Washington Report –July, 2010



Washington Report –July, 2010

Bill Finerfrock, David Connolly, Lea Wink, Amanda Craig

CMS/ONC Issue Meaningful Use Criteria

HBMA Testifies Before NCVHS

Berwick Gets Recess Appointment to CMS Post

HHS issues Interim Final Rule on Pre-Existing Condition Insurance Plan Program

HHS Launches New Consumer Focused Health Care Website:

CMS to hold Meeting on ACA Requirements for ICD-10 Crosswalk Revisions

Dispute Over findings of the Medicare Trustees Erupts

CMS Reviewing PECOS Enrollment Process

Ready for a MAC Attack?

States Receive Federal Matching Funds for Electronic Health Record Incentives Program

CMS Transmittals

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CMS/ONC Issue Meaningful Use Criteria

On July 13, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) release the final rule establishing the “meaningful use” criteria for providers to obtain the EHR incentive payments and the final rule outlining the certification criteria that EHR products must meet.

CMS has established a very useful website that provides up-to-date information on the EHR incentive program, changes to the program and regulatory or policy updates. To go to this new website, go to:

This official web site provides up-to-date, detailed information about the Electronic Health Record (EHR) incentive programs.

Supporters of the widespread adoption and use of EHRs maintain that the nation’s healthcare system is in the midst of a “transformation in an effort to improve quality, safety and efficiency of care, from the upgrade to ICD-10 to information exchanges of EHR technology.” EHR advocates maintain that the adoption and meaningful use of EHR will facilitate and hasten the streamlining process.   

The Medicare and Medicaid EHR incentive programs will provide incentive payments to eligible professionals (physicians, NPs, CNMs and certain PAs) as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology.  Providers will have to choose whether to receive EHR Medicare incentive payments or EHR Medicaid incentive payments. They will not be able to receive both – simultaneously. However, providers will have the opportunity to make a one-time switch from Medicare EHR incentive payments to Medicaid or vice versa. Both programs begin in 2011.

It should be noted that the EHR Incentive program is separate from other CMS incentive programs, such as the PQRI and e-Prescribing incentive programs; although the new meaningful use criteria will incorporate aspects of both the PQRI and e-prescribing programs.

The final rule issued on July 13th follows the proposed rule issued earlier this year. HBMA along with many other organizations submitted comments and made numerous recommendations on how to improve and streamline the EHR Incentive program. Not all of HBMA’s recommendations were adopted.

Below are links to various documents CMS has produced that will give more detailed information about the EHR incentive programs, the criteria for receipt of the incentive payments and other important EHR related information.

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|Fact Sheet: Medicare and Medicaid EHR Incentive Programs: Title IV of Recovery Act (June 16, 2009) |

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|Press Release: CMS and ONC Final Rules to Support Meaningful Use of Electronic Health Records (July 13, 2010) |

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|Fact Sheet: Final Regulations Define Meaningful Use and Set Standards for EHR Incentive Programs (July 13, 2010) |

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|Fact Sheet: Electronic Health Records At-a-Glance (July 13, 2010) |

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|Fact Sheet: Medicare EHR Incentive Program Final Rule Overview (July 16, 2010) |

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|Fact Sheet: Medicaid EHR Incentive Program Final Rule Overview (July 16, 2010) |

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|Fact Sheet: Meaningful Use Final Rule Overview (July 16, 2010) |

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|Health IT Frequently Asked Questions |

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HBMA Testifies Before NCVHS

On July 20th, a representative of the Healthcare Billing and Management Association (HBMA) was joined by representatives of the AMA, AHIP, Blue Cross/Blue Shield Association, the National Association of Insurance Commissioners and others to discuss the establishment of new operating rules for electronic insurance eligibility verification and claims status information.

The National Committee on Vital and Health Statistics (NCVHS) listened to various stakeholders, vendors and standard setting organizations over a 2 ½ day period in order to assist the NCVHS in developing recommendations for new HIPAA related standards. The NCVHS is the body identified by the Secretary of Health and Human Services (HHS) to advise the Secretary on all HIPAA related issues.

Jerry Killough, President of Clinix and a member of the HBMA ICD-10 Task Force presented HBMA’s testimony and responded to questions from the Committee.

Although enacted nearly 15 years ago, many providers and billing companies have failed to experience the Administrative Simplification benefits promised by HIPAA because the standards and regulations adopted in response to the HIPAA law were either inadequate or had so many “loopholes” so as to make the standards meaningless.

Part of the healthcare reform bill (the Patient Protection and Affordable Care Act) signed into law earlier this year by President Obama were new HIPAA related mandates calling for tighter and more effective electronic transaction standards. HBMA was a strong advocate for these more stringent standards.

In his formal remarks, Killough stated, “As we all know, we’ve been down this road of administrative simplification before and the mere fact that we are meeting here today to discuss “new” reforms 15 years after the original HIPAA administrative simplification reforms were enacted represents the formal acknowledgement of the failure of HIPAA to truly deliver the administrative simplification promised when it was signed into law by President Clinton.”

One issue before the NCVHS is who will be the standard setting organization for the new operating rules. Various existing Standard Development Organizations including the National Council for Prescription Drug Programs (NCPDP), X-12 and others presented their views on why their organization would be best-suited to take on this responsibility for the federal government.

One of the more interesting and informative presentations was made by the NCPDP, a non-profit ANSI accredited Standards Development Organization representing the pharmacy services industry. It was clear from the testimony presented and the questions from the Committee members that the NCPDP pharmacy program for eligibility verification and claims status is very robust and although developed specifically for pharmacy, could be replicated in the medical/health insurance arena.

NCVHS hopes to make recommendations to the Secretary in the next few months and will be conducting additional hearings over the next year on the development of other HIPAA related standards. HBMA will continue to be involved in this process and presenting the views of medical billing and practice management companies.

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Berwick Gets Recess Appointment to CMS Post

In early April, President Obama announced his intention to nominate Donald Berwick, MD to be the next CMS Administrator. If confirmed, Berwick would fill a vacancy at CMS that has existed since the Bush Administration. Although Berwick’s professional experience and credential are impressive, several GOP Senators expressed grave reservations about Berwick and his possible support for government supported healthcare rationing.

Fearful of a possible filibuster of the Berwick nomination, President Obama, in early July, made Dr. Berwick a “recess appointee” to the CMS position. The Constitution authorizes the President to appoint people to positions that otherwise require the “advice and consent” of the Senate if the appointment occurs during a time when the Senate is in recess. Although originally intended to allow the President to fill critical vacancies when the Senate would be away from Washington for long periods of time, the authority has been increasingly used by President’s of both parties to circumvent the Senate confirmation process. However, Dr. Berwick’s recess appointment is only valid through the next Congress. The Senate must act favorably on the Berwick nomination (which is still technically pending before the Senate) between now and the end of the 112th Congress (roughly November/December 2012), in order for him to continue in the position. If the Senate fails to act favorably on the Berwick nomination, his tenure as CMS Administrator would come to an end concurrent with the end of the 112th Congress.

Ultimately, Berwick’s fate may rest with the outcome of the Fall Congressional elections. If Republicans gain in numbers in both the House and Senate, they could use their new found political power to adversely affect the Appropriations bills – particularly CMS’s appropriations.

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HHS issues Interim Final Rule on Pre-Existing Condition Insurance Plan Program

 

The Patient Protection and Affordable Care Act (ACA) required that a temporary high risk health insurance pool program be established to provide affordable health insurance coverage to uninsured individuals with pre-existing conditions.  On July 30th, the Department of Health and Human Services (HHS) issued interim final rules that establish the Pre-Existing Condition Insurance Plan (PCIP) program. The PCIP program is a temporary program intended to cover the time-period until insurance companies can no longer exclude on the basis of pre-existing conditions. The prohibition on pre-existing condition provisions goes into effect on January 1, 2014.

 

This regulation became effective on the day it was released - July 30, 2010. 

 

The Department of Health and Human Services (HHS) may carry out the PCIP program directly or through contracts with either States or non-profit organizations. 

 

An individual is eligible to enroll in a PCIP if he or she:

• Is a citizen or lawfully present in the U.S.;

• Has not been covered under creditable coverage for a 6-month period prior to their application date;

• Has a pre-existing condition; and

• Is a resident of the State falling within the PCIP service area.

 

The intent is to promote continuity of coverage for individuals who enroll in a PCIP until they are able to obtain coverage through a Health Benefits Exchange, which will also begin operation in January, 2014. If an individual eligible for participation in the PCIP moves out of the service area, he or she can immediately apply for PCIP in the new State of residence.

 

The benefits and excluded services parallel that of the Federal Employees Health Benefits Plan.  A pre-existing condition is defined as a limitation or exclusion of benefits based on the fact that the condition was present before the date of enrollment in coverage or denial of coverage.

 

Premium rates are to be established at “a standard rate for a standard population,” which refers to the premium rates offered in the individual market in a given State.  The rule provides that a PCIP established under this section must not offer enrollees premiums at a rate that exceeds 100 percent of the standard individual market rate in the PCIP service area.  A PCIP must calculate the standard rate using reasonable actuarial techniques.  Premium rates can vary on the basis of age by a factor of no greater than 4 to 1.

  

The interim final rule requires the PCIP to develop, implement, and execute operating procedures to prevent detect, recover over-payments, and promptly report to HHS incidences of waste, fraud, and abuse.

 

The interim final rule prevents insurer dumping.  If it is determined that insurance issuers currently providing coverage to a high-risk beneficiary is discouraging those high-risk individuals from remaining enrolled in their coverage, the Secretary may bill the insurance company for any medical expenses incurred by the PCIP for such enrollees.

 

The ACA appropriates $5 billion dollars to pay the claims and administrative costs of the PCIP program.  No more than 10 percent of the allotted funds may be used towards administrative expenses.  Over time, spending under the PCIP program will be determined based on the actual enrollment and cost experience of the PCIPs across the country.  Finally, the new law imposes a “maintenance of effort” requirement on states.  In order for a State to enter into a contract to administer a PCIP, a State must agree not to reduce the annual amount it expended on the operation of an existing State high risk pool in the year preceding the year in which a PCIP contract begins.

If you would like to view the PCIP final rule, go to:



 

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HHS Launches New Consumer Focused Health Care Website

 

The U.S. Department of Health and Human Services has unveiled a new on-line tool that intended to help consumers take control of their health care by connecting them to “new information and resources that will help them access quality, affordable health care coverage.”  According to HHS Secretary Kathleen Sebelius, is “the first website to provide consumers with both public and private health coverage options tailored specifically for their needs in a single, easy-to-use tool.” 

 

In announcing the new website, Sebelius said, “For too long, the insurance market has been confusing and hard to navigate.  makes it easy for consumers and small businesses to compare health insurance plans in both the public and the private sector and find other important health care information.”

 

According to an HHS press release, is the first central database of health coverage options, combining information about public programs, from Medicare to the new Pre-Existing Conditions Insurance Plan, with information from more than 1,000 private insurance plans. 

 

The website is being marketed as a “one-stop-shop” for information about the Affordable Care Act as well as other health care resources. 

 

In October, 2010, HHS intends to begin publishing price estimates for health insurance plans on the new website. It is not clear how this information will differ from information already available on commercial websites (i.e. e-health insurance) that aggregate benefit and estimated cost information.

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CMS to hold Meeting on ACA Requirements for ICD-10 Crosswalk Revisions

On September 15th, the Centers for Medicare and Medicaid Services (CMS) will host a meeting of the ICD-9-CM Coordination and Maintenance (C&M) Committee.  The C&M meeting is a public forum for the presentation of proposed modifications to the ICD-9, Clinical Modification. In order to participate in this meeting, attendees must register ahead of time and space is limited.

The Affordable Care Act requires the C&M Committee to convene a meeting before January 1, 2011, to “receive stakeholder input regarding the crosswalk between the Ninth and Tenth Revisions of the International Classification of Diseases (ICD-9 and ICD-10, respectively),” for the purpose of making appropriate revisions to the crosswalk.  The new law also mandates that any revised crosswalk be treated as a code set for which a standard has been adopted by the Secretary, and that revisions to this crosswalk be posted to the CMS website.

The C&M Committee will use the morning of September 15th to fulfill the ACA requirement. HBMA will be represented at this meeting. Anyone wishing to attend in person must register for the meeting. If you simply want to listen in by phone, registration is not required.

To register, go to

If you want to listen in on the meeting via phone, the call-in information is:

Participant Dial In Number (800) 837-1935

Conference ID # 88801009

For additional information, go to and click on the ICD-9 Coordination & Maintenance Committee link page on the left.

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Dispute Erupts Over Findings of the Medicare Trustees

On August 5th the Medicare Trustees released their annual report on the future of Medicare.  The Report garnered some significant media attention and both CMS and the Obama Administration pointed to the report as evidence of the positive impact the Affordable Care Act would have on the future sustainability of the Medicare program.

Normally there are 7 individuals who serve as the Trustees of the Medicare Trust Fund. Three Cabinet Secretaries – Treasury, Labor and HHS, the Commission of the Social Security Administration and the Administrator of CMS and two Public Trustees. The Public Trustee positions are currently vacant. Therefore the signators to the report are:

Timothy F. Geithner, Secretary of the Treasury

Hilda L. Solis, Secretary of Labor

Kathleen Sebelius, Secretary of Health and Human Services

Michael J. Astrue, Commissioner of Social Security

Donald M. Berwick, M.D., Administrator of the Centers for Medicare & Medicaid Services,

According to the Trustees, in 2009, total Medicare benefits paid were $502 billion and total Medicare income was $508 billion. When you add in administration and overhead expenses, total Medicare expenditures were $509 billion in 2009 leaving an annual deficit of $ 1 Billion. The accumulated assets of the Medicare Trust Fund held in issue U.S. Treasury securities were $381 billion at the end of 2009.

Medicare Hospital Insurance (Part A) Trust Fund expenditures have exceeded income annually since 2008 and the Trustees project that this trend will continue through 2013. However, the Trustees report that beginning in 2014, trust fund surpluses are estimated to occur for several years. The 2010 – 2013 shortfalls will be covered by cashing in the Treasury Notes mentioned above.

The 2010 report marks the fifth straight year that the Trustees must issue a “Medicare funding warning,” indicating that Federal general revenues are becoming a substantial share of total financing for Medicare. When a warning is issued, the President is required to submit to Congress proposed legislation to respond to the warning. It is not clear when the President intends to submit that proposed legislation.

Considerable media attention was paid to the Trustee’s conclusion that the Medicare savings included in the Affordable Care Act would extend the solvency of the Medicare Trust fund from 2017 as previously projected, until 2029. 

 

Considerably less attention was paid to the Actuarial Report issued by Medicare’s Chief Actuary in conjunction with this report.  The Actuary’s Report can be found in the Appendix of the Trustees Report: ()

 

The Actuary raised several significant concerns about the Trustees report an in particular, the assumptions upon which the report is based.

After attesting to the validity of the report in terms of using accepted actuarial principles, the Actuary (Richard Foster) goes on to state, that although the projections are “valid” in the sense of reflecting the law, he argues that they are unrealistic from a practical sense.  He suggests that the assumptions used by the Trustees in making drawing their conclusions are unrealistic and that the budgetary situation confronting the Medicare Trust Fund is far worse than projected.

For example, the Trustees make no provision in their assumptions for fixing the SGR problem. The Actuary believes it is unrealistic to presume the Congress will not fix the SGR problem. The significance of this difference of opinion is big because current estimates are that it will cost approximately $300 Billion in additional outlays from the Medicare Trust Fund over the next 10 years to fix the SGR problem.

In addition, the Trustees assume future cuts in Medicare spending for various providers that the Actuary also considers unrealistic. According to the Actuary, if the Trustees assumptions are correct, Medicare provider payments in the future will be less than Medicaid and about 50% of what commercial insurers will be paying for the same services. The Actuaries report states:

“While the Part B projections in this report are reasonable in their portrayal of future costs under current law, they are not reasonable as an indication of actual future costs. Current law would require physician fee reductions totaling an estimated 30 percent over the next 3 years—an implausible result.”

He opines that the magnitude of the cuts in physician, hospital and other provider payments that would be necessary to achieve the budget targets would be so severe that providers would stop seeing Medicare patients.  In turn, the political heat on Congress to restore the cuts would be so intense that the “savings” outlined in the report will never be realized.  He states,

 

      "Without major changes in health care delivery systems, the prices paid by Medicare for health services are very likely to fall increasingly short of the costs of providing these services. By the end of the long-range projection period, Medicare prices for hospital,     skilled nursing facility, home health, hospice, ambulatory surgical center, diagnostic laboratory, and many other services would be less than half of their level under the prior law. Medicare prices would be considerably below the current relative level of Medicaid, which have already led to access problems for Medicaid enrollees, and   far below the levels paid by private health insurance.

 

Well before that point, Congress would have to intervene to prevent the withdrawal of providers from the Medicare market and the severe problems with beneficiary access to care that would result. Overriding the productivity adjustments, as Congress has done repeatedly in the case of physician payment rates, would lead to far higher costs for Medicare in the long range than those projected under current law.

     

For these reasons, the financial projections shown in this report for Medicare do not represent a reasonable expectation for actual program operations in either the short range (as a result of the unsustainable reductions in physician payment rates) or the long range because of the strong likelihood that the statutory reductions in price updates for most categories of Medicare provider services will not be viable).”

If you would like to review the Trustees Report, go to:



If you would like to review the “illustrative alternative” projections that are basis for the Actuaries comments, go to:



 

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CMS Reviewing PECOS Enrollment Process

The Centers for Medicare & Medicaid Services (CMS) announced that the agency is working with providers to address concerns about enrollment in the Provider Enrollment, Chain and Ownership System (PECOS). Providers, billing companies and others have been reporting unacceptable delays and problems with the Medicare enrollment process. HBMA members companies are consistently reporting that it is taking between 90 and 120 days to get some providers enrolled in Medicare.

As part of those efforts, CMS announced that “for the time being” the agency will “not implement changes that would automatically reject claims based on orders, certifications, and referrals made by providers that have not yet had their applications approved…” CMS, in a statement released to HBMA and others acknowledged, “While more than 800,000 physicians and other health professionals have enrolled and have approved applications in the PECOS system, some providers have encountered problems.  CMS is continuing to update and streamline the process, and more providers have been enrolled in the past few days.”

In early May, CMS issued an interim final regulation implementing various provisions of the Affordable Care Act that permit only a Medicare enrolled physician or eligible professional to certify or order  home health services, durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) , and certain items and services under Medicare Part B.  Although the Affordable Care Act provisions were designed to prevent fraud in Medicare, the enrollment delays were going to prevent thousands of physicians from getting paid for legitimate services provided to Medicare beneficiaries.

Although the new PECOS regulations were technically effective on July 6, 2010, CMS has directed their contractors to hold-off on rejecting claims submitted by providers that have attempted to enroll in PECOS.  Because of the delayed enforcement of the new rule, billing companies and their physician clients should not see any change in the processing of submitted claims, they will continue to be reviewed and paid as they have historically been reviewed and paid.

Finally, CMS has established a mechanism for the enrollment of providers solely for the purpose of ordering or referring. CMS acknowledges that providers working in certain facilities may not need to personally submit a claim to Medicare (i.e. physicians working in VA hospitals, DOD facilities and certain cost-based reimbursed providers) but these providers refer patients to physicians who will submit claims to Medicare.

In order to address this particular problem, CMS is permitting certain providers to enroll in Medicare solely for the purpose of ordering or referring. By opting for this status, these VA/DOD/cost-based providers will not be deactivated when they do not submit a Medicare Part B claim within 12 months of enrollment. Here is a link to the CMS instructions to their Contractors and others on how to handle this situation:



It would appear that CMS could begin enforcing this policy in 2011. Billing companies and providers should be prepared for the possibility that the “ordering/referring” policy will be enforced effective with services delivered on-or-after January 1, 2011. While it is possible that CMS could again delay enforcement, billing companies and providers should not plan for that possibility.

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Ready for a MAC Attack?

When you say the word “MAC” to anyone familiar with the Medicare program, they will likely think of the Medicare Administrative Contractor program implemented a few years ago. But there’s a new MAC in town and this one may affect physicians and billing companies in numerous ways.

Officially created as part of the S-CHIP reauthorization legislation, the new Commission, the Medicaid and CHIP Payment and Access Commission or MACPAC got it’s funding from the Affordable Care Act. Although often ignored by policy makers and most taxpayers, the reality is that the Medicaid program is actually larger than Medicare in terms of the number of “covered lives”. Whereas Medicare is the principle payer for healthcare for 47 million elderly, Medicaid pays for the healthcare of more than 60 million low-income or disabled individuals. However, when it comes to spending, Medicare’s annual budget of more than $500 Billion dwarfs the annual Medicaid budget of less than $350 Billion ($200 Billion federal and $140 Billion state money). However, with the ACA calls for a doubling of the number of people covered by Medicaid over the next 10 years, the Medicaid issues confronting the state and federal governments will expand exponentially over the next few years.

The MACPAC will hold its first meeting September 23rd and 24th.

In many respects, MACPAC is expected to operate similar to MedPAC – the Medicare Payment Advisory Commission. Both organizations will have staffs of around 30 and a yearly budget of $11 million to $12 million. Like MedPAC, MACPAC intends to hold regular meetings, conduct public votes on recommendations, and issue reports to Congress. In fact, a former senior staffer for MedPAC has been selected as the groups first Executive Direct (ED). Lu Zawistowich, who previously served as MedPAC deputy director, began her new position as Executive Director of MACPAC in early August.

Diane Rowland, a long-time advocate for low-income, uninsured individuals has been chosen as the first Chair of MACPAC. Rowland previously served as executive director of the Kaiser Commission on Medicaid and the Uninsured.

In addition to Rowland, the other MACPAC Commissioners are:

o David Sundwall, MD, Executive Director, Utah Department of Health, and Commissioner of Health, State of Utah. Dr. Sundwall will serve as vice chair of MACPAC.

o Donna Checkett, MPA, MSW, Senior Vice President of Medicaid Business Development, Aetna.

o Patricia Gabow, MD, Chief Executive Officer, Denver Health and Hospital Authority.

o Mark Hoyt, FSA, MAAA, National Practice Leader of the Government Human Services Consulting Specialty Group, Mercer, LLC.

o Trish Riley, MS, Director, Maine Governor's Office of Health Policy and Finance.

o Steven Waldren, MD, MS, Director, Center for Health Information Technology, American Academy of Family Physicians.

o Richard Chambers, Chief Executive Officer, CalOptima.

o Burton Edelstein, DDS, MPH, Professor, Clinical Dentistry, College of Dental Medicine and Clinical Health Policy and Management, Mailman School of Public Health, Columbia University.

o Denise Henning, CNM, MSN, Service Line Leader for Women's Health, Collier Health Services.

o Judith Moore, Senior Fellow, National Health Policy Forum, George Washington University.

o Robin Smith, foster and adoptive parent of special needs children covered by Medicaid.

o Sharon L. Carte, MS, Executive Director, West Virginia Children's Health Insurance Program.

o Andrea Cohen, JD, Director of Health Services, NYC Office of the Deputy Mayor for Health and Human Services.

o Herman Gray, MD, MBA, President, Children's Hospital of Michigan and Senior Vice President, Detroit Medical Center.

o Norma Martinez Rogers, PhD, RN, FAAN, Professor, Department of Family Nursing, University of Texas Health Science Center at San Antonio.

o Sara Rosenbaum, JD, Chair, Department of Health Policy and Harold and Jane Hirsh Professor of Health Law and Policy, George Washington (GW) University

o School of Public Health and Health Services.

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States Receive Federal Matching Funds for Electronic Health Record Incentives Program

As part of the Economic Recovery initiative approved by Congress last year, money was made available for the meaningful use of Electronic Health Records. While the bulk of the money made available to physicians and hospitals would flow through the Medicare program, a significant amount of the incentive dollars would be linked to Medicaid. However, unlike most Medicaid expenditures, the bulk of the cost of the Medicaid EHR incentive payments would come from federal dollars.

Over the past several months, CMS has been issuing grants to states to encourage providers to “adopt, implement or upgrade” an Electronic Health Records program. Unlike the “meaningful use” criteria which link incentive payments to the actual use of the EHR system, these Medicaid grant dollars assist eligible providers in the purchase or upgrading of their system.

CMS began releasing the EHR money to the states in November, 2009. At press time, more than $70 Million has been awarded to 45 states and the District of Columbia.

Additional information on implementation of the Medicaid-related provisions of the Recovery Act’s EHR incentive payment program may be found at:



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CMS Transmittals

The following links are to Transmittal issued by CMS since July 1, 2010.

|Transmittal No. |Subject |Effective Date |

|R756OTN |5010 Implementation-Changes to Present on Admission (POA) Indicator "";1""; and the K3|01/03/2011 |

| |Segment | |

|R2028CP |5010 Implementation--Processing Additional International Classification of Diseases, |01/03/2011 |

| |9th Revision-Clinical Modification (ICD-9-CM) Diagnosis and Procedure Codes in Pricer,| |

| |Grouper, and the Medicare Code Editor (MCE) | |

|R755OTN |National Council for Prescription Drug Programs (NCPDP) code set updates. |01/03/2011 |

|R752OTN |Processing Claims Spanning More than Ten Years with Unlimited Occurrence Span Codes |01/03/2011 |

| |(OSCs) | |

|R2026CP |Inpatient Rehabilitation Facility (IRF) Annual Update: Prospective Payment System |10/04/2010 |

| |(PPS) Pricer Changes for FY 2011 | |

|R753OTN |January Common Edits and Enhancements Module (CEM) Updates |01/03/2011 |

|R751OTN |Extract File Format Requirements to Fully Implement Change Request 6312 (Fiscal |01/03/2011 |

| |Intermediary Standard System (FISS) to Deactivate Billing Numbers for Non-Frequent | |

| |Billers) | |

|R750OTN |Health Insurance Portability and Accountability Act (HIPAA) 005010 837 Institutional |01/03/2011 |

| |(837I) Edits and 005010 837 Professional (837P) Edits - January 2011 Version | |

|R2020CP |Clarification of Billing Requirement for Ancillary Services Performed in the |09/07/2010 |

| |Ambulatory Surgical Center (ASC) by Entities Other Than ASCs | |

|R2023CP |Medicare Part A Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Pricer|10/04/2010 |

| |Update FY 2011 | |

|R749OTN |Health Insurance Portability and Accountability (HIPAA) 5010/D.0 Fixes |01/03/2011 |

|R745OTN |Payment for Implantable Tissue Markers (HCPCS Code A4648) and Implantable Radiation |11/06/2010 |

| |Dosimeters (HCPCS Code A4650) | |

|R2018CP |Indian Health Services (IHS) Hospital Payment Rates for Calendar Year 2010 |09/06/2010 |

|R746OTN |Changes to the Medicare Fraud Edit Modules |09/06/2010 |

|R2019CP |Identify All Beneficiaries in the Common Working File (CWF) With Dual Eligibility |10/04/2010 |

|R748OTN |Identify All Beneficiaries in the Common Working File (CWF) With Dual Eligibility |01/03/2011 |

|R2017CP |Medicare Contractor Annual Update of the International Classification of Diseases, |10/04/2010 |

| |Ninth Revision, Clinical Modification (ICD-9-CM) | |

|R744OTN |Jurisdiction 10 A/B MAC Merge of the Part B Alabama, Georgia, and Tennessee CICS |07/31/2010 |

| |Production and User Acceptance Test Regions | |

|R2008CP |Common Working File (CWF) Override Edit for Kidney Transplant Donor Claims When the |01/03/2011 |

| |Kidney Recipient is Deceased | |

|R2014CP |Common Working File (CWF) Unsolicited Response Adjustments for Certain Claims Denied |N/A |

| |Due to an Open Medicare Secondary Payer (MSP) Group Health Plan (GHP) Record Where the| |

| |GHP Record was Subsequently Deleted or Terminated | |

|R2011CP |Revised Instructions for Reporting Assessment Dates under the Inpatient Rehabilitation|01/03/2011 |

| |Facility (IRF), Skilled Nursing Facility (SNF), and Swing Bed (SB) Prospective Payment| |

| |Systems (PPS) | |

|R741OTN |Home Health Agencies (HHAs)Providing Durable Medical Equipment(DME)in Competitive |01/03/2011 |

| |Bidding Areas | |

|R2015CP |Revisions to Claims Processing Instructions for Services Rendered in Place of Service |01/03/2011 |

| |Home | |

|R734OTN |Timely Claims Filing: Additional Instructions |01/03/2011 |

|R2016CP |5010 Implementation--Processing Additional International Classification of Diseases, |01/03/2011 |

| |9th Revision-Clinical Modification (ICD-9-CM) Diagnosis and Procedure Codes in Pricer,| |

| |Grouper, and the Medicare Code Editor (MCE) | |

|R735OTN |Health Insurance Portability and Accountability Act (HIPAA) 005010 837 Institutional |01/03/2011 |

| |(837I) Edits and 005010 837 Professional (837P) Edits - January 2011 Version | |

|R733OTN |Further Instruction for Implementation of Health Insurance Portability and |01/03/2011 |

| |Accountability Act of 1996 (HIPAA) version 5010 for Transaction 835 - Health Care | |

| |Claim Payment/Advice and Updated Standard Paper Remit (SPR) | |

|R742OTN |Multi-Carrier System (MCS) Review and System Changes for IRS Reporting where Providers|01/03/2011 |

| |have been Paid under a Current and a Historic (or Multiple Historic) EIN Number in the| |

| |Same Calendar Year | |

|R743OTN |Analysis Change Request - The Inclusion of Veterans Administration (VA) Skilled |01/03/2011 |

| |Nursing Facility (SNF) Claims to the VA Medicare Remittance Advice (eMRA) Process | |

|R740OTN |Alternative Feedback Report Request Process for Quality Initiatives |01/03/2011 |

|R62SOMA |New State Code for Missouri; New CCN for Medicaid-Only Hospitals |01/03/2011 |

|R736OTN |5010: Workgroup for Pub. 100-04, Medicare Claims Processing Manual, Chapter 24 |08/30/2010 |

| |Revisions | |

|R2009CP |Implementation of the Interrupted Stay Policy under the Inpatient Psychiatric Facility|01/03/2011 |

| |Prospective Payment System (IPF PPS) | |

|R130BP |Definition of Ambulance Services |01/03/2011 |

|R730OTN |Allowing the Common Working File (CWF) to accept both Medicare Secondary Payer (MSP) |04/04/2011 |

| |and Non-MSP Lines on MSP Claims and MSP Adjustment Claims | |

|R732OTN |Shared System Separation of Duties Enforcement (Technical Control) |01/03/2011 |

|R348PI |Durable Medical Equipment (DME MAC) and the National Supplier Clearinghouse (NSC MAC) |10/04/2010 |

| |Procedures for Third Party Notification of Deceased Durable Medical Equipment, | |

| |Prosthetic, Orthotic and Supplies (DMEPOS) Supplier Associates | |

|R2004CP |Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index, and the Hospice |10/04/2010 |

| |Pricer for FY 2011 | |

|R2006CP |October Quarterly Update for 2010 Durable Medical Equipment, Prosthetics, Orthotics, |10/04/2010 |

| |and Supplies (DMEPOS) Fee Schedule | |

|R2007CP |Revisions and Re-issuance of Audiology Policies |08/11/2010 |

|R129BP |Revisions and Re-issuance of Audiology Policies |08/11/2010 |

|R61SOMA |Corrections to the Exhibits Table of Contents |07/23/2010 |

|R2005CP |Billing and Claims Processing for Automatic Implantable Cardiac Defibrillator |08/31/2010 |

| |(ICD)Services | |

|R2001CP |Changes to the Laboratory National Coverage Determination (NCD) Edit Software for |10/04/2010 |

| |October 2010 | |

|R2002CP |Claim Status Category and Claim Status Code Update |10/04/2010 |

|R60SOMA |Revisions to Appendix V-Interpretive Guidelines-Responsibilities of Medicare |07/16/2010 |

| |Participating Hospitals in Emergency Cases. | |

|R728OTN |Updates to the Inpatient Prospective Payment System (IPPS), Long Term Care Hospital |08/09/2010 |

| |(LTCH) PPS, Outpatient Prospective Payment System (OPPS), and Inpatient Rehabilitation| |

| |Facility (IRF) PPS Changes due to the Affordable Care Act (ACA) | |

|R347PI |Chapter 10 Manual Redesign |07/30/2010 |

|R172FM |Notice of New Interest Rate for Medicare Overpayments and Underpayments-4th |07/21/2010 |

| |Notification for FY 2010 | |

|R727OTN |Mailing To All Individual Practitioners, Medical Groups and Clinics and Independent |08/13/2010 |

| |Diagnostic Testing Facilities (IDTF) Who Are Billing or Have Billed For Advanced | |

| |Diagnostic Imaging Services | |

|R123NCD |Magnetic Resonance Angiography (MRA) |08/09/2010 |

|R1998CP |Magnetic Resonance Angiography (MRA) |08/09/2010 |

|R726OTN |Updates to the Inpatient Prospective Payment System (IPPS), Long Term Care Hospital |08/09/2010 |

| |(LTCH) PPS, Outpatient Prospective Payment System (OPPS), and Inpatient Rehabilitation| |

| |Facility (IRF) PPS Changes due to the Affordable Care Act (ACA) | |

|R2SBI |Conversion of Chapter 8, Premium Payments By States to the Internet Only Manual |07/02/2010 |

|R1996CP |Medicare Contractor Annual Update of the International Classification of Diseases, |10/04/2010 |

| |Ninth Revision, Clinical Modification (ICD-9-CM) | |

|R725OTN |Mailing To All Individual Practitioners, Medical Groups and Clinics and Independent |08/02/2010 |

| |Diagnostic Testing Facilities (IDTF) Who Are Billing or Have Billed For Advanced | |

| |Diagnostic Imaging Services | |

|R725OTN |Mailing To All Individual Practitioners, Medical Groups and Clinics and Independent |N/A |

| |Diagnostic Testing Facilities (IDTF) Who Are Billing or Have Billed For Advanced | |

| |Diagnostic Imaging Services | |

|R1994CP |Billing and Claims Processing for Automatic Implantable Cardiac Defibrillator (ICD) |08/31/2010 |

| |Services | |

|R1993CP |July Quarterly Update for 2010 Durable Medical Equipment, Prosthetics, Orthotics, and |07/06/2010 |

| |Suppliers (DMEPOS) Fee Schedule | |

|R346PI |Guidance on Implementing Section 3109 (a) of the Patient Protection and Affordable |01/03/2011 |

| |Care Act (PPACA) | |

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