CMS announced it has passed a new rule aimed at providing states and insurers with more flexibility in implementing the Affordable Care Act.
Consumers will have a consistent way to compare and enroll in health coverage in the individual and small group markets. This will make it easier for consumers to purchase insurance that will provide better quality, and expanded coverage and benefits.
Key Points are:
• A core package of “Essential Health Benefits” has been developed that must include items and services within at least the following 10 categories:
1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care
Note: Substance use disorder and behavioral health services have had a history of falling into the gap of coverage for millions of Americans. The rule seeks to fix that gap in coverage by expanding coverage of these benefits in three distinct ways:
o By including mental health and substance use disorder benefits as Essential Health Benefits.
o By applying federal parity protections to mental health and substance use disorder benefits in the individual and small group markets.
o By providing more Americans with access to quality health care that includes coverage for mental health and substance use disorder services.
• A benchmark-based approach is aimed at giving states the flexibility to define essential health benefits in a way that would best meet the needs of their residents. States are allowed to select benchmark plan from options offered in the market, which are equal in scope to a typical employer plan.
• In the individual and small group markets, four different actuarial value “metal levels” are outlined in the final rule. Plans that cover essential health benefits must cover a certain percentage of costs (actuarial value): 60 percent for a bronze plan, 70 percent for a silver plan, 80 percent for a gold plan, and 90 percent for a platinum plan.
These ”metal levels” will allow consumers to compare insurance plans with similar levels of coverage and cost-sharing based on premiums, provider networks, and other factors
• The annual amount of cost sharing that individuals will pay across all health plans (preventing insured Americans from facing catastrophic costs associated with an illness or injury) has been limited by this law.
Note: While not yet set for 2014, the comparable limit this year is $6,250 for self-only coverage.
• Accreditation standards for qualified health plans (QHPs) that will be offered through the Health Insurance Marketplaces (also known as Exchanges) are more clearly defined in the final rule.
The Exchanges will be reliable one-stop shops that will provide access to quality, affordable private health insurance choices.
For more information from CMS on this rule, visit:
http://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.html
Get Familiar with Stage 1 Meaningful Use Changes
The Stage 2 rule for the Electronic Health Record (EHR) Incentive Programs included changes to the Stage 1 meaningful use objectives, measures and exclusion for eligible professionals (EPs).
Effective January 1, 2013
Stage 1 Objective
Changes to Objective
Reporting Status
Use Computerized Physician Order Entry (CPOE) for medication orders directly entered by any licensed healthcare professional
Added Alternative Measure:
More than 30% of medication orders created by the EP during the EHR reporting period are recorded using CPOE.
An EP may select either measure for this objective in Stage 1 in order to achieve meaningful use.
(Note: This alternative measure will be required for all providers in Stage 2.)
Generate and transmit permissible prescriptions electronically (eRx)
Added Additional Exclusion:
Any EP who does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his/her EHR reporting period.
Reporting of exclusion is required.
Record and chart changes in vital signs
Changed Age Limitations on Growth Charts and Blood Pressure:
More than 50 percent of all unique patients seen by the EP during the EHR reporting period have blood pressure (for patients age 3 and over only) and height and weight (for all ages) recorded as structured data.
Reporting of this measure is optional.
Record and chart changes in vital signs
Changed: The age and splitting the EP exclusion.
Any EP who
(1) Sees no patients 3 years or older is excluded from recording blood pressure;
(2) Believes that all three vital signs of height, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them;
(3) Believes that height and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure; or
(4) Believes that blood pressure is relevant to their scope of practice, but height and weight are not, is excluded from recording height and weight.
Reporting of this exclusion is optional.
Public Health Reporting Objectives
Changed: All of the Stage 1 public health objectives (submitting data to an immunization registry, submitting data to a syndromic surveillance database, or submitting reportable lab results to a public health agency) will require that providers perform at least one test of their Certified EHR Technology’s capability to send data to public health agencies, except where prohibited.
Reporting required for all Stage 1 public health objectives.
Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, and diagnostic test results), among providers of care and patient authorized entities electronically
Changed: Objective now part of Stage 2.
Reporting of this measure is mandatory.
Want more information about the EHR Incentive Programs?
Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.
As Flu Season Continues Review Claim Reimbursement for Vaccinations
If your office is administering Influenza Virus and Pneumococcal vaccinations, you should review the following information to insure you are submitting the correct diagnosis and procedure codes to receive the proper claim reimbursement. The vaccine procedure code should be chosen based on the description of the drug and the age of the patient. Each vaccine code should be billed with the appropriate administration code as well.
Flu vaccination billing
The following procedure and diagnosis codes are used for influenza virus vaccinations:
CPT/HCPCS Code : Description
90654 : Influenza virus vaccine, split virus, preservative free, for intradermal use
90655 : Influenza virus vaccine, split virus, preservative free, for children 6-25 months of age, for intramuscular use
90656 : Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use
90657 : Influenza virus vaccine, split virus, for children 6-25 months of age, for intramuscular use
90660 : Influenza vaccine, live, for intranasal use
90662 : Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use. (High Dose)
Q2034 : Influenza virus vaccine, split virus, for intramuscular use (Agriflu)
Q2035 : Influenza virus vaccine, split virus, when administered to individuals 3 years of age and above, for intramuscular use (Afluria)
Q2036 : Influenza virus vaccine, split virus, when administered to individuals 3 years of age and above, for intramuscular use (Fluluval)
Q2037 : Influenza virus vaccine, split virus, when administered to individuals 3 years of age and above, for intramuscular use (Fluvirin)
Q2038 : Influenza virus vaccine, split virus, when administered to individuals 3 years of age and above, for intramuscular use (Fluzone)
G0008 : Administration of influenza virus vaccine
V04.81 : Influenza vaccination with dates of service 10/1/2003 and later
V06.6 : Influenza and pneumococcal vaccination (Report this code when the purpose of the visit was to receive both vaccinations during the same visit)
The following procedure and diagnosis codes are used for pneumococcal vaccinations:
90669 : Pneumococcal conjugate vaccine, polyvalent, for children under 5 years, for intramuscular use
90670 : Pneumococcal conjugate vaccine, 13-valent, for intramuscular use
90732 : Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use
G0009 : Administration of the pneumococcal vaccine when no physician fee schedule service on the same day
Pneumococcal vaccination : V06.6
Pneumococcal and influenza vaccination (Report this code when the purpose of the visit was to receive both vaccinations during the same visit)
CMS has available on it's website numerous resources to assist providers:
Facts on Influenza, Pneumococcal, and Hepatitis B Immunizations: http://www.cms.gov/Medicare/Prevention/Immunizations/index.html?redirect=/Immunizations/
The 2012- 2013 Immunizers’ Question & Answer Guide : http://www.cms.gov/Medicare/Prevention/Immunizations/Downloads/2012-2013_Flu_Guide.pdf
Current pricing information: http://www.cms.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp#TopOfPage
No comments:
Post a Comment