Transcript 2011 3rd Party Update - American Optometric Association
2011 3
rd
Party Update
In the 3 rd Party Area… What has happened in the last 12 months What to expect in the next 12 months 1
2011 3
rd
Party Update
HIPAA (EDI) Claim Format ICD-10-CM Privacy EHR PQRS eRx WPS CMS Noridian CEDI Medicaid Coding AOA Potpourri 2
2011 3
rd
Party Update
HIPAA (EDI)
Claim Format
ICD-10-CM Privacy EHR PQRS eRx WPS CMS Noridian CEDI Medicaid Coding AOA Potpourri 3
HIPAA EDI – Version 5010
The Health Insurance Portability and Accountabiliy Act (HIPAA) electronic data interchange (EDI) federal regulations require that health data be transmitted in a standardized form. HIPAA is updating that transmission method from HIPAA version 4010A1 to HIPAA version 5010 starting January 1, 2012.
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HIPAA EDI – Version 5010
WHO: Any plan, clearinghouse or provider who transmits any health information in electronic form. Includes changes to CMS-1500 claim forms.
WHY: The current format is unable to support ICD-10 and pay for performance (PQRS; eRx; EHR) . WHEN : Mandatory January 1, 2012. 5
HIPAA EDI – Version 5010
WHAT TO DO: Providers who use practice management and other applicable software programs should make sure that their software programs feature the updated Versions 5010 and D.0 HIPAA transaction standards.
It's likely that your practice management software will need to be upgraded. 6
HIPAA EDI – Version 5010
WHAT TO DO: To meet the January 1, 2012 implementation date, providers should begin testing Version 5010 with their trading partners NOW. You must test before January 1, 2012.
Talk to your software vendor, clearinghouse, or billing service NOW, and work together to make sure you'll have what you need to be ready. 7
HIPAA EDI – Version 5010
WHAT TO DO: Contact your Medicare Administrative Contractor MAC to inquire about their testing protocols. WPS Medicare http://www.wpsmedicare.com/j5macpartb/departments/edi_/ Noridian (CEDI) http://www.ngscedi.com/5010/5010.htm
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HIPAA EDI – Version 5010
WHAT TO DO: Use 9-digit zip codes for billing provider address Use 9-digit zip code for service facility locations (POS) Lock box and post office boxes are not acceptable billing provider addresses http://nebraska.aoa.org/prebuilt/noa/2011-05%203RD%20Party%20Newsletter.pdf
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HIPAA EDI – Version 5010
Paper Claims: CMS-1500 claim forms will also be altered Modification proposals are now being considered 10
HIPAA EDI – Version 5010
Resources for 5010 Versions 5010 & D.0 FAQs Now Available!
https://questions.cms.hhs.gov/app/answers/list/kw/5010 National Testing Day Message Now Available!
http://www.cms.gov/Versions5010andD0/Downloads/5010_National_Testing_Day_Message.pdf
5010/D.0 Errata requirements and testing schedule http://www.cms.gov/Versions5010andD0/Downloads/Errata_Req_and_Testing.pdf
Contact your MAC for their testing schedule http://www.cms.gov/Versions5010andD0/Downloads/Reminder-Contact_MAC.pdf
Have you done the following to be ready for 5010/D.0?
http://www.cms.gov/Versions5010andD0/Downloads/Readiness_1.pdf
What do you need to have in place to test with your MAC?
http://www.cms.gov/Versions5010andD0/Downloads/Readiness_2.pdf
Do you know the implications of not being ready?
http://www.cms.gov/Versions5010andD0/Downloads/Readiness_5010.pdf
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2011 3
rd
Party Update
HIPAA (EDI)
Claim Format
ICD-10-CM
Privacy EHR PQRS eRx WPS CMS Noridian CEDI Medicaid Coding AOA Potpourri 12
HIPAA – ICD-9 to ICD-10
Starting October, 2013 you will be required to use ICD-10 diagnosis coding instead of ICD-9 ICD-10 Coding is completely different than ICD-9.
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HIPAA – ICD-9 to ICD-10
https://www.cms.gov/ICD10/11b1_2011_ICD10CM_and_GEMs.asp
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HIPAA – ICD-9 to ICD-10
http://www.revoptom.com/content/d/practice_management/c/14816/ 15
HIPAA – ICD-9 to ICD-10
https://www.cms.gov/ICD10/Downloads/ICD-10QuickRefer.pdf
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2011 3
rd
Party Update
HIPAA (EDI)
Claim Format ICD-10-CM
Privacy
EHR PQRS eRx WPS CMS Noridian CEDI Medicaid Coding AOA Potpourri 17
HIPAA Privacy Updates
Be sure to give every new patient your “Notice of Privacy Practices” (NPP) and have the acknowledge receipt in writing.
Be sure to post your NPP in an obvious location in your office.
If your office has a web site, you must post your NPP in an obvious location on you website. 18
HIPAA Privacy Updates
If you alter your NPP, be sure to give every patient a copy of the revised NPP and have them acknowledge receipt in writing.
On subsequent visits, remind patient that the NPP is available. On subsequent visits, note in record whether NPP had previously be given and acknowledged in writing. 19
HIPAA Privacy Updates
Review your NPP with staff on a regular basis. (Dr. Quack receives HIPAA privacy questions which should be answered by the office’s NPP) Review your HIPAA Office Manual yearly, and update as needed (names of employees, etc.) 20
HIPAA Privacy Updates
Find “Uses and Disclosures for Treatment, Payment, and Health Care Operations,” which is at http://www.hhs.gov/ocr/privacy/hipaa/understandin g/ coveredentities/usesanddisclosuresfortpo.html Review the “Summary of the HIPAA Privacy Rule” at http://www.hhs.gov/ocr/privacy/hipaa/understandin g/summary/ index.html
FAQs bys by category may be found at http://www.hhs.gov/hipaafaq/ .
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2011 3
rd
Party Update
HIPAA Claim Format ICD-10-CM Privacy
EHR
PQRS eRx WPS CMS Noridian CEDI Medicaid Coding AOA Potpourri 22
2011 Payments
Payment based on 75 percent of their total Medicare allowed charges submitted no later than two months after the end of the 2011 calendar year. The maximum allowed charges used for a 2011 incentive payment are $24,000. This means that the maximum incentive payment an EP can receive for 2011 is $18,000.
Incentive payments will not be made until the EP meets the $24,000 threshold in allowed Medicare charges.
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Attestation Resources
CMS has resources to help you attest to having met meaningful use requirements in order to receive your EHR incentive payment.
An
Attestation page
, http://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp
, where participants in the Medicare EHR Incentive Program can find important information on attestation.
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Attestation Resources
The Meaningful Use Attestation Calculator, http://www.cms.gov/apps/ehr/ which allows EPs and eligible hospitals to check whether they have met meaningful use guidelines before they attest in the system. The calculator prints a copy of each EP's or eligible hospital's specific measure summary.
The Attestation User Guide for Medicare http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_User_Guide.pdf
, which provide step-by-step guidance for EPs and eligible hospitals participating in the Medicare EHR Incentive Program on navigating the attestation system.
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Attestation Resources
Attestation Worksheet
to use while attesting. for http://www.cms.gov/EHRIncentivePrograms/Downloads/EP_Attestation_User_Guide.pdf
, which allow users to fill out their meaningful use measure values, so they have a quick reference tool Attestation is currently open for all participants in the Medicare EHR Incentive Program via the
Medicare & Medicaid EHR Incentive Program Registration and Attestation System
https://ehrincentives.cms.gov/hitech/login.action
.
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EHR Approved Software
ActivEHR™ 2011.1 by EMRlogic Systems Advantage EHR Version 10 by Compulink Business Systems Crystal Practice Management by Abeo Solutions Electronic Health Records (EHR) Version 7.6
by Medflow ExamWRITER Version 10 by Eyefinity/OfficeMate MaximEyes® SQL Electronic Health Records Version 1.1.0 by First Insight Corporation Ocular Medical Records Version 11.0 by QuikEyes Practice Director by Williams Marketing RevolutionEHR Version 5.1.0 by Health Innovation Technologies 27
EHR and FAQs
CMS has posted the latest EHR FAQs document on the CMS website. Go to http://www.cms.gov/EHRIncentivePrograms/Downloads/FAQsRemediatedandRevised.pdf
CMS will continue to provide updates as new FAQs are added.
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2011 Attestation Q & A
Do you have questions about attestation?
Get answers to some of the most commonly asked questions about attestation.
How will I attest for the Medicare and Medicaid Incentive Programs?
What can I do now to prepare for attestation?
Where can I find user guides and other resources?
What will I need to login to the Attestation System?
What is the EHR Certification Number?
I am an Eligible Provider. Can I designate a third party to register and/or attest on my behalf?
https://www.cms.gov/EHRIncentivePrograms/32_Attestation.asp
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2011 3
rd
Party Update
HIPAA Claim Format ICD-10-CM Privacy EHR PQRS
eRx
WPS CMS Noridian CEDI Medicaid Coding AOA Potpourri 30
Medicare Reimbursement Adjustment (penalty).
2012 Medicare Payments docked 1%* 2013 Medicare Payments docked 1.5% 2014 Medicare Payments docked 2% *It is still unknown whether or not the -1% 2012 payment adjustment applies to ODs 31
Avoiding Adjustment
Must use approved eRx software as required by Medicare Must report at least 25 unique eRx events for patients in the denominator of the measure before 12/31/11. (92000 or 99000 exam). ODs use “Claims-based reporting” of the electronic prescribing measure. Report a successful e-Rx with G-code (G8553) for 2011 32
Avoiding the Medicare e-Prescribing “Adjustment” (penalty)
You can get e-Rx credit for re-prescribing an Rx…but you cannot get credit for giving a pharmacy permission to refill an Rx.
You can get credit if you successfully e-Rx with your approved e-Rx software, even if an intermediary changes your e-Rx to a Fax. 33
Exemptions and Exceptions
To request an exemption to the eRx Incentive Program and the payment adjustment, there are two “hardship codes” that can be reported via claims should one of the following situations apply, plus an exemption for not having prescribing privileges. There are also two exceptions 34
Exemptions
G8642 - The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act. 35
Exemptions
G8643 - The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act 36
New Exemptions
The final rule provides additional significant hardship exemption categories for 2011 for the 2012 eRx payment adjustment: (1) eligible professionals who register to participate in the Medicare or Medicaid EHR Incentive Program and adopt certified EHR technology ; 37
New Exemptions
(2) eligible professionals who are unable to electronically prescribe due to local, state, or federal law or regulation ; (3) eligible professionals who have limited prescribing activity ; (4) eligible professionals who have insufficient opportunities to report the e-prescribing measure due to limitations of the measure’s denominator .
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Exceptions
Does not have prescribing privileges . Note: (S)he must report (G8644) at least one time on an eligible claim prior to December 31, 2011; Does not have at least 100 cases containing an encounter code in the measure denominator (92000 and 99000 exam codes) 39
What to Do?
Go to the CMS e-prescribing web site Click on “How to get Started” (left column)
http://www.cms.gov/ERxIncentive/03_How_To_Get_Started.asp#TopOfPage
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2010 eRx Payments
LE will appear on the electronic remit.
CMS created a 4-digit code to indicate the type of incentive and reporting year. For the 2010 eRx incentive payments, the 4-digit code is RX10. For example, eligible professionals will see LE to indicate an incentive payment, along with RX10 to identify that payment as the 2010 eRx incentive payment.
The paper remittance advice will read, “This is an eRx incentive payment.” The year will not be included in the paper remittance.
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2010 eRx Payments
Who to Contact for Questions? Provider Contact
Center. The Contact Center Directory is available at http://www.cms.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip
The QualityNet Help Desk is available Monday through Friday from 7:00 a.m. – 7:00 p.m. CST at 1- 866-288-8912 or via questions.
. The help desk can also assist with program and measure-specific The following CMS resource is available to help eligible professionals understand the 2010 eRx Incentive Payments, view A Guide for Understanding the 2010 eRx Incentive Payment [PDF 57 KB] , on the CMS website.
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2011 3
rd
Party Update
HIPAA Claim Format ICD-10-CM Privacy EHR PQRS eRx
WPS
CMS Noridian CEDI Medicaid Coding AOA Potpourri 43
Nursing Home Coding
1.
Make sure there is a justifiable medical reason for the visit.
2.
If using E&M coding, make sure your documentation justifies your 99307, 99308, or 99309 claim. 3.
Don’t let your documentation look “cookie-cutter”. If all your documentation looks alike, it raises question of authenticity.
4.
3. The AOA says an OD can use the 92xxx exam codes when making nursing home visits, using the place of service codes of 31 (skilled nursing facility) or, more likely, 32 (nursing facility).
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Final Code must be Reasonable and Necessary
• • • • Considering Chief Complaint/ Reason for visit / Presenting Problem History Clinical findings Decision Making Required 45
Must Sign Written Order for Testing
WPS Medicare's Comprehensive Error Rate Testing (CERT) error findings for insufficient documentation accounted for 50% of all errors assessed.
The majority of these errors were due to the LACK OF A VALID PHYSICIAN ORDER for diagnostic services.
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CHANGES IN THE WPS OPTOMETRY LCD, EFFECTIVE JANUARY 1, 2011 The following CPT codes have been added to Table I for All Optometrists; •76513 •82962 •83516 •83520 92018 92019 92260 92270 92287 92541 92542 92544 99221-99223 99231-99233 99281-99283 99350 99354 99355 99356 99357 47
CHANGES IN THE WPS OPTOMETRY LCD, EFFECTIVE JANUARY 1, 2011 The following Codes have been added to Table II for Optometrists with a therapeutic license; 65272 65275 65286 65600 67825 67850 68020 98020 68530 68810 68840 76529 82785 87070 87081 87205 87809 87809 .
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CHANGES IN THE WPS OPTOMETRY LCD, EFFECTIVE JANUARY 1, 2011 The following CPT codes, found in Table II, no longer require a -55 modifier; 67820 67938 68040 68761 68801 49
2011 3
rd
Party Update
HIPAA Claim Format ICD-10-CM Privacy EHR PQRS eRx WPS
CMS
Noridian CEDI Medicaid Coding AOA Potpourri 50
Consolidated Billing
Medicare’s Consolidated Billing
is when you bill the patient's SNF for materials, and some services, rather than Noridian or WPS. Applies when the patient Had an inpatient hospital stay of 3 consecutive days or more.
Has remaining Medicare Part A benefits His/her doctor decided daily skilled care is needed.
The SNF has been certified by Medicare.
The skilled services are needed due to hospital stay.
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Consolidated Billing
Whenever you have a scheduled patient who is residing in a SNF, prior to examination you should always ask the SNF if the patient is currently covered under Medicare A.
If so, you need to explain to the SNF about consolidated billing, since most are unfamiliar with the term or its consequences.
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Consolidated Billing
All post-op DME billing that would normally go to Noridian must now go to the SNF.
The technical component of most ancillary testing must also go to the SNF. 53
Consolidated Billing
Technical component of the following codes must be billed to the SNF 92060 SPEC’L EYE EVAL.
92065 ORTHOPTICS 92081 VISUAL FIELDS 92082 VISUAL FIELDS 92083 VISUAL FIELDS 92133-4 DX IMAGING 92136 OPHTHALMIC BIOMETRY 92235 EYE EXAM WITH PHOTOS 92240 ICG ANGIOGRAPHY 92250 EYE EXAM WITH PHOTOS 92265 EYE MUSCLE EVALUATION 92270 ELECTRO-OCULOGRAPHY 92275 ELECTRORETINOGRAPHY 92283 COLOR VISION 92284 DARK ADAPTATION EYE 92285 EYE PHOTOGRAPHY 92286 INTERNAL EYE PHOTO Excerpted From http://cms.hhs.gov/medlearn/file2pctc1.
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Consolidated Billing
It is important that you work cooperatively with the SNF in these matters . If either you or the SNF have questions about consolidated billing, you can find further information at the CMS website on consolidated billing: http://www.cms.hhs.gov/medlearn/snfcode.asp.
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Medicare Limiting Charge
Non-Participating Medicare Providers Cannot Bill or Charge Usual and Customary Fees. The rules are….
You do not have to see Medicare patients. But, if you see ANY Medicare patients, federal law requires you to follow Medicare guidelines. Non-Par providers must file claims for their Medicare Patients.
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Medicare Limiting Charge
Non-Par providers must not bill more than the Medicare limiting charge (last column on Medicare Fee Schedule), under penalty of federal law. Non-par Providers Cannot Collect From Medicare Patients & Medigap &/or Patient a Total $ Amount More Than The Medicare
Limiting Charge Excessive billing or failure to file claims will
incur severe fines. 57
Medicare Limiting Charge
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Medicare Limiting Charge
A provider who violates the limiting charge is subject to Assessments of up to $10,000 per violation plus Triple the amount of the charges in violation, and Possible exclusion from the Medicare program. 59
Medicare Fees You Cannot Charge Medicare Patients Extra Fees such as
A Finance Charge
Interest
Other Similar Types Of Charges.
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New ABN Required November 1st
release date of 3/2011 printed in lower left hand corner https://www.noridianmedicare.com/dme/forms/docs/cms-r-131.pdf
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2011 3
rd
Party Update
HIPAA Claim Format ICD-10-CM Privacy EHR PQRS eRx WPS CMS
Noridian
CEDI Medicaid Coding AOA Potpourri 62
Medicare DME Enrollment
DME Suppliers Must Now Pay $500+ To Enroll Or To Re-Enroll
DME Suppliers Must Re-Enroll Every 3 Years. CMS requires that all DMEPOS suppliers re-enroll every three years with the NSC Requires application fee of $505 in 2011 as part of the enrollment process http://www.cms.gov/MLNMattersArticles/downloads/MM7350.pdf
http://www.cms.gov/MedicareProviderSupEnroll/ 63
DME Supplier Standards
•Medicare standards a supplier of DME must meet •The supplier must certify it meets the standards. •The supplier standards can be found in 424 CFR Section 424.57
DME Electronic Claims:
Annual CEDI Recertification
CEDI Recertification Now Required Annually
Beginning in 2011, CEDI is requiring all Trading Partners to recertify their user access on an annual basis. If you have your own submitter ID that contains A08, B08, C08, or D08, you are a "trading partner”. DO IT NOW.
http://www.ngscedi.com/forms/formsindex.htm
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2011 3
rd
Party Update
HIPAA Claim Format ICD-10-CM Privacy EHR PQRS eRx WPS CMS Noridian CEDI
Medicaid
Coding AOA Potpourri 66
Medicaid Managed Care
At the behest of the Unicameral, Medicaid managed care will go state wide in July (?) of 2012.
No one yet knows which insurers will be approved as MCOs in the newly affected areas of the state. 67
Medicaid Managed Care
MCOs authorize, arrange, provide, and pay for the delivery of health care services to enrolled clients.
Cover all Medicaid recipients except Those also covered by Medicare, Residents of nursing or intermediate care facilities Certain other narrow exclusions.
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Medicaid Managed Care
If the MCOs currently serving eastern Nebraska are approved for out-state, and If they handle the situation the same as they have in the eastern 10 counties, Then Nebraska ODs will need to be a Block Vision provider to see routine care Medicaid patients, and Will need to be a Share Advantage Nebraska and a Coventry provider to see medical diagnosis patients.
However BCBS should also be a strong contender. 69
2011 3
rd
Party Update
HIPAA Claim Format ICD-10-CM Privacy EHR PQRS eRx WPS CMS Noridian CEDI Medicaid
Coding
AOA Potpourri 70
WPS: 92004 Dilation
WPS Q & A on 92004 Eye Exams
CERT [Comprehensive Error Rate Testing] states that 92004 must include initiation of diagnostic and treatment services, and should include dilation, unless documentation show contraindication 71
Medicare Coverage
VEP And Tear Osmolarity Not Covered By Medicare Make sure you have a ABN signed if you plan to perform either test on Medicare patients.
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Medicare Coverage
Diabetic Examinations Despite HHS and CMS ostensibly advocating preventative medicine, 250.0x by itself is no longer reimbursable by Medicare.
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Medicare Probe Results for CPT 99213 - Optometry
Of all the specialties checked by WPS and displayed on their website, optometry was the only profession that had More 99214 claims than the national average Less 99213 claims than the national average Make sure your documentation shows justification for the level billed 75
Billing Punctal Plugs to Medicare
The bottom line: ignore the 50 modifier and all the fancy coding; Just vary the number of units. 3 plugs, three units. 4 plugs, 4 units. 76
Ordering/Referring Physicians Must Be in Capital Letters
Medicare Providers who order health care products for Medicare beneficiaries or refer Medicare beneficiaries for health care services must be identified entirely in capital letters on Medicare claims 77
2011 3
rd
Party Update
HIPAA Claim Format ICD-10-CM Privacy EHR PQRS eRx WPS CMS Noridian CEDI Medicaid Coding
AOA
Potpourri 78
From the AOA: Forget The S Codes!
Optometrists play an ever increasing role as members of the primary health care team and Using S Codes poses many risks for access to the full range of optometric services.
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Pay for Performance, Not for Procedures
From the AOA: National Strategy for Quality Improvement in Health Care-
Business as usual, including basing payment on procedures performed, is going by the wayside. Diagnosis related groups (Hospitals) Acute Care Episode (cardiac, orthopedic A & B) Episode of Care (Home Health) 80
2011 3
rd
Party Update
HIPAA Claim Format ICD-10-CM Privacy EHR PQRS eRx WPS CMS Noridian CEDI Medicaid Coding AOA
Potpourri
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FTC Red Flags Rule
Most Optometrists Exempt From Red Flags Rule
Applies only when 1) Using credit reports in the ordinary course of business 2) Furnishing information to credit reporting companies 3) Loaning money 82
Review Insurance Agreements
October is a great time to launch your 'annual' review of all the agreements you've signed with HMOs, medical insurers, and vision plans. 83
The Medical Home
The Medical Home: Communicate with Your
Patient's PCP -- In order for an optometrist to be considered a player in the upcoming medical home scenario, the OD must communicate significant findings to the patient's PCP on a regular basis. 11p4 84