5431 Yukon Court Suite A, Frederick, Maryland 21703 Tel: (410) 244-7320 Website

5431 Yukon Court Suite A, Frederick, Maryland 21703 tel: (410) 244-7320 website: Marylandeyemds.org e-mail: [email protected]

Monthly Report- March 2011

From the MSEPS President Michael X. Repka, MD Fellow Maryland Ophthalmologists: MSEPS had a wonderful reception in Annapolis during our vision screening project for members and legislative staff. Thanks for the continuing participation of the Maryland Society for Sight and Allergan in this effort to increase recognition of the value of vision.

The Annual Meeting of MSEPS will be held on May 20, 2011 at the BWI Hilton. All day programs for physicians and ophthalmic techs have been developed, along with code quest described elsewhere in this newsletter. New this year will be a specific program for residents (Maryland and DC) starting at 3 PM on business and advocacy issues important to young ophthalmologists. Thanks to the program directors for allowing their residents to participate.

Lastly, if you have not joined MSEPS this year, please consider joining the society. Many physicians think CMS sets policy for ophthalmological care. In fact most decisions are made at the state level by the legislature, the administration, and private insurers. Having a committed, strong membership able to reach out to these stakeholders is crucial to maintain our ability to ensure continued quality eye care in Maryland. As an example MSEPS suggested legislation to ensure early eye drop refills for beneficiaries who run out early (Maryland House Bill 888, Senate Bill 701). CMS solved this for Part D plans about one year ago, but this legislation will require private plans to also allow early refills. Mary Lou Collins, Sonny Goel, David Glasser, and Claire Jensen are expected to testify on behalf of the legislation.

Recent legislative action in Kentucky over surgical scope is an object lesson in the continuing need for an involved state-based ophthalmology membership. We need to remain engaged in the political process. It is our obligation, granted by the state, to ensure access to quality ophthalmology care. This responsibility requires commitment of time and resources by Maryland ophthalmologists.

Michael X. Repka, MD

Save the Date!!

MSEPS Annual Ophthalmic Convention Friday, May 20, 2011 Hilton BWI

Full day Physician program, Technician Program, CodeQuest program, & OMIC Risk Management program!

Thank you to all who volunteered at Annapolis Eye MD Day at the Statehouse!

A special thank you to: Allergan The Maryland Society for Sight

MSEPS Members: Michael X. Repka, MD Sonny Goel, MD Mary Lou Collins, MD Sachin Kalyani, MD

Alex Christoff, CO, COMT

From the Maryland State Medical Society Gene M. Ransom III

MedChi traditionally spends the first four months of every year fighting for the interests of Maryland physicians in the General Assembly. This year is no different, and, as in prior years, we need you to talk to elected officials about important legislation under consideration this session. During this session MedChi is pushing several technology related bills that are before the Senate Finance and House Health and Government Committees. The legislation would increase privacy protections for Health Information Exchanges, protect against insurance abuses and ensure Insurers pay their fair share toward health information technology. Please help us pass these bills by emailing your legislator today using our Legislative Action Center.

The legislative issue we face the toughest fight on in the technology arena is legislation that requires private payers to provide incentives for electronic health record adoption. The legislation requires the technology incentives are cash payments and would expand the State of Maryland electronic health medical records incentives to all physicians. Currently the incentive is only for a small percentage of Maryland doctors. MedChi strongly supports the bill because the incentives should be cash payments, so insurers don't game the system to avoid making meaningful contributions to adoption of electronic medical records. Furthermore, insurers benefit greatly from adoption of electronic medical records and reap the bulk of the cost savings; therefore they are better situated to manage the expense. In order for electronic medical record adoption to work everyone needs to be hooked into the system, not just a small number of physicians. We expect a major fight on this issue from the insurance lobby and some government bureaucrats.

MedChi also faces an attack from the trial lawyers, who are pushing House Bill 340 Health Care Malpractice - Certificate and Report of Qualified Expert - Objection. The bill was heard last week in the House Judiciary Committee, and we expect a vote any day. This is a bill which would allow the refiling of the certificate/report of an expert in a malpractice case if the initial certificate/report is dismissed by a judge. If enacted, House Bill 340 would allow a second filing (and third, fourth, etc.) of such a certificate/report at any time a filing is deemed insufficient. Moreover, House Bill 340 would only allow a doctor 14 days to contest the sufficiency of an expert certificate/report. MedChi strongly opposes the bill.

Please help us in our efforts against the enemies of medicine. We need you to email your legislator, come down and serve in the First Aid Room and participate in your component day. Your help can make the difference against rogue bureaucrats, sneaky trial lawyers and insurance executives, all of whom are tough enemies in Annapolis.

Ocular Systems Receives FDA 510(k) Clearance for EndoSerter™

FDA Clearance Allows Sale to Surgeons in U.S.

Winston-Salem, NC - February 21, 2011 - Ocular Systems, Inc. (OSI) announced today that it has received U.S. Food and Drug Administration (FDA) clearance to market the company's human corneal endothelium delivery instrument, the EndoSerter™. The device delivers a corneal endothelial allograft measuring ≤ 8.5mm in diameter and ≤ 175µm in central thickness through a single 4 mm incision during endothelial keratoplasty procedures. Endothelial keratoplasty, a type of corneal transplantation that does not require a full-thickness graft, has become the treatment of choice for restoring corneal clarity to patients with failed endothelium function.

"Today's announcement represents the successful culmination of a nearly two-year effort by Ocular System's staff, our manufacturing partner, advisors, and surgeons to bring EndoSerter™ to the U.S. market," commented OSI CEO Jerry Barker. "We are proud that our device is the first cleared by FDA for insertion of endothelial cells that restore corneal transparency," Mr. Barker continued.

"Each year approximately 18,000 patients in the U.S. have endothelial cell replacement surgery. OSI looks forward to making this device available to U.S. surgeons and providing them a new opportunity to benefit their patients," Barker concluded.

EndoSerter™ Sales and Ordering For EndoSerter™ information and ordering, please contact Ocular Systems at (336) 784-4603 or [email protected]. International customers should visit the Company website: www.ocularsystemsinc.com. The EndoSerter™ will be featured at Booth #425 during the upcoming ASCRS meeting, San Diego, CA, March 25-29, 2011.

About Ocular Systems, Inc. (www.ocularsystemsinc.com) Ocular Systems is located in the Piedmont Triad Research Park, Winston-Salem, NC. It was the first facility dedicated to the processing of human corneal tissue for endothelial replacement surgeries. Founded in 2004, the Company is an FDA-registered human tissue establishment and device manufacturer, and is also ISO 13485 registered. The Company makes the EndoSerter™ and EndoSaver™. The EndoSaver™ has been cleared for sale in Europe and other countries. The devices are protected by U.S. and International patent applications and trademarks.

From the MSEPS Third Party Insurance Consultant James McNally, CPC MSEPS Third Party Insurance Help Program Coding Help Now Available

Have a coding question? Use the new MSEPS member benefit!

To send a question on a Third Party insurance matter, click on the link here or call 718 445 3847. http://www.marylandeyemds.org/displayemailforms.cfm?emailformnbr=148498

Medicare to Reprocess Claims Affected by the Affordable Care Act and 2010 Medicare Physician Fee Schedule Changes

As reported previously, on March 23, 2010, the President signed the Affordable Care Act. Various provisions of the new law were effective April 1, 2010, or earlier and, therefore, were implemented some time after their effective date. In addition, corrections to the 2010 Medicare Physician Fee Schedule (MPFS) were implemented at the same time as the Affordable Care Act revisions to the MPFS, with an effective date retroactive to January 1, 2010.

Due to the retroactive effective dates of these provisions and the MPFS corrections, a large volume of Medicare fee-for-service claims will be reprocessed.

CMS will begin to reprocess these claims over the next several weeks. They expect that this reprocessing effort will take some time and will vary depending upon the claim-type, the volume, and each individual Medicare claims administration contractor.

In the majority of cases, you will not have to request adjustments because your Medicare claims administration contractor will automatically reprocess your claims.

Please do not resubmit claims because they will be denied as duplicate claims and slow the retroactive adjustment process. However, any claim that contains services with submitted charges lower than the revised 2010 fee schedule amount cannot be automatically reprocessed at the higher rates.

In such cases, you will need to request a manual reopening/adjustment from your Medicare contractor. While there is normally a one-year time limit for physicians and other providers and suppliers to request the reopening of claims, CMS believes that these circumstances fall under the “good cause” criteria and is extending the time period to request adjustment of these claims, as necessary.

Medicare claims administration contactors will follow the normal process for handling any applicable underpayments or overpayments that occur while reprocessing your claims.

Underpayments will be included in your next regularly scheduled remittance after the adjustment.

However, when a claim adjustment for a physician results in an overpayment, the Medicare contractor will send a request for repayment. If this overpayment is less than $10, your contractor will not request repayment until the total amount owed accrues to at least $10.

In addition, physicians impacted by the retroactive increases in payment rates for claims affected by the Affordable Care Act and 2010 MPFS changes, are reminded of the Office of Inspector General policy related to waiving beneficiary cost-sharing amounts attributable to retroactive increases in payment rates resulting from the operation of new Federal statutes or regulations.

The policy may be found at the following link: http://oig.hhs.gov/fraud/docs/alertsandbulletins/Retroactive_Beneficiary_Cost-Sharing_Liability.pdf

Please contact your Medicare claims administration contractor with any questions about this information or, for guidance, contact us through the Third Party Insurance Help Program.

Urgent News for Physician Owned Optical Shops CMS Finalizes Onerous Medicare-Enrollment Requirements - Physician-Owned Optical Shops Face Increased Scrutiny

The American Academy of Ophthalmology (AAO) has informed us that This week CMS released a final rule that creates a rigorous screening process for providers and suppliers of durable medical equipment, prosthesis, orthotics and supplies (DMEPOS) in the Medicare program. CMS was granted broad authority in the new health care reform law to reign in Medicare fraud. The rule takes effect March 25. Ophthalmologists and optometrists who provide post-cataract optical services and who are newly enrolling or revalidating DMEPOS suppliers will be subject to a $500 enrollment fee after March 25. If you are currently enrolled in Medicare and the Provider Enrollment, Chain, and Ownership System (PECOS) and do not have to revalidate as a DMEPOS supplier this year, you won’t see an immediate impact.

While CMS places most physicians in the lowest level of risk, the agency puts all current or revalidating physicians who supply DMEPOS as part of their services (e.g., physicians who provide) in the moderate level of risk. Newly enrolling DMEPOS suppliers will be placed in the highest level of risk, which includes fingerprinting, regardless of whether the supplier is a physician.

What this means Low-risk providers (most physicians) are now subject to:

 Verification of any provider/supplier-specific requirements established by Medicare  License verifications (may include licensure checks across states)  Database checks to verify: o Social Security number o National provider identifier o National practitioner databank information o Office of the Inspector General exclusion o Taxpayer identification number o Other information, such as recent deaths and other practice changes

Moderate-risk providers (includes DMEPOS suppliers) are subject to the above, plus:

 Unscheduled or unannounced site visits  $500 enrollment, adjusted annually based on the consumer price index

High-risk providers are subject to all of the above, plus:

 Fingerprint-based criminal-history record check of law enforcement repositories

If your National Supplier Clearinghouse is up for revalidation this year, the Academy recommends revalidating prior to March 25 in order to not be subject to the new fees.

The Academy, along with the AMA and a coalition of physician and other health care provider groups, pushed for all physicians to be considered lowest-risk providers, regardless of whether they supply DMEPOS to their patients as part of their practice. In 2008, we were successful in getting Congress to exempt physicians from burdensome accreditation requirements for DMEPOS. Despite several meetings with CMS and submission of comments outlining the groups’ concerns and the consequences of the more-burdensome requirements, the agency moved forward with implementing the rule. The Academy, along with the other groups, will fight these new requirements.

If you have questions, contact the Academy’s Governmental Affairs office at 202.737.6662.

CMS Releases Exceptions to Medicare Timely Filing Limits

As reported previously, the time limit for filing all Medicare Fee-For-Service claims (Part A and Part B claims) is 12 months, or one calendar year from the date services were furnished.

However, Medicare will allow for the following exceptions to the one calendar year time limit for filing Fee-For- Service claims:

 Administrative Error: This is where the failure to meet the filing deadline was caused by error or misrepresentation of an employee, the Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority. In these cases, Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider, or supplier received notice that an error or misrepresentation was corrected.  Retroactive Medicare Entitlement: This is where a beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished. For example, at the time services were furnished the beneficiary was not entitled to Medicare. However, after the timely filing period has expired, the beneficiary receives notification of Medicare entitlement effective retroactive to or before the date of the furnished service In these cases, Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the beneficiary, provider, or supplier received notification of Medicare entitlement retroactive to or before the date of the furnished service.  Retroactive Medicare Entitlement Involving State Medicaid Agencies: This is where a State Medicaid Agency recoups payment from a provider or supplier six months or more after the date the service was furnished to a dually eligible beneficiary. For example, at the time the service was furnished the beneficiary was only entitled to Medicaid and not to Medicare. Subsequently, the beneficiary receives notification of Medicare entitlement effective retroactive to or before the date of the furnished service. The State Medicaid Agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare, because the timely filing limit has expired. In these cases, Medicare will extend the timely filing limit through the last day of the sixth month following the month in which a State Medicaid Agency recovered Medicaid payment from a provider or supplier.  Retroactive Disenrollment from a Medicare Advantage (MA) Plan or Program of All-inclusive Care of the Elderly (PACE) Provider Organization: This is where a beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups its payment from a provider or supplier six months or more after the date the service was furnished. In these cases, Medicare will extend the timely filing limit through the last day of the sixth month following the month in which the MA plan or PACE provider organization recovered its payment from a provider or supplier.

For guidance on this issue, contact us through the Third Party Insurance Help Program.

Update on Commercial Insurers/Managed Care Organizations and the 2011 OCT Codes

Inquires from the membership have prompted a communication to a number of commercial insurers and managed care organizations with a request to state their policy on the new OCT codes for 2011, codes 92133 and 92134. The following responses have been received to date:

CIGNA CIGNA has indicated that the new OCT codes (92133 and 92134) are currently in their claims systems so they are able to receive and pay claims associated with these codes.

They were not added to the precertification list so prior authorization is not required

These codes are addressed in the CIGNA Medical Policy “Retinal Imaging for Diabetic Retinopathy” at the link here. http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0080_coveragepos itioncriteria_imaging_systems_optical.pdf

EBCBS/Wellpoint EBCBS/Wellpoint has indicated that the new OCT codes (92133 and 92134) are currently in their claims systems so they are able to receive and pay claims associated with these codes

However, they consider code 92132 to be investigational and not a payable code. Denials would be subject to all in-house appeal mechanisms before filing a complaint under the New York State External Appeals law or the New Jersey Independent Health Care Appeals Program (IHCAP).

Policy on codes 92133 and 92134 is located at the link here. http://www.empireblue.com/medicalpolicies/policies/mp_pw_a049927.htm (NOTE: EBCBS had pended some claims until the rates were loaded and then processed them and released them for payment. However, if any of your claims had been denied, you can resubmit as long as there was nothing paid on the claim at all so it will not deny as a duplicate).

Aetna Aetna is accepting these new codes effective January 1, 2011.

The Aetna Clinical Policy Bulletins (available at www.aetna.com) that correspond to these codes are as follows:

 CPT code 92132 - CPB 749 Anterior Segment Optical Coherence Tomography  CPT code 92133, 92134 - CPB 344 Optic Nerve and Retinal Imaging Methods  CPT code 92227, 92228 - CPB 563, Diabetic Retinopathy Telescreening Systems

If your practice has received a claim denial during the period that these codes were transitioning into the claims processing system, then follow the instructions on the EOB that you received from Aetna to file an appeal.

United Healthcare & Oxford Per their Medical Policy Unit, UHC had a policy on Digital Retinal Imaging which was retired because it was considered to be a routine standard of care in the treatment of diabetic eye disease. The new codes that describe Digital Retinal Imaging are payable without the necessity of review.

Policy documents can be located on the UHC and Oxford web sites at:

UHC www.unitedhealthcareonline.com

Oxford https://www.oxhp.com/ProviderPortal/

If your practice has received a claim denial during the period that these codes were transitioning into the claims processing system, then follow the instructions on the EOB that you received to file an appeal.

As more information becomes available and more entities respond, we will keep you posted.

Reminder on Medicare Payment for Codes 92133 and 92134

Numerous inquires have prompted a reminder as to how Medicare is now allowing for codes 92133 and 92134 when performed bilaterally.

Code 92133 and 92134) is considered unilateral OR bilateral in nature and the RT, LT and 50 modifiers are no longer to be used.

Contrary to the old (and now deleted) code payment for 92135, (full and one half when the service was performed bilaterally), the new codes are considered unilateral OR bilateral and have been assigned a Status Code 2 for bilateral services on the National Physician Fee Schedule Relative Value file.

A Status Code 2 designation means that the 150% payment adjustment does not apply.

RVUs are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier 50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), Medicare will base the payment for both sides on the lower of (a) the total actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code.

The RVUs are based on a bilateral procedure because (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure.

As for the managed care and private insurance community, it is anticipated that they will adopt this payment methodology as well.

The American Academy of Ophthalmology (AAO) has put out a helpful FAQ on the overall impact this, and other changes, will have on the practice of Ophthalmology.

Go to the link here: http://www.aao.org/aao/outofcs/wre/FAQs_2011_Reimbursement.pdf

IMPORTANT UPDATE:

The 2011 EHR Incentive Program & E-Prescribing Penalties

As reported previously, physicians who do not document e-prescribing by reporting the G-code G8553 on their claims 10 times during the first six months of 2011 will be penalized 1 percent on their Medicare payments in 2012.

The 2013 penalty will involve 1.5 percent reduction for physicians who do not report G8553 on their claims 25 times from January 1, 2011 to December 31, 2011.

More importantly, while physicians cannot claim both the Medicare e-prescribing and electronic health record (EHR) incentives at the same time, those who claim the EHR incentive in 2011 must report the e- prescribing G-code (G8553) on their claims in 2011 to avoid the 2012 e-prescribing payment penalty.

In other words, earning the EHR incentive will not exempt you from the 2012 Payment Adjustment.

In fact, one could fail to submit the 10 codes prior to June 30, and so be subject to the 2012 Adjustment, yet still submit 25 codes by December 31 and earn the 2011 MIPPA eRx Incentive (and also be exempt from the 2013 Adjustment because of submitting the 25.)

This issue is extremely confusing and requests for clarification from CMS have been responded to but have been of little assistance. In the meantime, organized medicine is actively fighting to have this E-Prescribing penalty rescinded.

United Healthcare Implements a new Coordination of Benefits policy

United Healthcare has switched to a “pay and pursue” coordination of benefits (COB) model for commercial claims processed with a billed amount of $10,000.00 or less.

This means that UHC will not delay claim payments to physicians while it waits for patients to respond to requests for COB information.

In essence, claims less than $10,000 in billed charges will be processed and released for reimbursement regardless of pending coordination of benefits inquiries.

The change became effective December 1, 2010.

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Just a reminder ...

PLEASE PAY YOUR 2011 DUES TODAY....

It's easy ... just log on to http://marylandeyemds.org/ and click on the Membership Renewal tab!