Summary: These charts examine how Medicare claims denials are affected by the transition from carriers to the new Medicare administrative contractor (MAC) system, based on the most recent CMS data available. Few MAC transitions were complete by 2008, though MAC jurisdictions 4 and 5 (Texas and Nebraska) were transitioned in early 2008. Claims data from 2006 was chosen as the "starting" data because no MAC transitions anywhere took place until March 2007 (PBN 8/7/06). NOTE: Transitions for J4 and J5 did not end until a few months into 2008, but because CMS claims data cannot be broken down by month, the 2008 denials reflect a combination of mostly post-transition claims and some claims processed by legacy carriers.

This week's question is answered by Regan Bode, CPC, CPC-H, CPMA, CEMC, ACS-EM, content manager for DecisionHealth and consultant for DecisionHealth Professional Services.

Q. Our agency bills based on electronic feeds received from clinics and code selections are defaulted based on patient age and criteria. As an example, a provider doesn't assign a code for an immunization, and the computer generates the code based on the patient's age. A coder does not verify the assigned code. We are now trying to have the physicians themselves code these visits but they are resisting. Are the physicians required to code their own visits?

CMS has softened the meaningful use requirements you must meet to earn $44,000 from the electronic health record (EHR) incentive program. The biggest change in the final rule is the reduction of meaningful use requirements you must meet in order to earn incentives. During the first stage of the program, you will need to satisfy 20 of the 25 meaningful use requirements. Fifteen of those standards will be core requirements for the program and you will select five others from a menu of 10 in order to qualify for the bonus.

Your carriers now have marching orders from CMS on how to process claims with the recently passed 2.2% payment increase and reprocess all claims that were paid with a -21.3% rate cut during the month of June. You don't need to take any action to get your claims reprocessed, but you must initiate internal controls at your practice to be sure your claims are paid at the right rate.

You now have an idea of what CMS will expect your practice to do when you offer newly covered annual wellness visits, a major new revenue source made possible by health reform. Assuming the proposed 2011 Physician Fee Schedule stands, the news is good. If a medium-sized primary care practice with 5,000 Medicare patients were to successfully furnish the new service to 90% of Medicare patients in one year, it would earn $779,850. 

You've got a new tool in the race to get your providers properly enrolled in CMS's Provider Enrollment, Chain and Ownership System (PECOS), an agency official announced in a July 7 open door call for home health providers. CMS has posted two lists, one for physicians and one for non-physician practitioners (NPPs), that show all pending PECOS applications currently being processed.

Primary care providers and general surgeons will be eligible for a bonus payment equal to 10% of their Medicare allowed charges for primary care and major surgical services, under rules laid out in the proposed 2011 Physician Fee Schedule (PFS) that CMS added to comply with the health reform law. But these payments come with significant restrictions that may not seem immediately obvious, a Part B News analysis reveals.

Earning a Medicare quality of care bonus in 2011 will be easier for you and your peers when you use your claims to submit reporting data to CMS. But the bonus incentive you'll receive will be much lower - shrinking to just 1% of your Medicare charges. The agency also proposed to make a handful of changes to the measures you would report in 2011.

The six-physician Center for Arthritis & Rheumatic Diseases in Chesapeake, Va., has implemented a five-step process to ensure claims get reimbursed at proper rates, says Donna Fickes, the patient account manager. She estimates her practice has about two days worth of claims that will need to be reprocessed by CMS under new fee schedule rates (see related story).

You have 60 days to comment on provisions in CMS's proposed 2011 Medicare Physician Fee Schedule (PFS). Here's how to do it: Visit www.regulations.gov and search for docket number "CMS-2010-0205." Select the proposed rule and click on the submit comment link to give your opinion.