicare and Medicaid Elec...
- Eligible professionals (EPs) participating in the Medicare EHR Incentive Program will receive a single lump sum payme... (more)
Eligible professionals (EPs) participating in the Medicare EHR Incentive Program will receive a single lump sum payment for each year they successfully demonstrate meaningful use of certified EHR technology no later than the end of the calendar year following the year in which the EP was eligible for the bonus payment. Eligible hospitals and critical access hospitals (CAHs) participating in the Medicare EHR Incentive Program will first receive an initial payment. The final payment will be determined at the time of settling the hospital cost report. Payments to Medicare providers will be made to the taxpayer identification number (TIN) selected at the time of registration, through the same channels their claims payments are made. However, for EPs practicing in a health professional shortage area (HPSA), the additional incentive payment will be paid separately to the same TIN as the incentive payment.
Medicaid incentives will be paid by the States. EPs, eligible hospitals, and CAHs participating in the Medicaid EHR Incentive Program should check with their State.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10161 (FAQ2901)
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[EHR Incentive Programs] Do specialty providers have to meet all of the meaningful use objectives for ...
- For eligible professionals (EPs) who participate in the Medicare and Medicaid EHR Incentive Programs, there are a tot... (more)
For eligible professionals (EPs) who participate in the Medicare and Medicaid EHR Incentive Programs, there are a total of 25 meaningful use objectives. To qualify for an incentive payment, 20 of these 25 objectives must be met. There are 15 required core objectives. The remaining 5 objectives may be chosen from the list of 10 menu set objectives. Certain objectives do provide exclusions. If an EP meets the criteria for that exclusion, then the EP can claim that exclusion during attestation. However, if an exclusion is not provided, or if the EP does not meet the criteria for an existing exclusion, then the EP must meet the measure of the objective in order to successfully demonstrate meaningful use and receive an EHR incentive payment. Failure to meet the measure of an objective or to qualify for an exclusion for the objective will prevent an EP from successfully demonstrating meaningful use and receiving an incentive payment.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10469 (FAQ3069)
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[EHR Incentive Programs] To meet the third measure of the objective of providing “a summary of care r...
- If a summary of care record used for an actual transition of care or referral is electronically exchanged with a recipie... (more)
- If a summary of care record used for an actual transition of care or referral is electronically exchanged with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender's EHR technology, then that exchange can be considered to have met the third measure of the objective for all providers involved in that transition of care and referral using the same Certified EHR Technology.
If the provider chooses instead to meet this third measure by exchanging with the CMS test EHR, we clarify that the use of test information about a fictional patient that would be identical in form to what would be sent about an actual patient (e.g., "dummy data") must be used for the purposes of conducting the test. Providers that use the same EHR technology and share a network for which their organization either has operational control of or license to use can conduct one test that covers all providers in the organization. For example, if a large group of EPs with multiple physical locations use the same EHR technology and those locations are connected using a network that the group has either operational control of or license to use, then a single test would cover all EPs in that group. Similarly, if a provider uses an EHR technology that is hosted (cloud-based) on the developer's network, then a single test would allow all EPs, eligible hospitals, and CAHs using the EHR technology that is hosted (cloud-based) on the developer's network to meet the measure. (FAQ7729)
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I recently enrolled in Medicare. Am I going to have to complete revalidation paperwork?
- Even if you recently enrolled, you may receive a request to revalidate your enrollment, since there are number of reason... (more)
- Even if you recently enrolled, you may receive a request to revalidate your enrollment, since there are number of reasons your provider enrollment information may require an update. If you receive a request from your Medicare Administrative Contractor (MAC) to revalidate, you must do so. Once you receive the request for revalidation from your Medicare Administrative Contractor, the quickest and easiest way to complete your revalidation application is through Internet-based PECOS (https://pecos.cms.hhs.gov/pecos/login.do). Paper 855 enrollment applications are also available at http://www.cms.gov/CMSFORMS/CMSForms/list.asp.
You have sixty days from the post mark date of the revalidation notification letter to submit your completed paper or internet based PECOS electronic revalidation enrollment application. You may complete the revalidation through internet- based PECOS (https://pecos.cms.hhs.gov/pecos/login.do) or you may submit the appropriate CMS 855 paper form available at https://www.cms.gov/medicareprovidersupenroll/02_enrollmentapplications.asp).
If you believe you received the request to revalidate in error, you should contact the Medicare Administrative Contractor (MAC). (FAQ3715)
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For eligible professionals (EPs) who see patients in both inpatient and outpatient settings (e.g., hospital...
- In this case, EPs should base both the numerators and denominators for meaningful use objectives on the number of unique... (more)
- In this case, EPs should base both the numerators and denominators for meaningful use objectives on the number of unique patients in the outpatient setting, since this setting is where they are eligible to receive payments from the Medicare and Medicaid EHR Incentive Programs.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10068 (FAQ2765)
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[EHR Incentive Programs] If an eligible professional (EP) in the Medicaid EHR Incentive Program wants to le...
- EPs may use a clinic or group practice's patient volume as a proxy for their own under three conditions:(1) T... (more)
EPs may use a clinic or group practice's patient volume as a proxy for their own under three conditions:
(1) The clinic or group practice's patient volume is appropriate as a patient volume methodology calculation for the EP (for example, if an EP only sees Medicare, commercial, or self-pay patients, this is not an appropriate calculation); (2) there is an auditable data source to support the clinic's patient volume determination; and (3) so long as the practice and EPs decide to use one methodology in each year (in other words, clinics could not have some of the EPs using their individual patient volume for patients seen at the clinic, while others use the clinic-level data). The clinic or practice must use the entire practice's patient volume and not limit it in any way. EPs may attest to patient volume under the individual calculation or the group/clinic proxy in any participation year. Furthermore, if the EP works in both the clinic and outside the clinic (or with and outside a group practice), then the clinic/practice level determination includes only those encounters associated with the clinic/practice.
In order to provide examples of this answer, please refer to Clinics A and B, and assume that these clinics are legally separate entities.
If Clinic A uses the clinic's patient volume as a proxy for all EPs practicing in Clinic A, this would not preclude the part-time EP from using the patient volume associated with Clinic B and claiming the incentive for the work performed in Clinic B. In other words, such an EP would not be required to use the patient volume of Clinic A simply because Clinic A chose to invoke the option to use the proxy patient volume. However, such EP's Clinic A patient encounters are still counted in Clinic A's overall patient volume calculation. In addition, the EP could not use his or her patient encounters from clinic A in calculating his or her individual patient volume.
The intent of the flexibility for the proxy volume (requiring all EPs in the group practice or clinic to use the same methodology for the payment year) was to ensure against EPs within the same clinic/group practice measuring patient volume from that same clinic/group practice in different ways. The intent of these conditions was to prevent high Medicaid volume EPs from applying using their individual patient volume, where the lower Medicaid patient volume EPs then use the clinic volume, which would of course be inflated for these lower-volume EPs.
CLINIC A (with a fictional EP and provider type) " EP #1 (physician): individually had 40% Medicaid encounters (80/200 encounters) " EP# 2 (nurse practitioner): individually had 50% Medicaid encounters (50/100 encounters) " Practitioner at the clinic, but not an EP (registered nurse): individually had 75% Medicaid encounters (150/200) " Practitioner at the clinic, but not an EP (pharmacist): individually had 80% Medicaid encounters (80/100) " EP #3 (physician): individually had 10% Medicaid encounters (30/300) " EP #4 (dentist): individually had 5% Medicaid encounters (5/100) " EP #5 (dentist): individually had 10% Medicaid encounters (20/200)
In this scenario, there are 1200 encounters in the selected 90-day period for Clinic A. There are 415 encounters attributable to Medicaid, which is 35% of the clinic's volume. This means that 5 of the 7 professionals would meet the Medicaid patient volume criteria under the rules for the EHR Incentive Program. (Two of the professionals are not eligible for the program on their own, but their clinical encounters at Clinic A should be included.)
The purpose of these rules is to prevent duplication of encounters. For example, if the two highest volume Medicaid EPs in this clinic (EPs #1 and #2) were to apply on their own (they have enough Medicaid patients to do that), the clinic's 35% Medicaid patient volume is no longer an appropriate proxy for the low-volume providers (e.g., EPs #4 and #5).
If EP #2 is practicing part-time at both Clinic A, and another clinic, Clinic B, and both Clinics are using the clinic-level proxy option, each such clinic would use the encounters associated with the respective clinics when developing a proxy value for the entire clinic. EP #2 could then apply for an incentive using data from one clinic or the other.
Similarly, if EP #4 is practicing both at Clinic A, and has her own practice, EP # 4 could choose to use the proxy-level Clinic A patient volume data, or the patient volume associated with her individual practice. She could not, however, include the Clinic A patient encounters in determining her individual practice's Medicaid patient volume. In addition, her Clinic A patient encounters would be included in determining such clinic's overall Medicaid patient volume.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10362 (FAQ2993)
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[EHR Incentive Programs] For the meaningful use objective of "capability to exchange key clinical informati...
- For the purposes of the "capability to exchange key clinical information" measure, exchange is defined as electronic tra... (more)
- For the purposes of the "capability to exchange key clinical information" measure, exchange is defined as electronic transmission and acceptance of key clinical information using the capabilities and standards of certified EHR technology (as specified at 45 CFR 170.304(i) for eligible professionals and 45 CFR 170.306(f) for eligible hospitals and cricitcal access hospitals). There are many acceptable transmission methods for conducting a test of the electronic exchange of key clinical information with providers of care and patient authorized entities (see FAQ #) To meet the measure of this objective a provider must:
use certified EHR technology to generate a continuity of care document (CCD)/continuity of care record (CCR), and electronically transmit the CCD/CCR. To complete step 2, an eligible professional, eligible hospital, or critical access hospital may use any means of electronic transmission according to any transport standard(s) (SMTP, FTP, REST, SOAP, etc.) regardless of whether it was included by an EHR technology developer as part of the certified EHR technology in the eligible professional’s, eligible hospital’s, or critical access hospital’s possession.
Please note that the use of USB, CD-ROM, or other physical media or electronic fax would not meet the measure of this objective and has been addressed in another FAQ (see FAQ #10638) If the test involves the transmission of actual patient information, all current privacy and security regulations must be met.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10691 (FAQ3359)
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[EHR Incentive Programs] What funding sources may States use to fund the 10% non-federal share of HIT...
- States must fund the 10 percent non-federal share of the Health Information Technology (HITECH) Act administrative ex... (more)
States must fund the 10 percent non-federal share of the Health Information Technology (HITECH) Act administrative expenditures consistent with the law and regulations applicable to the non-federal share for all Medicaid expenditures. Consistent with that authority, which includes Social Security Act sections 1902(a)(2), 1903(a), 1903(w), and 42 CFR Part 433, subpart B, states may fund the non-federal share of Medicaid expenditures through legislative appropriations to the Medicaid agency, intergovernmental transfers (IGTs), certified public expenditures (CPEs), permissible health-care related taxes, and bona-fide donations.
States must submit their proposed strategies for funding the non-federal share of HITECH administrative payments to CMS for review as part of the HIT plan approval process. CMS will review each individual State’s proposal to ensure that each proposed non-federal share funding source meets federal requirements. During this process, CMS can address specific questions about funding the non-federal share of Medicaid expenditures.
CMS strongly urges States to work on their funding proposals with their CMS HIT Coordinators as early as possible before claiming for HITECH administrative expenditures, to ensure funding structures are appropriate. HITECH administrative expenditures, like other title XIX expenditures, are subject to audit, and federal funds may be at risk if funding sources are found not to be in compliance with federal requirements.
Below are some statutory and regulatory citations pertaining to non-federal share financing requirements. Please note this is not an all-inclusive list of funding requirements.
• Use of Federal Funds o Social Security Act §1903 o 42 CFR 433.51(c)
• State Appropriations o Social Security Act §1902(a)(2) o 42 CFR 433.51
• Intergovernmental Transfers o Social Security Act §1903(w)(6)(A) o 42 CFR 433.51
• Certified Public Expenditures o Social Security Act §1903(w)(6)(A) o 42 CFR 433.51
• Healthcare-Related Taxes and Provider-Related Donations o 42 CFR part 433, subpart B
Created 2/7/2013 (FAQ7809)
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How were Medically Unlikely Edits (MUEs) developed?
- MUEs were developed based on Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code... (more)
- MUEs were developed based on Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code descriptors, CPT coding instructions, anatomic considerations, established CMS policies, nature of service/procedure, nature of analyte, nature of equipment, and clinical judgment. All edits based on clinical judgment as well as many others were reviewed by workgroups of contractor medical directors.
Prior to implementation of MUEs, the proposed edits were released for a review and comment period to the AMA, national medical/surgical societies, and other national healthcare organizations, including non-physician professional societies, hospital organizations, laboratory organizations, and durable medical equipment organizations.
In 2008 all MUE values were validated with 100% of submitted claims data for a six month period in 2006. (FAQ2283)
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[EHR Incentive Program] Will the Centers for Medicare & Medicaid Services (CMS) conduct audits as...
- Any provider attesting to receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program ... (more)
Any provider attesting to receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program potentially can be subject to an audit. Here's what you need to know to make sure you're prepared: Overview of the CMS EHR Incentive Programs Audits • All providers attesting to receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Programs should retain ALL relevant supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses. Documentation to support the attestation should be retained for six years post-attestation. Documentation to support payment calculations (such as cost report data) should continue to follow the current documentation retention processes. • CMS, and its contractors, will perform audits on Medicare and dually-eligible (Medicare and Medicaid) providers. • States, and their contractors, will perform audits on Medicaid providers. • CMS and states will also manage appeals processes. Preparing for an Audit • To ensure you are prepared for a potential audit, save the electronic or paper documentation that supports your attestation. Also save the documentation that supports the values you entered in the Attestation Module for Clinical Quality Measures (CQMs). Hospitals should also maintain documentation that supports their payment calculations. • Upon audit, the documentation will be used to validate that the provider accurately attested and submitted CQMs, as well as to verify that the incentive payment was accurate. Details of the Audits • There are numerous pre-payment edit checks built into the EHR Incentive Programs' systems to detect inaccuracies in eligibility, reporting, and payment. • Post-payment audits will also be completed during the course of the EHR Incentive Programs. • If, based on an audit, a provider is found to not be eligible for an EHR incentive payment, the payment will be recouped. • CMS has an appeals process for eligible professionals, eligible hospitals, and critical access hospitals that participate in the Medicare EHR Incentive Program. • States will implement appeals processes for the Medicaid EHR Incentive Program. For more information about these appeals, please contact your State Medicaid Agency.
What information should an eligible professional, eligible hospital, or critical access hospital participating in the Medicare or Medicaid Electronic Health Record (EHR) Incentive Programs maintain in case of an audit? An audit may include a review of any of the documentation needed to support the information that was entered in the attestation. The level of the audit review may depend on a number of factors, and it is not possible to include an all-inclusive list of supporting documents. The primary documentation that will be requested in all reviews is the source document(s) that the provider used when completing the attestation. This document should provide a summary of the data that supports the information entered during attestation. Ideally, this would be a report from the certified EHR system, but other documentation may be used if a report is not available or the information entered differs from the report. This summary document will be the starting point of most reviews and should include, at minimum: • The numerators and denominators for the measures • The time period the report covers • Evidence to support that it was generated for that eligible professional, eligible hospital, or critical access hospital. Although the summary document is the primary review step, there could be additional and more detailed reviews of any of the measures, including review of medical records and patient records. The provider should be able to provide documentation to support each measure to which he or she attested, including any exclusions claimed by the provider. A few examples of additional support are as follows: • Drug-Drug/Drug-Allergy Interaction Checks and Clinical Decision Support – Proof that the functionality is available, enabled, and active in the system for the duration of the EHR reporting period. • Electronic Exchange of Clinical Information – Screenshots from the EHR system or other documentation that document a test exchange of key clinical information (successful or unsuccessful) with another provider of care. Alternately, a letter or email from the receiving provider confirming the exchange, including specific information such as the date of the exchange, name of providers, and whether the test was successful. • Protect Electronic Health Information – Proof that a security risk analysis of the certified EHR technology was performed prior to the end of the reporting period (e.g., report which documents the procedures performed during the analysis and the results). • Drug Formulary Checks – Proof that the functionality is available, enabled, and active in the system for the duration of the EHR reporting period. • Immunization Registries Data Submission, Reportable Lab Results to Public Health Agencies, and Syndromic Surveillance Data Submission– Screenshots from the EHR system or other documentation that document a test submission to the registry or public health agency (successful or unsuccessful). Alternately, a letter or email from registry or public health agency confirming the receipt (or failure of receipt) of the submitted data, including the date of the submission, name of parties involved, and whether the test was successful. • Exclusions – Documentation to support each exclusion to a measure claimed by the provider. For Medicare eligible professionals and for hospitals that are eligible for both Medicare and Medicaid EHR incentive payments - When a provider is selected for an audit, they will receive an initial request letter from the audit contractor. The request letter will be sent electronically by the audit contractor from a CMS email address and will include the audit contractor’s contact information. The email address provided during registration for the EHR Incentive Program will be used for the initial request letter. The initial review process will be conducted at the audit contractor’s location, using the information received as a result of the initial request letter. Additional information might be needed during or after this initial review process, and in some cases an on-site review at the provider’s location could follow. A demonstration of the EHR system could be requested during the on-site review. A secure communication process has been established by the contractor, which will assist the provider to send any information that could be considered sensitive. Any questions pertaining to the information request should be directed to the audit contractor. States will have separate audit processes for their Medicaid EHR Incentive Program. For more information about these audit processes, please contact your State Medicaid Agency.
(FAQ7711)
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To whom does the revalidation effort apply?
- The Medicare enrollment revalidation effort over the next four years applies to all practitioners. Through the end of 20... (more)
- The Medicare enrollment revalidation effort over the next four years applies to all practitioners. Through the end of 2011, CMS is focusing the on revalidating providers and suppliers that were enrolled prior to March 25, 2011, providers and suppliers whose identification numbers are not in the Provider Enrollment Chain Organization System, and providers and suppliers in the moderate screening categories.
(FAQ3681)
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We are concerned that we will not receive the revalidation requests that are mailed to the provider by the ...
- A list of providers and suppliers who have been sent requests to revalidate their Medicare enrollment is available at... (more)
A list of providers and suppliers who have been sent requests to revalidate their Medicare enrollment is available at:
http://www.cms.gov/MedicareProviderSupEnroll/11_Revalidations.asp#TopOfPage. The list will generally be routinely updated by the 20th of each month.
Providers and suppliers using Internet-based PECOS will also be able to see if a request for revalidation has been sent by the Medicare Administrative Contractor (MAC). A “Revalidation Notice Sent” date will be displayed on the My Enrollments page. This will reflect the date in which the revalidation letter was mailed by the MAC to the provider/supplier. The date will display on the My Enrollments page for 120 days. (FAQ3763)
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What are the financial benefits of participation in the Physician Quality Reporting System (Physician Quali...
- A Physician Quality Reporting participant who reports satisfactorily will earn a financial incentive based on a percenta... (more)
- A Physician Quality Reporting participant who reports satisfactorily will earn a financial incentive based on a percentage of the Medicare Part B Physician Fee Schedule (PFS) total estimated allowed charges for covered services provided during the longest or most advantageous reporting period for which the professional satisfied criteria for at least one reporting option. Reference: http://www.cms.gov/pqrs
(FAQ2323)
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What's the difference between the Outpatient Code Editor edits and the CCI edits?
- The OCE edits and the CCI edits are two editing systems used to process fiscal intermediary (hospital outpatient) and ca... (more)
- The OCE edits and the CCI edits are two editing systems used to process fiscal intermediary (hospital outpatient) and carrier-related claims, respectively. The CCI edits are developed based on coding conventions defined in the AMA's CPT Manual, current standards of medical and surgical coding practice, input from specialty societies, and based on analysis of current coding practice. The CCI edits are used for carrier processing of physician services under the Medicare Physician Fee Schedule while the OCE edits are used by intermediaries for processing hospital outpatient services under the Hospital OPPS.
The OCE is used in processing OPPS claims. Within the OCE are over 50 OCE edits, which determine whether a specific code is payable under the hospital OPPS. Many of the CCI edits are included in the OCE edits (see edit #19, 20, 39, and 40 below). The OCE edits are used exclusively under the hospital OPPS - they are not used within the Medicare Physician Fee Schedule.
The CCI edits always consist of pairs of HCPCS codes, and are arranged in two tables. One is the column 1/column 2 correct coding edits table, and the other is known as the mutually exclusive edits table. The OCE edits are arranged in numerical order with descriptions for each edit, as well as a claim disposition for each edit. Examples of OCE edits are listed below. For further information on the latest OCE edits within the hospital OPPS, please visit our website at http://www.cms.hhs.gov/Manuals/ to find the latest transmittal (program memorandum) on the OCE. EditDescriptionDisposition1Invalid diagnosis codeReturn to Provider (RTP)2Diagnosis and age conflictRTP3Diagnosis and sex conflictRTP4Medicare secondary payer alertSuspend19Mutually exclusive procedure that is not allowed by CCI even if appropriate modifier is presentLine Item Rejection20Component of a comprehensive procedure that is not allowed by CCI even if appropriate modifier is presentLine Item Rejection39Mutually exclusive procedure that would be allowed by CCI if appropriate modifier were presentLine Item Rejection40Component of a comprehensive procedure that would be allowed by CCI if appropriate modifier were presentLine Item Rejection (FAQ1909)
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Can you please provide the reference link that identifies those providers and suppliers who will be deemed ...
- The following links you directly to the article which addresses the ACA related enrollment changes: ... (more)
- The following links you directly to the article which addresses the ACA related enrollment changes: https://www.cms.gov/MLNMattersArticles/downloads/MM7350.pdf .
(FAQ3797)
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[EHR Incentive Programs] For meaningful use objectives of the Medicare and Medicaid Electronic Health Recor...
- No, if multiple EPs are using the same certified EHR technology in different physical locations/settings (e.g., differen... (more)
- No, if multiple EPs are using the same certified EHR technology in different physical locations/settings (e.g., different practice locations), there must be a single test performed for each physical location/setting. This is true even if the certified EHR technology that is used in the different physical locations is connected to the same server. The purpose of this testing is to demonstrate that the information can be transferred from where it was created (the physical location/setting of the EP or group of EPs) to another provider of care, patient-authorized entity or public health agency. While we understand that several different physical locations/settings may send this information through a central server or on mostly the same path, there may be some degree of variation in the path of transmission or the infrastructure involved.
For more information about the Medicare and Medicaid EHR Incentive Program, please visit http://www.cms.gov/EHRIncentivePrograms.
Keywords: FAQ10979 (FAQ3819)
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