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UPDATE as of 02/28/2018
1. ECS has confirmed with its CMS sources that the Work GPCI
issue as discussed below will be retroactive to 01/01/2018.
2. Medicare Contractor Updates... - WPS Medicare - has posted information on their website (see
original link below)
- Noridian - has updated their fee schedules, but there is no
explanation on their website of how they will reprocess previously paid
claims
- Palmetto GBA - has updated their fee schedules, but there is no
explanation on their website of how they will reprocess previously paid claims
- Novitas - has updated their fee schedules, but there is no
explanation on their website of how they will reprocess previously paid claims
- First Coast Services - has updated their fee schedules, but there
is no explanation on their website of how they will reprocess previously paid
claims
- CGS Medicare - has updated their fee schedules, but there is no
explanation on their website of how they will reprocess previously paid claims
3. On 2/28/2018 - CMS released an updated summary today which has this
tidbit...
"For Sections 50201 “Extension of Work Geographic Practice Cost Index
(GPCI) Floor”, 50202 “Repeal of
Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate
Therapy”, and 50203
“Medicare Ambulance Services” provision changes, Medicare
Administrative Contractors (MAC) will
implement these changes no later than February 26, 2018, and will provide
additional details on
timelines for reprocessing or release of held claims impacted by these changes.
The following are
brief descriptions of these provisions:"
Section 50201 - Extension of Work Geographic Practice Cost Index (GPCI) Floor -
The new law
extends a provision raising the Work GPCI to 1.000 for all localities that
currently have a Work
GPCI of less than 1.000. The Work GPCI Floor impacts the fees for all codes
paid under the
Medicare Physician Fee Schedule (MPFS) for those localities. The Work GPCI
floor is extended
through December 31, 2019. No new provider action is necessary for
implementation.
Source: https://www.cms.gov/Center/Provider-Type/All-Fee-For-Service-Providers/Downloads/Medicare-Expired-Legislative-Provisions-Extended.pdf
4. Our last bit of advice is UPDATE Your Fee Schedule to these
new rates!!! If you continue to underbill, you may get underpaid.
===================================================================================================
By: Karl M. Ellzey, President, Ellzey Coding Solutions
Original Date of Publication: February 23, 2018
Ellzey Coding Solutions is alerting all Dermatologists and staff on an interesting issue that has come about as
part of the recently passed 2018 Federal Budget.
This issue will affect Medicare reimbursement rates (POSITIVELY) for
providers in 53 of the 112 Medicare payment localities.
In addition to funding the government, extending CHIP and other healthcare
programs, part of the Federal budget passed a few weeks ago included a quietly
released tidbit within the "Sustain Care Act of 2018"
You can read about the entire Act here...
https://rules.house.gov/sites/republicans.rules.house.gov/files/115/PDF/sxs_summary.pdf
The Sustain Care Act of 2018 (Section 2112) re-instated the Work GPCI (work
geographic adjustment factor) floor of 1.000 which will positively affect the
2018 Medicare Physician Fee Schedules Rates in certain Medicare payment
localities.
A little background... The Work GPCI is just one of several components and
variables used in the calculation of the physician fee schedule for each of the
112 Medicare payment localities. CMS uses the "national average"
geographic adjustment factors of 1.000 to represent the median for all Medicare
localities. Some variables are adjusted higher, and some are adjusted lower for
each locality based on geographic factors such as cost of living, cost of malpractice
insurance, wages, rent, etc. For example, the geographic adjustment factors for
providers in Mississippi are weighted less than the adjustment factors for
physicians practicing in Manhattan, NY.
Prior to 2018, as part of compromises to avoid massive payment reductions for
physician fee schedules (remember the Sustainable Growth Rate issues providers
faced for 10 years?), CMS placed a lower limit or "floor" value of
1.000 for the Work GPCI, even if a locality had a predetermined work adjustment
factor of less than 1.000. For example, the Work GPCI for Missouri
in January was calculated at a value of 0.961. Unfortunately, the previous
provision that allowed for this "floor" of 1.000 expired
12/31/2017.
This meant that starting January 1, and prior to the recently passed budget, 53
of the 112 Medicare payment localities used Work GPCI values of less than 1.000
in calculating the published 2018 Medicare Physician Fee Schedule rates. This
meant that up until this Act was passed, many physician practices have
been billing and being paid at lower reimbursement rate than will soon
be in effect once CMS finalizes these new payment changes.
Example 1: A provider in Mississippi that does Mohs (CPT 17311)
will now get paid $601.89 vs. $593.19
Example 2: A provider in Missouri that destroys 15 or more AKs (CPT
17004) will now get paid $131.72 vs. $129.79
Example 3: A provider in Chicago, Illinois will not be affected by
this policy change as their Work GPCI is currently already above 1.000 (1.008)
Some of these changes may seem small, but they can add up over the course of a
year if you underbill or have significant Medicare volume.
On Friday, February 23, CMS published updated 2018 Relative Value Unit files
that reflect the 1.000 Work GPCI floor that is now in place.
What CMS has not made clear...
1. Is the Work GPCI calculation retroactive to all claims
filed/paid as of 1/1/2018 or starting at a certain date?
Update on 02/26/2018 - CMS has confirmed this
is retroactive to 01/01/2018
2. If these changes are retroactive to 1/1/2018, will Medicare
contractors retroactively adjust and make a bulk payment adjustmentsto
all providers that had claims previously paid at the lower rates?
Update on 02/26/2018 - CMS has confirmed that Medicare
contractors will make the appropriate adjustments and reprocess claims
As of 02/23/2018 CMS and the Medicare contractors have released very little information
about this important change.... or at least remained relatively quiet
about it!
As of February 23, 2018...
Noridian Medicare has no information about this
change on their website for providers located in Arizona, Idaho, Montana, North
Dakota, Oregon, Utah, Washington, and Wyoming.
Source: https://med.noridianmedicare.com/web/jfb/fees-news/fee-schedules/mpfs
Palmetto GBA has no information in its website regarding these
changes. This affects North Carolina, South Carolina, West Virginia, and
Virginia!
Source: https://www.palmettogba.com/palmetto/providers.nsf/DocsCatHome/JM%20Part%20B
Novitas Solutions has no information in its website regarding these
changes. This affects Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma,
and parts of Texas.
Source: https://www.novitas-solutions.com/webcenter/portal/FeeSchedules_JH
First Coast Service Options which affects providers in Florida, PR,
and the USVI has no updates yet!
Source: https://medicare.fcso.com/Landing/140047.asp
CGS Medicare which affects providers in Kentucky and Ohio has no
updates on their site!
Source: https://cgsmedicare.com/partb/fees/index.html
However, we did find one carrier (WPS Government Health
Administrators) which has indicated that the change is effective for
claims processed ON and AFTER 2/16/2018. Updated fees are available
on their website and affects providers in Iowa, Kansas, Missouri and Nebraska.
Source: https://www.wpsgha.com/wps/portal/mac/site/fees-and-reimbursements/guides-and-resources/2018-fee-schedule
Will other carriers follow? What about claims prior to 2/16/2018?
Update on 02/26/2018 - CMS has confirmed that this will be
retroactive!
Ellzey Coding Solutions has reached out to it's contacts at CMS to get
additional clarification or instructions on what is supposed to happen with the
new Work GPCI floor limits and how it affects the first 7 weeks of claims
processed in 2018!
Ellzey Coding Solutions recommends seeing if you are impacted
by this change, and making any changes/updates in your billing systems,
especially if you submit the actual Medicare allowables to Medicare (i.e., no
Medicare fee schedule mark-up).
If you currently have an office fee schedule that his higher than
Medicare and you submit these higher rates to Medicare, you should be OKAY, but
watch your EOBs for correct payments!
To see how you will be impacted by this change, check your State/Locality in
the listing below. If a Work GPCI value of less than 1.000 is displayed, you
will be affected.
DermCoder.com and ClaimCoder.com have been defaulted to the revised/updated 2018 Fee Schedules!
DermCoder.com or ClaimCoder.com 30-day Free Trial
If you are not currently a subscriber (or past subscriber), you may be eligible* for a 30-day free trial to DermCoder.com or ClaimCoder.com.
Visit: www.dermcoder.com/register or www.claimcoder.com/register
* Certain restrictions apply
Are you affected?
Here is a listing of Work GPCIs (by Medicare Payment Locality) that were in
place earlier this year...
If you see a value of less than 1.000, you will be affected by this change!
Locality Name Work GPCI prior to new budget
ALABAMA - STATEWIDE 0.979
ALASKA - STATEWIDE 1.500
ARIZONA - STATEWIDE 0.980
ARKANSAS - STATEWIDE 0.971
CALIFORNIA - BAKERSFIELD 1.020
CALIFORNIA - CHICO 1.020
CALIFORNIA - EL CENTRO 1.020
CALIFORNIA - FRESNO 1.020
CALIFORNIA - HANFORD-CORCORAN 1.020
CALIFORNIA - LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES
CTY 1.046
CALIFORNIA - LOS ANGELES-LONG BEACH-ANAHEIM (ORANGE
CNTY) 1.046
CALIFORNIA - MADERA 1.020
CALIFORNIA - MERCED 1.020
CALIFORNIA - MODESTO 1.020
CALIFORNIA - NAPA 1.055
CALIFORNIA - OXNARD-THOUSAND OAKS-VENTURA 1.024
CALIFORNIA - REDDING 1.020
CALIFORNIA - REST OF STATE 1.020
CALIFORNIA - RIVERSIDE-SAN BERNARDINO-ONTARIO 1.020
CALIFORNIA - SACRAMENTO--ROSEVILLE--ARDEN-ARCADE 1.025
CALIFORNIA - SALINAS 1.024
CALIFORNIA - SAN DIEGO-CARLSBAD 1.022
CALIFORNIA - SAN FRANCISCO-OAKLAND-HAYWARD (ALAMEDA/CONTRA
C 1.075
CALIFORNIA - SAN FRANCISCO-OAKLAND-HAYWARD (MARIN
CNTY) 1.062
CALIFORNIA - SAN FRANCISCO-OAKLAND-HAYWARD (SAN FRANC
CNTY) 1.075
CALIFORNIA - SAN FRANCISCO-OAKLAND-HAYWARD (SAN MATEO
CNTY) 1.075
CALIFORNIA - SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO
CTY 1.041
CALIFORNIA - SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA
CTY 1.083
CALIFORNIA - SAN LUIS OBISPO-PASO ROBLES-ARROYO
GRANDE 1.020
CALIFORNIA - SANTA CRUZ-WATSONVILLE 1.026
CALIFORNIA - SANTA MARIA-SANTA BARBARA 1.028
CALIFORNIA - SANTA ROSA 1.023
CALIFORNIA - STOCKTON-LODI 1.020
CALIFORNIA - VALLEJO-FAIRFIELD 1.055
CALIFORNIA - VISALIA-PORTERVILLE 1.020
CALIFORNIA - YUBA CITY 1.020
COLORADO - STATEWIDE 0.996
CONNECTICUT - STATEWIDE 1.021
DELAWARE - STATEWIDE 1.007
DISTRICT OF COLUMBIA - DC + MD/VA SUBURBS 1.045
FLORIDA - FORT LAUDERDALE 0.983
FLORIDA - MIAMI 0.990
FLORIDA - REST OF STATE 0.975
GEORGIA - ATLANTA 0.998
GEORGIA - REST OF STATE 0.980
HAWAII/GUAM - STATEWIDE 1.001
IDAHO - STATEWIDE 0.962
ILLINOIS - CHICAGO 1.008
ILLINOIS - EAST ST. LOUIS 0.984
ILLINOIS - REST OF STATE 0.982
ILLINOIS - SUBURBAN CHICAGO 1.009
INDIANA - STATEWIDE 0.969
IOWA - STATEWIDE 0.969
KANSAS - STATEWIDE 0.966
KENTUCKY - STATEWIDE 0.974
LOUISIANA - NEW ORLEANS 0.987
LOUISIANA - REST OF STATE 0.977
MAINE - REST OF STATE 0.970
MAINE - SOUTHERN MAINE 0.980
MARYLAND - BALTIMORE/SURR. CNTYS 1.023
MARYLAND - REST OF STATE 1.009
MASSACHUSETTS - METROPOLITAN BOSTON 1.033
MASSACHUSETTS - REST OF STATE 1.020
MICHIGAN - DETROIT 1.000
MICHIGAN - REST OF STATE 0.978
MINNESOTA - STATEWIDE 0.998
MISSISSIPPI - STATEWIDE 0.961
MISSOURI - METROPOLITAN KANSAS CITY 0.984
MISSOURI - METROPOLITAN ST. LOUIS 0.985
MISSOURI - REST OF STATE 0.961
MONTANA - STATEWIDE 0.965
NEBRASKA - STATEWIDE 0.970
NEVADA - STATEWIDE 1.002
NEW HAMPSHIRE - STATEWIDE 0.991
NEW JERSEY - NORTHERN NJ 1.041
NEW JERSEY - REST OF STATE 1.024
NEW MEXICO - STATEWIDE 0.982
NEW YORK - MANHATTAN 1.052
NEW YORK - NYC SUBURBS/LONG ISLAND 1.041
NEW YORK - POUGHKPSIE/N NYC SUBURBS 1.016
NEW YORK - QUEENS 1.052
NEW YORK - REST OF STATE 0.987
NORTH CAROLINA - STATEWIDE 0.975
NORTH DAKOTA - STATEWIDE 0.978
OHIO - STATEWIDE 0.990
OKLAHOMA - STATEWIDE 0.961
OREGON - PORTLAND 1.010
OREGON - REST OF STATE 0.991
PENNSYLVANIA - METROPOLITAN PHILADELPHIA 1.022
PENNSYLVANIA - REST OF STATE 0.990
PUERTO RICO - PUERTO RICO 0.998
RHODE ISLAND - STATEWIDE 1.027
SOUTH CAROLINA - STATEWIDE 0.977
SOUTH DAKOTA - STATEWIDE 0.961
TENNESSEE - STATEWIDE 0.976
TEXAS - AUSTIN 0.994
TEXAS - BEAUMONT 0.985
TEXAS - BRAZORIA 1.020
TEXAS - DALLAS 1.012
TEXAS - FORT WORTH 1.007
TEXAS - GALVESTON 1.020
TEXAS - HOUSTON 1.020
TEXAS - REST OF STATE 0.990
UTAH - STATEWIDE 0.980
VERMONT - STATEWIDE 0.979
VIRGIN ISLANDS - VIRGIN ISLANDS 0.998
VIRGINIA - STATEWIDE 0.992
WASHINGTON - REST OF STATE 0.997
WASHINGTON - SEATTLE 1.027
WEST VIRGINIA - STATEWIDE 0.966
WISCONSIN - STATEWIDE 0.983
WYOMING - STATEWIDE 0.983
This article is copyrighted, 2018, by Ellzey Coding Solutions, Inc. and may not be reproduced or reprinted without the express written consent of the author.
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