Med Law Blog : Pennsylvania Health Care Lawyers & Attorneys : Tucker Arensberg Law Firm : Employee Benefits, HIPAA & HIT in Pittsburgh, PA

The NPI is here.  The NPI is now.  Are you using it?

Industry-Wide Enforcement of the NPI Compliance Date

 The compliance date for the NPI for all HIPAA covered entities except small health plans was May 23, 2007.  (Small health plans have until May 23, 2008 to comply.)  In guidance provided on April 2, 2007, CMS announced that, through May 23, 2008, it would not impose penalties on covered entities that deploy contingency plans to facilitate the compliance of their trading partners.   On May 24, 2008, CMS will lift its enforcement-leniency policy.  Complaints will be investigated as they are today, but penalties will be a legitimate resolution if the entity does not demonstrate compliance or corrective action.  CMS will continue to employ a complaint-driven approach to enforcement.   For example, if a complaint is received alleging a failure to comply with the NPI requirements, CMS will contact the entity to secure evidence of compliance and the contingency plan that had been in place.  If violations are identified, enforcement actions will take place.

This notice does not prohibit covered entities from lifting contingency plans prior to May 24, 2008.

In sum, no later than May 24, 2008, all covered entities are expected to be using the NPI in a compliant manner, and all contingency plans should be lifted.

NPPES and the NPI Enumerator: Misconceptions & Facts

In conversations and correspondence with health care providers, health plans, and others within the health care industry, it is very clear that there are misconceptions concerning the National Plan and Provider Enumeration System (NPPES) and the NPI Enumerator.  Below we have listed some common misconceptions and the facts that correct those misconceptions.

CMS has posted information that lists the specific duties and responsibilities of the NPI Enumerator in a recent MLN Matters article located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0751.pdf on the CMS website.   An article that further clarifies the functions of NPPES and the NPI Enumerator is in development; this article will be announced once available. 

Important Information for Medicare Providers

Medicare’s Key Dates

There are two key dates remaining for 2008 in Medicare's NPI implementation plan.  There is also some confusion as to the difference between the implementation steps for March 1^st and May 23^rd.  The chart below indicates the implementation steps for each date; as well a new column to help further clarify the difference between these two dates. 

Only 4 Months Until May 23rd - Test NPI-only claims NOW

While Medicare is receiving well over 90% of claims containing an NPI in primary provider fields, there is a very small percent of claims submitted with NPI- only.  Until you submit claims with an NPI-only, you will not have a preview of what your experience will be on May 23rd.  The time for correcting problems, should there be any, is getting short.  CMS urges that ALL Medicare providers test NOW so that problems can be resolved prior to May 23^rd. For example, if there is a problem that requires a change in your Medicare enrollment information, you will need to act immediately.

 How to test - After Medicare providers have submitted claims containing both NPIs and legacy identifiers and those claims have been paid, Medicare urges these providers to send a small batch of claims now with only the NPI in the primary provider fields.  If the results are positive, begin increasing the number of claims in the batch. 

(Reminder:  For institutional claims, the primary provider fields are the Billing and Pay-to Provider fields.  For professional claims, the primary provider fields are the Billing, Pay-to, and Rendering Provider fields.  If the Pay-to Provider is the same as the Billing Provider, the Pay-to Provider does not need to be identified.)

Remember, if you test and your claims are processed successfully, you can approach the May 23rd date with confidence. If you do not, you may face unanticipated cash flow problems.

Medicare DMEPOS Suppliers: If Your Claims Are Rejecting!

Medicare DMEPOS suppliers may be experiencing claims rejections if they did not obtain their NPIs properly, if they are not properly enrolled in Medicare, or both.  For example, if a DMEPOS supplier who is a sole proprietorship enrolled with the National Supplier Clearinghouse (NSC) as an organization and furnished an Employer Identification Number (EIN) instead of a Social Security Number (SSN), but obtained a National Provider Identifier (NPI) as an Entity type 1 - Individual, the Medicare NPI Crosswalk will be unable to link that DMEPOS supplier's Medicare legacy identifier (the NSC number) to its NPI.  This is because the NSC number and the NPI identify different entity types--one identifies an organization and the other an individual.  When a linkage between a Medicare legacy identifier and an NPI used in a claim does not exist in the Medicare NPI Crosswalk, the claim will reject.  DMEPOS suppliers should contact the DME MAC if they do not understand the error message they received.

If the rejection was due to the inability of the Medicare NPI Crosswalk to link the NPI to the NSC number, the DMEPOS supplier should  check the NPPES record to ensure the appropriate Entity type (1 = Individual; or 2 = Organization) is reflected in that record.  Individuals (including sole proprietorships) obtain NPIs as Entity type 1.  Organizations obtain NPIs as Entity type 2.  If the NPPES record shows the appropriate Entity type, the DMEPOS supplier should contact the NSC to ensure the enrollment record is correct.  If the NPPES record does not show the appropriate Entity type, the DMEPOS supplier needs to take action to ensure the appropriate Entity type is selected.  If assistance is necessary, the NPI Enumerator (1-800-465-3203) can explain to the DMEPOS supplier how this is done. 

Once the NPPES record is correct, the DMEPOS supplier needs to ensure that it is properly enrolled in Medicare.  The NSC, once contacted, will ask appropriate questions to determine if the DMEPOS supplier is, in fact, a sole proprietorship, and if so, properly reflected as such in the enrollment record.  The NSC will assist the DMEPOS suppliers in correcting their enrollment records.

DMEPOS suppliers who are sole proprietorships should be aware of the following:

• A DMEPOS supplier who is a sole proprietorship obtains an Entity type 1 (Individual) NPI. 
• When enrolling in Medicare (form CMS-855S) with the NSC, a DMEPOS supplier who is a sole proprietorship furnishes his/her SSN as the Taxpayer Identification Number (TIN). 
• The Legal Name of the sole proprietorship business is the sole proprietor’s name. 
• It is possible for the sole proprietorship to have a “doing business as” (dba) name.  The dba name can be reported on the CMS-855S and in the NPI application (in the “Other Name” field).  A dba name, however, is not a Legal Name.
• It is possible that the sole proprietorship requested and received an Employer Identification Number (EIN) from the IRS if the sole proprietorship has employees.  This EIN will protect the sole proprietor’s SSN from appearing in claims and on W-2s. 
• Medicare will treat the EIN as the TIN for purposes of claims processing, but the SSN must still be reported on the CMS-855S. 
• When Medicare reports tax information to the IRS for that EIN, the IRS will link that EIN to the sole proprietor’s SSN.

Additional Information on Reporting a National Provider Identifier (NPI) for Ordering/Referring and Attending/Operating/Other/Service facility for Medicare Claims

Visit http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5890.pdf for a recently released MLN Matters Article on the topic of reporting NPIs for order/referring and attending/operating/other/service facility for Medicare claims. 

CMS to Host National NPI Roundtable on 2/6/2008

CMS will host a national NPI Roundtable on Wednesday, February 6^th from 2:30 – 4PM ET.  This call will focus on the status of the Medicare implementation and a related question and answer session.  Registration details are available at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/listservwording2-6-08npicall.pdf on the CMS website.  

WEDI to Host NPI Audiocast

The Workgroup for Electronic Data Interchange (WEDI) will host an audiocast to discuss NPI implementation from an industry-wide standpoint.  The audiocast will be held on February 21, 2008.  Visit http://www.wedi.org/npioi/index.shtml for registration details.  Please note there is a charge to participate in WEDI events. 

Need More Information?

Not sure what an NPI is and how you can get it, share it and use it?  As always, more information and education on the NPI can be found through the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website.  Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203.  Having trouble viewing any of the URLs in this message?  If so, try to cut and paste any URL in this message into your web browser to view the intended information. 

Note: All current and past CMS NPI communications are available by clicking "CMS Communications" in the left column of the www.cms.hhs.gov/NationalProvIdentStand  CMS webpage.

• Email This
• Print
• Comments
• Share Link

• Email This
• Print
• Comments
• Share Link

• Email This
• Print
• Comments
• Share Link

EXHAUSTION OF ADMINISTRATIVE REMEDIES CONFIRMED AGAIN

A Colorado Federal District Court has confirmed the applicability of the doctrine of exhaustion administrative remedies regarding credentialing disputes. In Catholic Health Initiatives, Colorado v. Gross, Dr. Gross terminated the hospital peer review process by resigning during the early stages of an investigation. The facts of the case indicate that a quality issue regarding Dr. Gross’ performance arose at the hospital. The hospital notified Dr. Gross of its evaluation and indicated that he should either voluntarily withdraw his privileges to perform certain surgical cases or that he continues to perform the procedures only with the assistance of a proctor under specified conditions. Rather than comply, Dr. Gross resigned. When Dr. Gross attempted to withdraw his resignation, the hospital took the position that the resignation was final and that Dr. Gross’ only recourse was to reapply for medical staff membership and clinical privileges.

Dr. Gross filed suit in District Court alleging breach of a duty of good faith, denial due process and tortious interference with contractual relationships. The District Court granted the hospital’s motion for summary judgment on the due process and breach of contract issues, but split its decision on two tortious interference claims. One claim based upon a Data Bank Report was dismissed based upon HCQIA immunity. The second, based upon the hospital’s non-peer review conduct, was not dismissed.

The Federal District Court followed the recent holding of the Colorado Supreme Court in Crow v. Penrose-St. Francis Healthcare System, which required that a physician must exhaust all peer review committee administrative remedies before seeking relief in court. This decision was featured in a Med Law Blog post on October 29, 2007.

A copy of the full opinion is available at the following link:

http://op.bna.com/hl.nsf/id/mapi-79zptc/$File/catholic.pdf

• Email This
• Print
• Comments
• Share Link

HSA limits for 2008 are as follows:

Annual Contribution Limits:   The maximum HSA contribution is  $2,900 for individual coverage and $5,800 for family coverage.

High Deductible Health Plan Limits:  

·        Deductible:  The minimum deductible for HSA-qualified high deductible health plans is $1,100 for individual coverage and $2,200 for family coverage policies.

·         Out- of-Pocket Maximums:    The out- of-pocket maximums are $5,600 for individual coverage and $11,200 for family coverage policies.

Original Source:   Rev. Proc 2007-36  http://www.irs.gov/irb/2007-22_IRB/ar14.html#d0e3138

• Email This
• Print
• Comments
• Share Link

• Email This
• Print
• Comments
• Share Link

JOINT COMMISSION ANNOUNCES MS.1.20 TASK FORCE

The Joint Commission today announced the establishment of a special fact finding task force that will examine implementation issues related to revised hospital medical staff standard MS.1.20 and address issues of concern that have been raised.   The Joint Commission expects the task force report at the Board of Commissioners meeting on February 29, 2008. The text of the Joint Commission press release can be accessed through the link below.

http://www.jointcommission.org/NewsRoom/NewsReleases/nr_1_3_08.htm

• Email This
• Print
• Comments
• Share Link

As of February 1, 2008, U.S. citizens may begin to apply for the New Passport Card. The passport card will facilitate travel between the U.S. and land border as well as sea ports-of-entry countries such as Canada, Mexico, Bermuda and the Caribbean. The new passport card will carry the same rights and privileges as a U.S. passport and is being issued in response to a need for a more efficient and cost effective means of travel for border communities.

www.medlawblog.com/US citizen passport cards(1).pdf

Lisa Ventresca

• Email This
• Print
• Comments
• Share Link

CORF SERVICES

I.          INTRODUCTION

CORF Services may consist of physician services, physical and occupational therapy services, speech pathology services, respiratory services, prosthetic or orthotic devices and related services, social and psychological services, drugs and biologicals, vaccines and supplies, appliances and equipment. Any of these services may be provided provided a physician first certifies the medical necessity of skilled rehabilitation services and establishes a plan of treatment in accordance with 42 CFR §410.105. The 2008 Regulations are intended to do the following:

1.          Distinguish the types of physician services which are comprehensive outpatient rehabilitation facility (CORF) services provided by a physician and, therefore, included within the CORF reimbursement, from physician services which are separate medical or surgical physician services and therefore not included within CORF reimbursement but are separately billable;

2.          Coordinate the regulations with the existing fee schedule reimbursement structure;

3.          Revise the conditions for coverage; and

4.          Clarify the coverage of nursing services, drugs and biologicals, and vaccines.

 II.         PHYSICIAN SERVICES

1.          Statute: The distinction is based upon the statutory language of 42 USC §1395x(cc)(1)(2), which defines CORF services and CORF. The definition of services includes physician services but is not intended to cover typical outpatient or inpatient physician services.

2.         Regulations: The 2008 Regulations distinguish between types of services. 42 CFR §414.100(a) specifically provides that CORF physician services are administrative in nature and that diagnostic and therapeutic physician services are not CORF services, but (if otherwise covered) would be separately reimbursable under part 414.

a.         Physician Services are defined in 42 USC §1395x(q) as surgical and medical or consultative services. 

b.         CORF services are defined in 42 USC §1395x(cc) to exclude any services which would not be covered if provided to an inpatient at a hospital facility.

c.         42 USC §1395x(b)(4) defines hospital inpatient services and specifically excludes medical or surgical services provided by physicians (including residents or interns) certified nurse midwives, certified registered nurse anesthetists, and psychologists.

III.         REIMBURSEMENT

42 CFR §414.1105 defines the payment mechanism for CORF services, which has been in effect since 1999 when CORF reimbursement was changed from cost-based reimbursement to physician fee schedule reimbursement. 

1.         Section 414.1105(b) specifically states that there will be no separate payment for physician services that are CORF services (physician/administration services).

2.         All other services are paid pursuant to the physician fee schedule pursuant to Section 414.1105(a) which states, that CORF services will be paid at the lesser of 80% of the following:

            a.         The actual charge for the item or services; or

b.         The non-facility amount determined under the physician fee schedule established under Section 1848(b) of the act for the item or service.

That reference is to Section 1848 of the Social Security Act, i.e., 42 USC

§1395w-4, which established the Medicare RB-RVS physician fee schedule in 1992.

3.          Supplies and durable medical equipment that are CORF services under 42 CFR §410.100(f), orthotic devices that are CORF services under 42 CFR §410.100(g), and drugs and biologicals that are CORF services at the lesser of eighty percent (80%) of either (1) actual charge or (2) the DMEPOS fee schedule.

a.         Prosthetic devices are devices that replace all or part of an organ or body member but exclude dental and renal dialysis machines.

b.         Orthotic devices include orthopedic devices and services reasonably necessary to effectuate their use.

c.         Drugs and biologicals are those prescribed by a physician and not otherwise excluded from Part B coverage.

IV.        COVERAGE REQUIREMENTS.   

CMS has revised the coverage requirements of 42 CFR §410.105 to clarify that all services provided must be necessary for the rehabilitation of the patient, allows certain home services, and extends the review period to 90 days instead of 60 days, except for respiratory services. 42 CFR §410.105(c)(1)(ii) now requires that treatment plan to:

1.        Indicate the diagnosis and rehabilitation goals;

2.        Prescribe the type, amount, frequency and duration of the skilled rehabilitation services, including PT, OT, speech and respiratory therapy; and

3.        Indicate the other CORF services to be furnished that relate directly to such rehabilitation goals. 

• Email This
• Print
• Comments (3)
• Share Link

REPORTING OF CARDIAC REHABILITATION SERVICES

Cardiac rehab services were being reported as CPT 93797 (physician services for outpatient cardiac rehabilitation without continuous ECG monitoring) and CPT 93798 (physician services for outpatient cardiac rehabilitation with continuing ECG monitoring). CMS proposed to establish two new HCPCs codes to report cardiac rehab services, i.e., GXXX 1 (physician services for outpatient cardiac rehabilitation without continuous ECG monitoring per hour) and GXXX 2 (physician services for outpatient cardiac rehabilitation with continuous ECG monitoring per hour).

• Email This
• Print
• Comments
• Share Link

(Department of Homeland Security, Bureau of Customs and Border Protection) U.S., Canadian and Bermudian citizens entering the United States at land or sea ports-of-entry must establish their identity and citizenship to the satisfaction of a U.S. Customs and Border Protection (CBP) Officer. Under current CBP procedures, such individuals may provide any proof of identity and citizenship.

• Email This
• Print
• Comments
• Share Link