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Psychotherapy probe review findings CPT® code 90834


First Coast Service Options Inc. (First Coast) recently conducted post payment provider specific probes reviews in response to data aberrancies identified for Current Procedural Terminology® (CPT®) code 90834 (psychotherapy, 45 minutes with patient and/or family member). Post payment medical reviews resulted in high error rates. Services were denied because submitted medical records did not meet documentation requirements as outlined in The Psychiatric Diagnostic Evaluation and Psychotherapy Services Local Coverage Determination (LCD) (L33128). Specifically the medical records were missing one or more of the following documentation requirements for each date of service:

• Documentation of measurable goals on the treatment plan;

• Detailed summary of the psychotherapy sessions, including descriptive documentation of therapeutic interventions;

• Degree of patient participation and interaction with the therapist;

• Reaction of the patient to the therapy sessions;

• Documented progress toward measurable goals since the last sessions; and changes or lack of changes in the patient’s symptoms or behavior;

• Documentation of adjustments in the treatment plan that reveal the dynamics of treatment;

• Treatment plan was not updated and did not support the medical necessity of each psychotherapy session.

The documentation for psychotherapy services should include on a periodic basis the patient’s capacity to participate and benefit from psychotherapy. Such periodic documentation should include the estimated duration of treatment in terms of number of sessions required and the target symptoms, measurable and objective goals of therapy related to changes in behavior, thought processes and/or medications, methods of monitoring outcome, and why the chosen therapy is an appropriate modality either in lieu of or in addition to another form of psychiatric treatment. For an acute problem, there should be documentation that the treatment is expected to improve the mental health status or function of the patient. For chronic problems, there must be documentation indicating that stabilization of mental health status or function is expected. Documentation will reflect adjustments in the treatment plan that reveals the dynamics of treatment.

It is expected that the treatment plan for a patient receiving outpatient psychotherapy (i.e., measurable and objective treatment goals, descriptive documentation of therapeutic intervention, frequency of sessions, and estimated duration of treatment) will be updated on a periodic basis, generally at least every three months.
The medical record documentation maintained by the provider must indicate the medical necessity of each psychotherapy session and include the following:

• The presence of a psychiatric illness and/or the demonstration of emotional or behavioral symptoms sufficient to alter baseline functioning; and

• A detailed summary of the session, including descriptive documentation of therapeutic interventions such as examples of attempted behavior modification, supportive interaction, and discussion of reality; and

• The degree of patient participation and interaction with the therapist, the reaction of the patient to the therapy session, documentation toward goal oriented outcomes and the changes or lack of changes in patient symptoms and/or behavior as a result of the therapy session.

• The rationale for any departure from the plan or extension of therapy should be documented in the medical record. The therapist must document patient/therapist interaction in addition to an assessment of the patient’s problem(s).

First Coast recommends providers be familiar with medical necessity indications and documentation requirements for psychotherapy services as indicated in the Psychiatric Diagnostic Evaluation and Psychotherapy Services LCD. LCDs are available through the CMS Medicare coverage database at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx external pdf file


Simply Healthcare plans may go out of business in few counties


As of January 1st 2015, Simply healthcare plans will no longer be available for Medicare beneficiaries residing in Broward, Palm Beach, Duval, Clay, Brevard, Hillsborough, Hernando, Pasco and Pinellas Counties in Florida.
 
Medicare patients will be receiving a formal notice from Simply Healthcare dated October 2, 2014. The CMS approved letter will be sent to the affected members which will provide information to help them make informed decisions about their Medicare coverage options for 2015. These members will also no longer receive instructions about their eligibility to enroll in another Medicare health plan. If Medicare patients do not sign up for a new plan by the end of 2014, their current coverage will end on December 31, 2014 and patients would be covered through original Medicare from January 1, 2015.

Please contact your Provider relations team for more information.

Florida Blue - Type 2 NPI is Required for Providers Billing with EIN


For individual providers who submit electronic claims with their Employee Identification Number (EIN) rather than their Social Security Number (SSN), a new policy from Florida Blue applies immediately. The policy, which strengthens alignment with the Centers for Medicare & Medicaid Services (CMS), requires such providers to have a valid Type 2 National Provider Identification (NPI) on file with us. For providers who continue to use their Social Security Number and not an EIN, a Type 1 NPI can continue to be used. 

For more information please refer to the Frequently Asked Questions or contact Florida Blue at 800-727-2227, Mon. through Fri., 8 a.m. – 8 p.m. ET.

Review New and Updated FAQs for the EHR Incentive Programs


To keep you updated with information on the Medicare and Medicaid EHR Incentive Programs, CMS has recently added one new FAQ and updated seven FAQs to the CMS FAQ system. We encourage you to stay informed by taking a few minutes to review the new information below.

New FAQ:

  1. For Measure 2 of the Stage 2 Summary of Care objective for the EHR Incentive Programs, may an eligible professional,  eligible hospital, or critical access hospital count a transition of care or referral in its numerator for the measure if they electronically create and send a summary of care document using their CEHRT to a third party organization that plays a role in determining the next provider of care and ultimately delivers the summary of care document? Read the answer.

Updated FAQs: 

  1. If my practice does not typically collect information on any of the core, alternate core, and additional clinical quality measures (CQMs) listed in the Final Rule on the Medicare and Medicaid EHR Incentive Programs, do I need to report on CQMs for which I do not have any data? Read the answer.
  2. Can eligible professionals use CQMs from the alternate core set to meet the requirement of reporting three additional measures for the Medicare and Medicaid EHR Incentive Programs? Read the answer.
  3. If one of the measures for the core set of CQMs for eligible professionals is not applicable for my patient population, am I excluded from reporting that measure for the Medicare or Medicaid EHR Incentive Programs? Read the answer.
  4. If none of the core, alternate core, or additional clinical quality measures adopted for the Medicare and Medicaid EHR incentive programs apply, am I exempt from reporting on all CQMs? Read the answer.
  5. If the denominators for all three of the core CQM are zero, do I have to report on the additional CQMs for eligible professionals under the Medicare and Medicaid EHR Incentive Programs? Read the answer.
  6. For the Medicare and Medicaid EHR Incentive Programs, if the certified EHR technology possessed by an eligible professional generates zero denominators for all CQMs in the additional set that it can calculate, is the eligible professional responsible for determining whether they have zero denominators or data for any remaining CQMs in the additional set that their certified EHR technology is not capable of calculating? Read the answer.
  7. I am an eligible professional who has successfully attested for the Medicare EHR Incentive Program, so why haven't I received my incentive payment yet? Read the answer.

Providers and Suppliers to Comply with MAC Request for Fingerprints within 30 Days


CMS implemented the fingerprint-based background requirement on August 6, 2014, as discussed in the rule published on February 2, 2011. Fingerprint-based background checks are required for all individuals with a 5 percent or greater ownership interest in a provider or supplier that falls into the high risk category and is currently enrolled in Medicare or has submitted an initial enrollment application. Medicare Administrative Contractors (MACs) have begun sending letters to these providers and suppliers, listing all owners who are required to be fingerprinted. The letters are being mailed to the provider or supplier’s correspondence address and the special payments address on file with Medicare. 

Identified individuals have 30 days from the date of the letter to be fingerprinted. Failure to comply with the fingerprint requirements could result in denial of your Medicare enrollment application or revocation of your Medicare billing privileges. Visit Accurate Biometrics for fingerprinting procedures, to find a fingerprint collection site, and to ensure the fingerprint results are accurately submitted to the Federal Bureau of Investigation (FBI) and properly returned to CMS. For more information on this requirement, see MLN Matters® Special Edition Article #SE1427, “Fingerprint-based Background Check Begins August 6, 2014.” If 
you have any questions, contact Accurate Biometrics at 866- 361-9944, or visit their website at www.cmsfingerprinting.com.

National Breast Cancer Awareness Month


October is National Breast Cancer Awareness Month. During this national health observance, CMS reminds health professionals that breast cancer is the second most common form of cancer in women. Medicare provides coverage for screening mammography to facilitate the early detection of breast cancer for women with no signs or symptoms of disease. Medicare does not require a physician’s prescription or referral for screening mammography. The screening mammography is a Medicare Part B benefit with no co-pay/co-insurance or deductible. Medicare does not cover screening mammography for men. However, Medicare does provide coverage for diagnostic mammography for men and women who meet certain coverage criteria. 

A clinical breast exam is also covered under Medicare Part B as part of the screening pelvic examination for beneficiaries who meet coverage criteria. There is no copay/co-insurance or deductible for this screening benefit.

Also see: Coverage information for Screening Mammography

Claims with HCPCS code A9552 reported for Oncologic conditions will be held by Medicare


Claims for fluorodeoxyglucose (FDG) positron emission tomography (PET) for solid tumors submitted October 6 through November 10 will be held to ensure Medicare systems can accurately calculate payments. Specifically, these are claims containing Healthcare Common procedure Coding System (HCPCS) A9552 for all oncologic conditions. These claims will be processed beginning November 11 after the system has been fully tested. No action is required by providers.

For more information: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8739.pdf

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