NNEACC - ACC Updates

News Alert from the ACC Regarding Humana Settlement
February 28, 2011 Deadline to Resubmit Claims

Managed Care Advisory Group and the American College of Cardiology want to remind you that if you have not already done so, now is the time to resubmit for separate payment of 12 Lead ECG interpretations (CPT 93010) under the Humana Settlement negotiated by the American College of Emergency Physicians.

Under the Settlement, Humana will make eligible for payment resubmitted claims with dates of service from October 1, 2009 through March 31, 2010 for Electrocardiograms (EKG) 12-Lead service (CPT code 93010) when billed with the following E&M codes (CPT Codes 99217,99218, 99220, 99234, 99235, 99236, 99281-99285, 99291 and 99292) with or without the appending a Modifier 25 to the E&M Code (hereinafter “Claims”).

After a formal compliance dispute filed by ACEP in 2009, Humana has ceased bundling claims for CPT 93010 (12 lead ECGs) diagnostic interpretations when reported with the E&M codes above as of April 16, 2010 (Effective Date). Humana will reimburse one professional interpretation as of the Effective Date and the first claim received for 12 ECG will be reimbursed. In addition to the prospective relief, ACEP negotiated for the lifting of the edit going forward as a primary goal.

Physicians have up to and including February 28, 2011 to resubmit these Claims. Resubmitted Claims received by Humana after this date will not be reprocessed.

The following fields will need to be provided:

Provider Name
Provider Tax ID # (TIN)
Member Name
Member ID
Patient Name
Patient Date of Birth
Date of Service
E&M CPT code billed with CPT Code 93010
Billed Amount (for the 93010)

Based on the Aetna settlement for payment of ECGs, also negotiated by ACEP, payment for CPT code 93010 typically ranges between 10 and 15 dollars, so this can mean significant incremental reimbursement for your group.

Managed Care Advisory Group is ready to assist with your filing. They can be reached at 800.355.0466, or at physicianservices@mcaginc.com. More information and documentation can be found at the following website http://www.acep.org/Content.aspx?id=50396.

Congress Needs to Hear From You on the
Sustainable Growth Rate

Now is the time for Congress to hear from cardiovascular specialists that a permanent replacement of the flawed sustainable growth rate (SGR) formula is necessary. As of March 1, the temporary patch for the SGR will expire, and Medicare payments to all medical providers will be cut an additional 21.5 percent. Although the House of Representatives in November 2009 passed a bill to eliminate the SGR cuts (H.R. 3961), the Senate has been unsuccessful in passing similar legislation (S. 1776).

Tell your members of Congress to pass legislation to permanently replace the broken SGR formula. Contact your member of the House by clicking here, your Senators by clicking here or call them at (800) 210-7193.

Visit the CardioAdvocacy Network page to learn more.

The PINNACLE Network™ www.pinnaclenetwork.org

In an effort to help practices not only survive, but thrive, in today’s challenging health care environment, the ACC is launching the new PINNACLE Network. This first-ever, registry-based cardiovascular network is designed to promote practice innovations and achieve clinical excellence.

The PINNACLE Network™ immediately addresses the rapidly shifting business environment that private cardiovascular practices face with a wealth of practice management and financial management tools. It also builds a foundation for innovative, registry-based systems to reward practices for the high quality care that they provide.

Specifically, the PINNACLE Network builds on the College's commitment, experience and leadership in cardiovascular care and forms a one-stop shop for:

Practice management tools
Workflow and workforce solutions
Educational and advocacy resources
Health IT tools
Risk management strategies for lowering medical liability costs, and
The PINNACLE Registry – formerly the IC3 Program

The ACC believes that the systematic practice of quality care is the foundation for practice success—clinically, financially and professionally. The PINNACLE Network is the community and the pathway to help you and your practice achieve that success.

Contact pinnacle@acc.org with any questions.

CIGNA Revises Modifier (-25 and -59) Policy

CIGNA changed its policy to require providers to submit supporting documentation for any claims with procedures and services that are appended with a CPT modifier 25 or 59. As of April 20, 2009, CIGNA planned to require documentation for approximately 17,000 NCCI code pairs. After listening to numerous providers and professional medical societies including the American College of Cardiology and the AMA, CIGNA has decided to significantly reducing the number of NCCI code pairs for which it requires documentation to fewer than 500 (less than 5 percent of CIGNA's total claims). CIGNA will delay full implementation of this program until April 27, 2009.

CIGNA will also provide helpful hints to ensure the supporting documentation physicians submit via fax or mail for these NCCI code pairs contains the appropriate information to successfully match the documentation with the electronic claim submission. In the meantime, please instruct physicians and their practice staff to check Box 19/Loop 3200 on their claim submission to indicate that they submitted supporting documentation. Supporting documentation can be faxed to CIGNA at (570) 496-2945 or sent via mail to the CIGNA address on the back of the patient’s ID card.

Here are some important instructions for your practice:

As of April 20:

CIGNA was pleased to report the mandatory submission of documentation for NCCI code pairs appended with CPT modifier 59 will be delayed until April 27, 2009. Beginning April 27, the list of code combinations that require supporting documentation for modifier 59 will be significantly reduced.
Documentation submission requirements for NCCI code pair edits appended with CPT modifier 25 will be active through April 24. Physicians and their practice staff must choose to either submit these code pairs with documentation or postpone submission to the following week. Physicians and their practice staff should remember to always appropriately document the performance of procedures and services prior to submitting a claim. Beginning April 27, the list of code combinations that require supporting documentation for modifier 25 will also be significantly reduced.

Once the revised list is released, the ACC will highlight the code pairs most frequently billed by cardiologists.

Please instruct your practice staff to keep visiting www.cignaforhcp.com for the revised list of which NCCI code pairs that will require supporting documentation with the claims submission when appended with a CPT modifier 25 or 59. For the complete list of current code combinations that require supporting documentation when modifiers 25 or 59 are billed, log in to the secure CIGNA for Health Care Professionals Web site (www.cignaforhcp.com) and select “Resources” then “Claim Editing Procedures.” The updated code combination lists will be available online prior to April 27.

Physicians who are not currently registered for the CIGNA for Health Care Professionals Web site will need to complete the registration process to log on. They can go to www.cignaforhcp.com and select “Register Now,” located in the left side bar.

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