IN THIS ISSUE
* Welcome
* Beta Release of Azalea℠ EHR available December 1st or New Software Platform
* What is an ACO?
* How the Version 5010 Changes Modify Your Transition
* Billing Tip: 25 Modifier Usage
* Events
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Welcome
Greetings to all of our Azalea Health Innovations friends and thank you for reading this month’s newsletter. We hope everyone had a wonderful Thanksgiving and we wish everyone a happy and healthy holiday season in December!
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Beta Release of Azalea℠ EHR available December 1st
We are currently in the process of beta releasing the new Azalea℠ EHR and completely redesigned Azalea℠ PM to select beta clients. For further information about our beta testing program, or for more information on the specifics of Azalea℠ EHR and Azalea℠ PM, please contact us at: http://www.azaleahealth.com/contact
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What is an ACO?
An accountable care organization (ACO) is a type of payment and delivery reform model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers form an ACO, which then provides care to a group of patients. The ACO may use a range of different payment models (capitation, fee-for-service with asymmetric or symmetric shared savings, etc.). The ACO is accountable to the patients and the third-party payer for the quality, appropriateness, and efficiency of the health care provided. According to the Centers for Medicare and Medicaid Services (CMS), an ACO is “an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it.”
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How the Version 5010 Changes Modify Your Transition
90-Day Period of Enforcement Discretion for Compliance with Version 5010 Deadline
The Centers for Medicare & Medicaid Services (CMS) recently announced a 90-day enforcement discretion period for all HIPAA covered entities regarding the Version 5010 (ASC X12 Version 5010) transition.
The compliance deadline for the implementation of Version 5010 is still January 1, 2012; however, CMS will not initiate enforcement action until March 31, 2012. CMS made this decision based on industry feedback that many organizations and their trading partners were not yet ready to finalize system upgrades for this transition.
CMS encourages you to continue internal testing and external testing of Version 5010 transactions with trading partners to ensure compliance for Version 5010. Although enforcement action will not be taken prior to March 31, 2012, it is important that you continue to move forward to meet Version 5010 requirements as soon as possible.
During the 90-day enforcement discretion period, the Office of E-Health Standards and Services (OESS) will continue to accept complaints associated with compliance with Version 5010, NCPDP D.0 and NCPDP 3.0 transaction standards beginning January 1, 2012. HIPAA covered entities that are subject to these complaints must produce evidence of either compliance or an established plan to become compliant within the enforcement discretion period. In addition to testing, if you have not yet created a transition plan for Version 5010, you should do so in order to meet these compliance deadlines.
Please visit the CMS ICD-10 Website Latest News page for additional resources and more information on this enforcement discretion period.
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Billing Tip: 25 Modifier Usage
How do I know if I am utilizing the 25 modifier properly?
As a company that both develops practice management software and provides Revenue Cycle Management services, we often get questions about the proper usage of the 25 modifier. We like to refer to the “Use of Modifier 25” study released by the Office Of Inspector General (OIG) under the Department of Health and Human Services in 2006. This release (while 23 pages long) provides excellent insight into the proper and improper usage of the modifier as well as the documentation guidelines. We also like to reference Chapter 12 Sections 30.6.6(B) and 40.2 Of the Medicare Claims Processing Manual.
From the OIG Manual:
Guidance and Outreach
Modifier 25 is used to facilitate billing of evaluation and
management services on the day of a procedure for which separate
payment may be made. It is used to report a significant,
separately identifiable evaluation and management service
performed by the same physician on the day of a procedure. The
physician may need to indicate that on the day a procedure or
service that is identified with a [Current Procedural Terminology]
code was performed, the patient’s condition required a significant,
separately identifiable evaluation and management service above
and beyond the usual preoperative and postoperative care
associated with the procedure or service that was performed.
Required Documentation
- Clinical information confirming that the E/M service billed was above and beyond the E/M services included in the procedure,
- Information to support that the provider submitting the claims for payment is the same provider that furnished both the medical procedure(s) and the E/M service, and
- Information indicating that a single beneficiary received both the medical procedure(s) and the E/M service billed.
Keep in mind that Modifier 25 should only be used with the E/M portion of the claim and not on the procedure itself.
Example: Code a level 3 office visit for an established patient with a benign lesion excision, trunk, arms, or legs, excised diameter 0.6 to 1.0 CM
Correct Usage:
99213-25
11401
Incorrect Usage:
99213-25
11401-25
or
99213
11401-25
How do I know when to use modifier 57 vs 25?
It basically depends on the type of procedure (minor vs major surgery) being performed and its global period (0,10, or 90 days).
From Chapter 12 Section 40.2 Of the Medicare Claims Processing Manual:
You can use Modifier 57 in situations when:
Evaluation and management services on the day before major surgery or on the day of major surgery that result in the initial decision to perform the surgery are not included in the global surgery payment for the major surgery and, therefore, may be billed and paid separately.
If evaluation and management services occur on the day of surgery, the physician bills using modifier “-57,” not “-25.” The “-57” modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.
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Upcoming Events:
AHI will be exhibiting Azalea Labhub℠ at the CLMA ThinkLab’12 – Clinical Laboratory Management Association. The event is being held at the Georgia World Congress Center in Atlanta, GA on April 29 – May 2, 2012.
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Thank you!
Azalea Health Innovations, Inc.
105 West Central Avenue
Valdosta, GA 31601
Toll Free: 877-777-7686
Local: 229-269-4620
Toll Free Fax: 866-683-8679
Web: http://www.AzaleaHealth.com
Email: info@azaleahealth.com
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