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Medicare Billing Boosters January 2015

Value –Based Reimbursement

HHS announced on January 26, 2015 that they have now set explicit goals to move toward a value-based reimbursement approach sooner than expected. They want to

  • By the end of 2016: Tie 30% of fee-for-service Medicare payments to quality or value through alternative payment models, such as accountable care organizations or bundled payments and tie 85% of traditional Medicare payments to quality or value

  • By the end of 2018: Tie 50% of fee-for-service Medicare payments to quality or value through alternative payment models, such as accountable care organizations or bundled payments and tie 90% traditional Medical payments to quality or value

To read the announcement click Here.


Are your Medicare Advantage Plan payors applying the Sequestration cut to your reimbursements? Did you know that sequestration does NOT mandate the 2% reduction of reimbursement to Advantage Plan providers? Medicare Advantage plans themselves are subject to the 2 % reductions; however, they cannot pass that cut along to the provider unless their contracts with specific providers permit the pass-through. Providers should review their contracts. If the contract does not permit these cuts, they should challenge the reductions as contrary to their participation and network agreements.

CPT Modifier -59

Effective 1/1/2015 there will be new rules in the use of CPT modifier -59. Modifier -59 is used to identify a service that is separate and distinct from another service with which it would usually be considered to be bundled. CMS says –59 is the most widely used modifier in the HCPCS. It is popular because it can be used in numerous circumstances (different encounters, different anatomical sites, distinct services). However, providers are not always clear on why they are using the modifier and CMS believes that it is misused. The 2013 CERT program projected $770 million in improper payments involving modifier –59. CMS hopes to reduce that misuse and overpayments with more precise coding options. Four new HCPCS modifiers have been created to define subsets of the –59 modifier. They are referred to as –X{EPSU} modifiers:

  • XE Separate Encounter

  • XS Separate Structure

  • XP Separate Practitioner

  • XU Unusual Non-Overlapping Service

An example is CPT 20610 Trigger Point Injections. A provider could perform multiple joint injections, for example, in both the shoulder and a knee. The XS modifier would best describe the situation. Of course, in ICD-10 the specific diagnosis of arthritis of the (right/left) shoulder or (right/left) knee would also give a great deal more information that would make the separate structure situation obvious.

Expect more clarification from CMS on how to actually use the modifiers. CMS says that either –59 or a subset modifier may be payable on a claim line, though “a rapid migration of providers to the more selective modifiers is encouraged.” It is not clear how CCI will accept or not accept –59 or a subset modifier. Modifier –59 is intended to be used when a more descriptive modifier is not available. It is not to be used to bypass the CCI edits unless the proper criteria for the use of a modifier are met.

Global Periods

Medicare is phasing out the 10- and 90-day global periods, starting with the 10-day global in 2017 followed by the 90-day global period in 2018. In lieu of the global periods, Medicare will reimburse separately for visits and services after the date of surgery and revalue surgical codes to a zero-day global period. It is believed that the current global period structure does not appropriately value services. They are, however, researching whether a different bundled surgical structure can be constructed.


The Physician Quality Reporting System (PQRS) has been using incentive payments, and will begin to use payment adjustments (aka penalties) in 2015, to encourage eligible health care professionals (EPs) to report on specific quality measures. Penalties for not adhering to Medicare’s PQRS begin in 2015 at 1.5% and increase to 2% in 2016 and beyond. For more information read our blog posting “Hot Topics in Medical Billing for 2015”.


CMS published a revised MLN Matters (SE1321) in November clarifying regarding hospice patients. Providers should identify if a patient is enrolled in hospice by asking the patient or his/her legal representative. All information should be documented in the patient medical record. Providers should educate patients and their families that once enrolled in hospice, they should contact the hospice provider to arrange care. If the hospice provider does not arrange the services needed, the patient may be financially responsible for the services. Hospice election may be revoked in writing and cannot be back-dated. Medicare will deny Part B services furnished are submitted without either (a) a GV modifier (attending physician is not employed or paid under arrangement by hospice provider and services are related to the terminal prognosis), or (b) a GW modifier (service is not related to the terminal prognosis.) A GW modifier will be denied when the service is determined to be related to the terminal prognosis. A GV modifier will be denied if it is determined that services were provided by hospice-employed/contracted providers.

Pneumonia Vaccine

Effective for dates 9/19/2014, Medicare will cover (a) an initial pneumococcal vaccine to all Medicare beneficiaries who have never received the vaccine under Medicare Part B; and (b) a different, second pneumococcal vaccine one year after the first vaccine was administered (that is, 11 full months have passed following the month in which the last pneumococcal vaccine was administered). Prior pneumococcal vaccination history should be taken into consideration. See MLN Matters # MM905.

Preventive and Screening Services Update

CMS issued MLN Matters MM8874 updating coverage information for preventive and screening services for Intensive Behavioral Therapy for Obesity, Screening Digital Tomosynthesis Mammography, and Anesthesia associated with Colonoscopy. The article can be reviewed Here.

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