December 2014
Survey request: Real-Time Prescription Benefit Inquiry
The National Council for Prescription Drug Programs (NCPDP), the organization responsible for creating and maintaining prescription drug electronic standards, is seeking input from the health care industry to help set priorities for the creation of a real-time prescription benefit inquiry (RTPBI) transaction. An RTPBI transaction is intended to provide patient-specific prescription benefit information at the point of care. The purpose of the survey is to determine the scope of content for a future RTPBI transaction. The survey contains use cases which identify specific content areas possible for the RTPBI.

Click here to access the survey.

Responses are not limited to NCPDP members. Please feel free to forward the survey to other interested parties. The survey will close at 10:00 a.m. MST on Thursday, Dec. 18, 2014.

We encourage you to participate in this survey. Strong provider participation will ensure that your need for accurate, patient-specific prescription benefit information at the point of prescribing is heard.
Prior Authorization of Drugs - Jan. 1
The true administrative simplification of the prior authorization process for prescription drugs will not be realized until health information technology can allow for a completely integrated process for ordering, authorization and dispensing of medications. 

Until such technology is available and in use, C.R.S. 10-16-124.5 - concerning the development of a prior authorization process to be used in obtaining prior approval from carriers for coverage of drug benefits - is intended to improve the communication surrounding prior authorization by requiring that information on any specific requirements for medications, as well as the process itself be readily available to the prescribing provider. In addition, timeframes have been established for processing of the authorization. Click here for a fact sheet.

Beginning on Jan. 1, 2015, all carriers are required to utilize the uniform prior authorization process established by regulation 4-2-49. Click here for more information.

Chronic Care Management
Beginning Jan. 1, 2015 Medicare will pay for Chronic Care Management (CCM) services, CPT� code 99490 under Part B fee for service. The CPT� definition is:

"Services are provided when medical and/or psychosocial needs of the patient require establishing, implementing, revising, or monitoring the care plan. Patients who receive chronic care management services have two or more chronic conditions or episodic health conditions that are expected to last at least 12 months , or until the death of the patient, and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline."

Per CPT� 99490 billing requirements include:
  • At least 20 minutes of clinical staff time directed by a physician spent in chronic care management services;
  • Can only be billed once per month/per patient, AND by only one physician;
  • Comprehensive care plan is established, implemented, revised or monitored.
Additional Medicare billing requirements were identified in Table 33 of the 2015 final physician fee schedule rule and include:
  • Use of an EHR
  • Beneficiary notification and consent - identify CCM services and obtain written agreement to have the services provided, including authorization for the electronic communication of his/her medical information with other treating providers (NOTE: Medicare pays for the service at 80 percent and the patient is liable for the 20 percent co-insurance.)
  • Providing patient a written or electronic copy of the care plan

To view the complete table, click here.

ICD-10 logo
ICD-10 resources from the Centers for Medicare and Medicaid Services
With the Oct. 1, 2015, ICD-10 compliance date drawing nearer, now is the time to prepare for the transition. To support the health care community, the Centers for Medicare and Medicaid Services offers resources that explain ICD-10 for providers, payers, vendors, and non-covered entities.

Medscape Continuing Medical Education Resources
CMS has created two videos and one expert column to help educate health care professionals about ICD-10. Beyond providing tips and advice, these free resources offer continuing medical education (CME) and nursing continuing education (CE) credits. Anyone who completes the modules can earn a certificate. Note that, while free, viewers must have or create a free account to view the webinars.
Road to 10 Tool for Small Physician Practices
Available on the Provider Resources page of cms.gov/ICD10, the "Road to 10" tool is an online resource built with the help of providers in small practices. This tool is intended to help small medical practices jumpstart their ICD-10 transition and can help you:
  • Understand the basics of ICD-10
  • Build an ICD-10 action plan to map out your transition
  • Answer frequently asked questions
  • Learn how ICD-10 affects your practice with tailored clinical scenarios and documentation tips for Family Practice and Internal Medicine, Obstetrics and Gynecology, Orthopedics, Cardiology, and Pediatrics
CMS.gov Resources
To support the health care community with the transition to ICD-10, the federal CMS has developed a variety of resources available at cms.gov/ICD10, including fact sheets, guides, and webinar presentations. They also distribute regular email updates with information about ICD-10. Subscribe today to stay up to date on the latest news and resources from the Centers for Medicare and Medicaid Services. 

Federal CMS announces ICD-10 acknowledgement testing weeks
The Centers for Medicare and Medicaid Services is in the process of implementing ICD-10. All covered entities must be fully compliant on Oct. 1, 2015. CR8858 instructs all Medicare Administrative Contractors (MACs) and the Durable Medical Equipment MAC Common Electronic Data Interchange (CEDI) contractor to promote ICD-10 Acknowledgement Testing with trading partners during three separate testing weeks, and to collect data about the testing. The first testing week was held Nov. 17-21, and two additional weeks are scheduled:
  • March 2-6, 2015
  • June 1-5, 2015
While submitters may acknowledgement test ICD-10 claims at any time through implementation, the ICD-10 testing weeks have been created to generate awareness and interest, and to instill confidence in the provider community that the federal CMS and the MACs are ready and prepared for the ICD-10 implementation.

These testing weeks will allow trading partners access to MACs and CEDI for testing with real-time help desk support. The event will be conducted virtually and will be posted on the federal CMS website, the CEDI website and each MAC's website.

Key points of the testing process:
  • Test claims with ICD-10 codes must be submitted with current dates of service since testing does not support future dated claims.
  • Claims will be subject to existing NPI validation edits.
  • MACs and CEDI will be staffed to handle increased call volume during this week.
  • Test claims will receive the 277CA or 999 acknowledgement as appropriate, to confirm that the claim was accepted or rejected by Medicare.
  • Test claims will be subject to all existing EDI front-end edits, including submitter authentication and NPI validation.
  • Testing will not confirm claim payment or produce a remittance advice.
  • MACs and CEDI will be appropriately staffed to handle increased call volume on their Electronic Data Interchange (EDI) help desk numbers, especially during the hours of 9 a.m. to 4 p.m. local MAC time, during this week.
  • Your MAC will announce and promote these testing weeks via their listserv messages and their website.
For more information about acknowledgement testing, refer to the information on Novitas's website, www.novitas-solutions.com.

In This Issue

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CO Drug Card

Compliments of CMS: Reduce patient callbacks, HIPAA compliant, RX Savings up to 75%, click for free customization COLORADO DRUG CARD.

National Jewish Health invites your health care providers to the 51st Annual Clinical Diabetes and Endocrinology Conference in Snowmass, January 23-27, and the 37th Annual Pulmonary and Allergy Update in Keystone, February 4-7. To learn more, call 800.844.2305 or visit www.njhealth.org/cme or email [email protected].

Webinar: HIE's Expanding Role in Population Health Management
Thursday, Dec. 18, 2014,
11 a.m. - 12 p.m. MT
Click here to register.

Submit your event by e-mailing [email protected].

Medicare news: Revalidation for Jurisdiction H (JH) Providers and Suppliers
Novitas has updated the Revalidation Request Mailing Schedule on their website. As outlined in the schedule, mailings will begin on Dec. 16, 2014 and will continue through Jan. 8, 2015. These mailings comprise approximately 9,700 providers/suppliers. The Centers for Medicare and Medicaid Services will publish the listing of providers/suppliers included in these mailings on their website approximately 3-4 weeks after all contractors have provided their mailing information for the months of December-January. You may also use their Provider Enrollment Status Inquiry Tool to determine if a revalidation notice was issued.

If you have questions related to the revalidation initiative, please visit Novitas's Enrollment Center for more information.

PQRS penalty starts Jan. 1
Reminder: The PQRS penalty of 1.5 percent begins Jan. 1, 2015 if you did not successfully report in 2013. To avoid future penalties you will need to review the PQRS quality measures for 2015 and begin reporting.

Click here to read complete coverage on how Medicare incentives are turning into penalties in the September/October issue of Colorado Medicine. It includes a special two-page Medicare payment and delivery reform timeline.

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