The New Era of Healthcare and the Affordable Care Act (ACA) is bringing monumental changes and obstacles to physician and hospital reimbursement and operations – expanded insurance coverage through Medicaid and Health Insurance Exchanges, data collection including ICD-10 transition and meaningful use, and payer audits to ensure proper provider documentation and coding.

Stay up to date with these recent payer announcements:

Medicaid Primary Care Payment Increase
The Affordable Care Act (ACA) enacted changes to Medicaid primary care reimbursement. Eligible physicians will receive supplemental payments for services rendered between January 1, 2013 and December 31, 2014. These supplemental payments will raise the Medicaid reimbursement to Medicare rates. To be eligible for the supplemental payments, physicians must self-attest as having a specialty in family medicine, general internal medicine, and/or pediatric medicine. Only physicians can complete the attestation! Staff or other representatives are not allowed to complete the attestation on the provider’s behalf.
Click here to complete provider attestation.

cmsCenters for Medicare and Medicaid Services (CMS) – Transmittal 1165, Change Request 8109

Implementation Date: April 1, 2013

Effective Date: October 1, 2014

Subject: ICD-10 Conversion from ICD-9 and Related Code Infrastructure of the Medicare Shared Systems as They Relate to CMS National Coverage Determinations (NCDs).

Summary: To both create and update national coverage determination (NCD) hard-coded shared system edits that contain ICD-9 diagnosis codes with comparable ICD-10 diagnosis codes plus all associated coding infrastructure such as procedure codes, HCPCS/CPT codes, denial messages, frequency edits, POS/TOB/provider specialties, etc.

The implementation date is prior to the effective date in order to be prepared to meet the timeline to implement the new ICD-10 diagnosis codes on October 14, 2014. The shared systems began implementation of the necessary changes to the NCDs in the January 2013 systems release and continue with CRs in subsequent releases.

Click here for full content of CMS Transmittal 1165, and spreadsheet showing all affected ICD-9 codes and their corresponding ICD-10 codes as they relate to their respective NCDs, in addition to the rest of the coding infrastructure specific to each NCD.

Medicare (Novitas)

Novitas is resuming with the revalidation process as of March 1, 2013.

Novitas average processing time for applications has increased to 90 days—as a result of incentive program deadlines and transition from Trailblazer.

Anthem BCBS (CO) – Change to Imaging Guidelines

Effective April 15, 2013 the following AIM clinical appropriateness imaging guidelines will be revised for the purpose of expanding requirements to increase conservative therapy prior to imaging; clarify appropriate imaging for inflammatory and infectious etiologies; and to expand guidelines for the work-up of tumors:

  • CT Cervical Spine, Thoracic Spine and Lumbar Spine
  • MRI Cervical Spine, Thoracic Spine and Lumbar Spine
  • CT Upper Extremity
  • MRI Lower Extremity

These clinical guidelines can be accessed on AIM’s website at

Drug fee schedule update: CMS average sales price (ASP) first quarter fee schedule (effective 1/1/13) will go into effect on February 1, 2013. To view the ASP fee schedule, go to CMS website at

Anthem BCBS – Central Region (IN, KY, MO, OH, WI)

Robotic Assisted Surgery – Facility Reimbursement

Effective May 8, 2013, Anthem will not allow additional payment for charges associated with robotic technology. The use of robotic technology is considered integral to the primary surgery being performed and not eligible for separate reimbursement.


TRICARE West Region: UnitedHealthcare Military and Veterans launched the TRICARE West Region website on February 15, 2013. The website will be updated with new information for TRICARE network providers until the contract transitions to UnitedHealthcare on April 1, 2013. Contracting is underway! Practices/providers will need to return the Demographic Form and/or Service Code Listing as these are important components of your agreement with UnitedHealthcare Military and Veterans.

Revision to Documentation Requirements for Modifier 22: Effective June 2013, UnitedHealthcare will follow CMS guidelines and require a concise statement outlining how the service differs from the usual service performed, in addition to the operative report before the additional 20% in reimbursement will be considered.

Revision to Speech Therapy Policy (Physical Medicine and Rehabilitation): Effective the second quarter of 2013, the Speech Therapy Policy will be revised to deny reimbursement for CPT codes 99201-99499 when reported by speech and language therapists/pathologists.

Changes to Prior Authorization List: Effective for dates of service on or after April 1, 2013, UnitedHealthcare West and commercial plans will require prior authorization for skilled nursing and private duty nursing in addition to nutritional services for home health coverage.


Coming soon – One website for all Cigna Patient information: Practices will be able to verify eligibility and benefits, precertification requirements and submit requests, checking claim status, check details of processed claims, important updates and more!


Specialists need to be on the lookout for requests from Aetna to review selected medical records for office visits. The purpose is to compare the provider’s documentation and the coding that was submitted on the claim form. Requests are based on provider trends in coding relative to his peers in the same specialty, and the characteristics of the claim. The affected specialties are:

  • Dermatology
  • ENT
  • Hand surgery
  • Neurology
  • Neurosurgery
  • Orthopedic surgery
  • Pain management
  • Physiatry
  • Plastic surgery
  • Podiatry
  • Sports medicine
  • Urology

Aetna will also review medical records for procedures in Dermatology and Urology.