1. THE HEALTH CARE REFORM
LAW: HOW IT AFFECTS YOUR
MEDICARE PAY
PREPARE YOUR PRACTICE
FOR THE CHANGES
Torrey Kim, MA, CPC
Editor-in-Chief
Part B Insider
torreyk@inhealthcare.com
Link to Slides at:
www.scribd.com/doc/30938016/PPCA-Impact-on-Medicare-Pay

2. When I’m not working on Part B Insider, I’m trying to
wrangle my three boys!
Torrey Kim, MA, CPC
Editor-in-Chief, Part B Insider
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3. Coding and billing staffers may feel like the woman on the right when they
think about how the law might create systems confusion
Patient Protection and Affordable Care Act –
Signed Into Law March 233

4. Agenda
 What Is the PPACA?
 How Will the PPACA Impact Medicare?
 What Are the Implementation Timelines?
 Who is Responsible for Making Changes
to Your Systems?
 What Steps Should You Take Now?
 Health Care Reform Resources
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5. What is the PPACA?
 The Patient Protection and Affordable Care Act, also known as the
PPACA, HR 3590, or simply the “health care reform law,” includes
over 2,000 pages of health care-related provisions that will take
effect over the next four years.
 Many of the PPACA’s other provisions, such as pre-existing
condition coverage, have received widespread media attention, but
some practices are still unclear of how it impacts Medicare
 Today’s presentation will break down a few of the most important
factors involving Medicare pay that the PPACA has in store
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6. How Will The PPACA Impact Medicare?
Annual Wellness Visits (Sec. 4103)
 Every year other than the patient’s first year on Medicare,
beneficiaries will benefit from a “health risk assessment,” not
subject to their deductible or coinsurance, which includes an exam
of height, weight, blood pressure, and other routine measurements
 Based on the results of the health risk assessment, the provider will:
 Provide a screening schedule for the next 5 to 10 years
 Create a list of risk factors, counseling services, and referrals to other
professionals to provide interventions on such issues as weight loss,
smoking cessation, nutrition, fall prevention, and physical activity
 The wellness visits will take effect as of Jan. 1, 2011
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7. How Will The PPACA Impact Medicare?
10% Bonus for Primary Care (Sec. 5501)
 Effective Jan. 1, 2011, primary care practitioners “shall be
paid (on a monthly or quarterly basis) an amount equal to 10
percent of the payment amount for the service,” in addition to
their normal fees
 Who qualifies? Doctors, nurse practitioners, clinical nurse
specialists, or physician assistants with the primary specialty
designation of family medicine, internal medicine, geriatric
medicine, or pediatrics qualify for the bonus.
 The catch: These practitioners will have to bill at least 60
percent of their allowed charges as ‘primary care services,’
which are defined by codes 99201-99215, 99304-99340, or
99341-99350.
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8. How Will The PPACA Impact Medicare?
You Have One Year to Submit Claims (Sec. 6404)
 In the past, Part B providers had 15 months or more
to submit their claims to Medicare, but the new
legislation requires you to submit your claims “one
calendar year after the date of service” for services
provided on or after Jan. 1, 2010.
 Caveat: The legislation states that “the Secretary may
specify exceptions to the 1 calendar year period,” but
does not yet indicate what types of situations might
qualify for exceptions.
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9. How Will The PPACA Impact Medicare?
Health Professional Shortage Area (HPSA) Bonuses (Sec. 5501)
 Major surgical procedures performed between Jan. 1, 2011 and
Dec. 31, 2015 by a general surgeon in a health professional
shortage area will qualify for a 10 percent bonus
 The 10% payment will be disbursed “on a monthly or quarterly
basis”
 A general surgeon is defined as a doctor who has designated
specialty code 02 (General surgery) as their primary specialty
 “Major surgical procedures” are those with 10- or 90-day global
periods
 HPSA basics: Medicare will adjust your payment accordingly if you
provide services in a ZIP code that falls within a pre-designated
HPSA county; however, if you practice in a county not designated
as an HPSA but your town is designated as one, you’ll have to
append modifier AQ (Services provided in an HPSA) to your claims
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10. How Will The PPACA Impact Medicare?
Outpatient Therapy Cap Exceptions Extension (Sec.
3103)
 The law extends the exceptions process for outpatient
therapy caps, which means that these therapy providers
may continue to submit claims with the KX modifier
(Specific required documentation on file) when an
exception is appropriate, for services furnished between
Jan. 1 and Dec. 31, 2010
 The current outpatient therapy cap is $1,860 for physical
therapy and speech language pathology services
combined, and a separate $1,860 limit for occupational
therapy services provided in a calendar year.
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11. How Will The PPACA Impact Medicare?
Labs Can Bill TC for Hospital Patients (Sec.
3104)
 Effective retroactive to Jan. 1, 2010,
independent labs can submit claims to
Medicare for the technical component of
physician pathology services furnished to
hospital patients, whether the patient was an
inpatient or an outpatient
 Labs that were previously denied for such
services should contact their MACs “for
further instructions,” CMS advises.
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12. How Will The PPACA Impact Medicare?
Extension of 5% Mental Health Bonus (Sec. 3107)
 Three years ago, CMS reduced Part B payments for mental
health services during what it called a “Five Year Review”
period. Congress gave mental health providers a 5 percent
bonus payment in 2008 to make up for these cuts, but that
expired on Dec. 31, 2009. The PPACA restores the 5
percent bonus payment through Dec. 31
 The law makes the 5 percent bonus retroactive to Jan. 1,
2010
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13. How Will The PPACA Impact Medicare?
PQRI Program Extended (Sec. 3002)
 The following PQRI incentives/reductions are now
applicable through 2016 and beyond:
 2011: Incentive payment of a 1 percent bonus
 2012 through 2014: Incentive payment of a 0.5 percent bonus
 2015: Penalty of 1.5 percent
 2016 and beyond: Penalty of 2 percent
 The PPACA calls for an informal appeals process to be in
effect as of Jan. 1, 2011 for providers “to seek a review of
the determination that an eligible professional did not
satisfactorily submit data on quality measures”
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14. How Will The PPACA Impact Medicare?
Timeliness of Refunding Overpayments (Sec. 6402)
 If you receive an overpayment from Medicare, you must
report and return the overpayment within 60 days after the
overpayment was identified, or the date any corresponding
cost report is due (whichever is later)
 You must notify the secretary, state, intermediary, carrier, or
contractor in writing and inform them of the reason for the
overpayment
 “Overpayment” refers to “any funds that a person receives or
retains…to which the person, after applicable reconciliation, is not
entitled”
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15. How Will The PPACA Impact Medicare?
Other Ways the Legislation Will Affect Medicare:
 Effective Jan. 1, 2011, your claims must include an NPI
(Sec. 6402)
 Any applicable manufacturer must submit a report on March
31, 2013 and on the 90th day of each calendar year
thereafter that includes information regarding “transfers of
value” that they made to covered recipients (including
physicians). These include cash, items, services, consulting
fees, gifts, entertainment, education, travel, and other fees
(Sec. 6002)
 The PPACA expands the Recovery Audit Contractor (RAC)
program and rolls it out into Medicare Parts C and D by the
end of 2010 (Sec. 6411)
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16. What Are the Implementation Timelines?
 Question: The healthcare reform bill included several pay
boosts that were retroactive to Jan. 1. When will the fee
schedule incorporate those retroactive changes?
 Answer: “There’s a complex calculation of a variety of those
changes that we are going through to put them together,” said
CMS’s Amy Bassano during an April 13 CMS Open Door
Forum. CMS must prepare before it incorporates the pay
boosts, which could take “a month or two,” she said
 Plus: Even after CMS releases the new rates, “We still have
our Medicare contractors do extensive tests on those to make
sure they are correct, so that takes a little bit of time as well,”
said CMS’s Stewart Streimer on the April 13 call.
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17. Who Is Responsible for Making
Changes to Your Systems?
 Billing Dept: If your practice chronically submits
claims more than one year after the date of
service, talk to your billing department or
outsource company about how to make claims
processes more efficient
 Front and Back Office: Prepare to institute
internal systems that will allow for annual wellness
visits without collecting deductibles or
coinsurance, effective in 2011
 Practice Manager/Physicians: If you don’t have
an NPI yet, enroll via the online NPPES system or
using a paper form
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18. Steps to Take Now
 Be ready for questions from Medicare patients,
who may expect changes to be in effect
immediately
 Tighten up your billing systems or talk to your
billing outsource companies to prepare for the
new 1-year deadline for claims filing
KEEP IN MIND:
CMS staffers don’t even have all of the
answers yet, so you may not either.
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19.  You can read the entire PPACA law (2,393 pages) at
www.opencongress.org/bill/111-hh3590/show
 To determine whether your area qualifies as a health
professional shortage area, visit
www2.cms.gov/HPSAPSAPhysicianBonuses
 To obtain an NPI, visit
www.cms.gov/NationalProvidentStand/03_apply.asp
 Updates are continuing in Part B Insider and via our
webinars, visit our Web site at www.supercoder.com
 Email me any time at torreyk@inhealthcare.com
Thank you!
Health Care Reform Resources
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20. Thank
YOU!
Helping coders
help physicians!
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21. Supercoder.com
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