Coding Challenge

Medical Coders: Accepting a PFFS Plan is Your Choice

auditorHere are the pros and cons to help guide your decision.

Question: Our practice is considering accepting patients with PFFS plans. We’re heard that some patients are starting to have them, but we’re not sure whether we’re going to accept them or not. Are PFFS plans beneficial for us?

Answer: PFFS are Private Fee-for-Service plans, which are non-network plans. These plans let members receive care from any doctor or hospital that accepts the plan’s payment terms and conditions.

If your practice decides to accept these terms, you would become a “deemed” provider. Plan members can receive covered services from any deemed provider in the U.S. However, member patients must confirm that the provider is deemed every time a service is provided.

PFFS plans are different from Medicare Advantage plans because they do not require a doctor or hospital to contract with a health plan to provide services. This means that doctors or hospitals that do not agree to the PFFS plans’ terms and conditions may choose not to provide health care services to a plan member, except in emergencies.

Coming soon: Starting in 2011, PFFS plans will have to measure and report on their providers’ quality of care. But the catch is that they’ll also have to form provider networks with contracts.

In counties where there are two or more non-PFFS plans, PFFS plans will no longer be able to simply “deem” providers into the plan without a contract. Under current law, PFFS plans don’t have to prove they can meet access standards if they allow any willing qualified Medicare provider to participate, and they pay as traditional Medicare would pay.

One argument is that the network requirement would provide better access to care because there would be contracts between the providers of services and the plan. On the...

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June 18, 2010
CMS / Hot Coding Topics / ICD-10

Heads Up Coders: 2013 ICD-10 Implementation Date Is Firm

Plus: CMS has proposed freezing the ICD-9 codeset after next year.

If you were hoping that the Oct. 1, 2013 ICD-10 implementation date wasn’t set in stone, you are out of luck. That’s the word from CMS during a June 15 CMS Open Door Forum entitled “ICD-10 Implementation in a 5010 Environment.”

“There will be no delays on this implementation period, and no grace period,” said Pat Brooks, RHIA, with CMS’s Hospital and Ambulatory Policy Group, during the call. “A number of you have contacted us about rumors you’ve heard about postponement of that date or changes to that date, but I can assure you that that is a firm implementation date,” she stressed.

Brooks indicated that the rumor about a potential delay in the implementation date continues to persist throughout the physician community, and recommended that practice managers alert their physicians to the fact that that the rumor is untrue.

The Oct. 1, 2013 date will be in effect for both inpatient and outpatient services. Keep in mind that the ICD-10 implementation will have no impact on CPT and HCPCS coding, Brooks said. You will still continue to bill your CPT and HCPCS procedure codes as before.

You’ll Find Nearly 55,000 Additional Codes

Currently, CMS publishes about 14,000 ICD-9 codes, but there are over 69,000 ICD-10 codes. The additional codes will allow you to provide greater detail in describing diagnoses and procedures, Brooks said.

If you’re wondering which specific codes ICD-10 includes for your specialty, you can check out the entire 2010 ICD-10 codeset, which CMS has posted on its Web site. “Later this year, we’ll be posting the 2011 update,” Brooks said during the call.

@ For more details on CMS’ upcoming plans, subscribe to Part B Insider (Editor: Torrey Kim, CPC).

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June 18, 2010
Provider News

Part B Payment: Expect Claims To Be Released Today

MACs won’t process June claims until today, in hopes that Congress will act.

The Senate’s delays could mean serious payment crunches for your practice.

Last month, the freeze that has been keeping the Medicare conversion factor at 2009 levels expired, meaning that Part B practices were due to face a 21-percent cut effective for dates of service June 1 and thereafter. Because Congress had not yet intervened to stop those cuts, CMS initially instructed MACs to hold claims for the first 10 business days of June while lawmakers could deliberate whether to eliminate the looming cuts.

When the Senate reconvened on June 7, many analysts expected its members to vote on H.R. 4213, “The American Jobs and Closing Tax Loopholes Act of 2010,” which was expected to increase your payments through the end of this year, according to the text listed on the House Ways and Means Committee Web site. However, the bill has not passed, leading CMS to extend the MACs’ claims hold through June 17.

According to a June 14 CMS notification, the agency directed its contractors “to continue holding June 1 and later claims through Thursday, June 17, lifting the hold on Friday, June 18.”

CMS acknowledged in its June 14 notification that the lengthened claims hold period “may present cash flow problems for some Medicare providers. However, we expect that the delay, if any, beyond the normal processing period will be only a few days.”

The impact of the 17-day claims hold will vary, depending on the practice and how many Medicare patients it sees, says Quinten A. Buechner, MS, MDiv, CPC, ACSFP/GI/PEDS, PCS, CCP, CMSCS, president of ProActive Consultants in Cumberland, Wis.

Those practices with large Medicare populations could face a cash flow crisis, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I,...

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June 18, 2010