CMS TO CORRECT 96361 EDIT

  • 0
  • May 7, 2013

5/7/2013
Medicare Denials and eRx Updates
CMS Transmittal 2636, Change Request 7501 dated January 16, 2013 provides a list of add-on CPT codes and the primary service codes that they must be performed in conjunction with. The Add-On Code edit file released for April 1, 2013 listed CPT code 96360 (IV infusion, hydration; initial 31 minutes to 1 hour) as the only primary code for add-on code 96361 (each additional hour of hydration). Because of this erroneous edit, practices have been experiencing denials when billing hydration (96361) as a secondary or subsequent service after a different initial service.

CMS is taking steps to correct this edit error. In the Add-On Code Edits version for July 1, 2013, CMS will be expanding this list so that the primary codes will be listed as 96360, 96365, 96374, 96409, and 96413. In the meantime, it is suggested that oncologists may choose to delay submission of claims for CPT code 96361 to July 1, 2013 or later.

I will provide more information on this issue as it becomes available.

eRx DEADLINE TO AVOID 2014 PAYMENT PENALTY
The 2013 eRx 6-month reporting period (January 1, 2013 to June 30, 2013) is the final reporting period available to you if you wish to avoid the 2014 eRx payment adjustment. If you do not successfully report, a payment adjustment of 2% will be applied, and you will receive only 98% of your Medicare Part B PFS amount for covered professional services in 2014.

Avoiding the 2014 eRx Payment Adjustment
Individual EPs and eRx GPRO participants who were not successful electronic prescribers in 2012 can avoid 2014 eRx payment adjustment by meeting specified reporting requirements between January 1, 2013 and June 30, 2013. Below are the 6-month reporting requirements:

  • Individual EPs – 10 eRx events via claims
  • eRx GPRO of 2-24 EPs – 75 eRx events via claims
  • eRx GPRO of 25-99 EPs – 625 eRx events via claims
  • eRx GPRO of 100+ EPs – 2,500 eRx events via claims

Exclusions and Hardships Exemptions
Exclusions from the 2014 eRx payment adjustment only apply to certain individual EPs and group practices, and CMS will automatically exclude those individual EPs and group practices who meet the criteria. More information on exclusion criteria and hardship exception categories can be found on the Electronic Prescribing (eRx) Incentive Program: 2014 Payment Adjustment Fact Sheet.

Resources from CMS
eRx Incentive Program Payment Adjustment Information
Electronic Prescribing (eRx) Incentive Program: Updates for 2013.

Questions about eRx?
If you have questions regarding the eRx Incentive Program, eRx payment adjustments, or need assistance submitting a hardship exemption request, please contact the QualityNet Help Desk at 866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@sdps.org. The Help Desk is available Monday through Friday from 7am-7pm CT.