Action: July 1, 2013


TMA Action July 1, 2013  
 News and Insights from Texas Medical Association 

INSIDE: Act Now to Get Medicaid Fee Increase

Act Now to Get Medicaid Fee Increase
TMA Challenges Dentists' Sleep Apnea Rule
TMA Questions Cigna Red-Tape Hassle
HIEs Ready to Sign Physician Practices
TMA Helps You Meet New Meaningful Use Rules

ICD-10 Seminar Now Available on Demand
ACIP Updates MMR Vaccination Guidelines
TMA Wise Choice for Choosing Wisely Grant
TMA Foundation Grant Deadlines Coming
This Month in Texas Medicine

Act Now to Get Medicaid Fee Increase

Later this year, Texas will increase Medicaid payments to Medicare parity for two years – retroactive to Jan. 1, 2013 – for select primary care services provided by primary care physicians (PCPs) and related subspecialists.

However, to benefit from the fee increase, you must submit a signed self-attestation form to the state's Medicaid claims payer, the Texas Medicaid and Healthcare Partnership (TMHP). The state has not set a deadline for returning attestation forms but will do so in the coming months. (Physicians who return the attestation form after the deadline will not be eligible for increases retroactive to Jan. 1, 2013, though they will be eligible for higher payments through the end of 2014.) If you are eligible, attest early to ensure the state receives your paperwork.

 Who is eligible for the higher payments?
Pediatricians, family physicians, and general internists are eligible for the higher payments as are these subspecialists.

To qualify, you must be practicing in an eligible specialty and either board certified or attest that 60 percent of your Medicaid billings are eligible for evaluation and management (E&M) or vaccine administration CPT codes. 

Texas Medicaid will conduct a random, statistically valid audit of PCPs receiving the higher payments to ensure they are qualified.

Are advanced practice nurses and physician assistants eligible for higher payments? 
Yes. The rate increase will apply to services provided by advanced practice nurses (APNs) or physician assistants (PAs) under physician supervision. APNs or PAs who bill under their own Medicaid Texas provider identification (TPI) number will be paid at 92 percent of the Medicaid payment rate as per current Medicaid payment rules.

What CPT codes are eligible for the higher payments?
Evaluation and management codes 99201 to 99499, including new and established patient preventive care codes and behavioral health counseling codes not covered by Medicare, are eligible. So are vaccine administration codes 90460, 90461, 90471, 90473, and 90474.  The higher payments will apply to eligible services provided from Jan. 1, 2013, through Dec. 31, 2014.

How do I attest that I am eligible for the higher payments?
Complete and sign the self-attestation form.  

You must complete an attestation form for each individual physician Medicaid TPI number, such as those for Texas Health Steps or multiple practice locations. A group practice may submit attestation forms on behalf of each physician within the practice but cannot attest as a group.

When will higher payments begin, and how will they be made?
Texas anticipates beginning the higher payments in early fall. Eligible claims submitted before the start date will automatically be adjusted retroactively to Jan. 1, 2013, and paid in a lump sum. Thereafter, physicians will receive quarterly payments through the end of the two years.

Once payments begin, HMOs will disburse payments to network physicians for eligible services provided to their enrollees. TMHP will issue payments for services provided to fee-for-service enrollees.

Is the PCP payment increase linked to the state's decision to forego Medicaid expansion to low-income adults as authorized by the Patient Protection and Affordable Care Act? 
No. Eligible physicians will be paid the higher fees regardless of whether Texas eventually expands Medicaid.

What is the difference in Medicaid versus Medicare payments?
See this chart showing how the new payments for select CPT codes compare with current payments for Medicaid adult and child services.

The Texas Medical Association will send you updates on the fee increase in Action and post them on the TMA website. For additional help, call the TMA Knowledge Center at (800) 880-7955 or the TMHP Contact Center at (800) 925-9126.

TMA Challenges Dentists' Sleep Apnea Rule

Dentists should not independently diagnose and treat sleep apnea because they are not trained to do so, TMA told officials of the Texas State Board of Dental Examiners.

"It is beyond the scope of practice of dentistry in Texas to diagnose a medical disease or disorder, including a sleep disorder, or to independently treat such disorder once diagnosed," TMA President Stephen L. Brotherton, MD, said in a letter to the board's executive director.

Among TMA's concerns, Dr. Brotherton wrote, is that the dental board is considering adopting a rule that allows dentists to diagnose and treat sleep apnea in collaboration with a physician and that says a "dentist shall ensure that the patient has been evaluated by the physician for a sleep disorder in compliance with the Texas Medical Practice Act and Texas Medical Board rules, and is being monitored by the physician for potential complications of the sleep disorder."

Dr. Brotherton said that language "would not only impose an undue burden on a dentist, but it would require knowledge beyond the scope of a dentist's training or license. A dentist cannot know if a physician is acting in compliance with the Medical Practice Act and Texas Medical Board rules, because a dentist does not practice medicine or have medical training. It would be inappropriate for a dentist to oversee, monitor, or judge a physician's treatment of a patient."

His letter also said other provisions of the rule could be misinterpreted to expand the scope of dentistry.

Supreme Court Lets Scope Ruling Stand 
The Texas Supreme Court decided not to review TMA's case against the Texas State Board of Chiropractic Examiners, in which the association argued that chiropractors are not allowed to diagnose. The ruling leaves standing TMA's successful challenge to the board's manipulation-under-anesthesia and needle electromyography regulations. It also has the effect of allowing chiropractors to make a chiropractic diagnosis limited to their scope of practice, as statutorily defined.

TMA is considering whether to continue with its constitutional challenge when it is remanded back to the trial court.

TMA Questions Cigna Red-Tape Hassle

TMA believes a Cigna referral policy imposes a red-tape hassle on physicians and patients and will ask the Texas Department of Insurance (TDI) to determine if the company has violated the agency's network adequacy rules.

Cigna requires physicians and patients to sign a form whenever the physicians refer patients to a non-Cigna network physician or other provider. Physicians must explain on the form why they recommend out-of-network services, must disclose whether they have a financial relationship with the other provider, and must obtain the patient's consent to the referral by having the patient check a box and sign the form. Physicians aren't required to send the forms anywhere but must keep them on file indefinitely.

TMA notified Cigna of its opposition to the requirement two years ago, before TDI adopted network adequacy rules. Earlier this year, TDI granted insurers permission to include contract provisions that require certain disclosures about out-of-network referrals. The rules say insurers can require referring physicians and other health care professionals to disclose ownership interests in facilities or whether the referral is to a person or facility that "might not be a preferred provider." 

TMA questions the overly broad approach Cigna is taking on out-of-network referrals and the new rules. The TMA Council on Socioeconomics and the TMA House of Delegates adopted policy opposing such forms and the intrusion into the patient-physician relationship they represent, said Lee Spangler, TMA's vice president for medicine economics.  


TMLT Action Ad 4.13

HIEs Ready to Sign Physician Practices

One of the greatest promises of health information technology and electronic health records is the ability to securely access and share patient information at the point of care. Currently, there are 12 health information exchanges (HIEs) in Texas funded with federal grants that can provide information about patients at the point of care.

Some of this information includes lab results, current medications, recent hospitalizations, and radiology reports. Each HIE is developing various services according to the needs in its specific region. It is important that you reach out to the HIE in your region to find out what services are offered and to learn details about participation, including cost.

Click here to find out which HIE covers your area. You will be able to access contact information to learn more. TMA has developed a set of questions you should ask before joining an HIE. Those are available for you in the TMA HIE Resource Center

Join TMA for a Tech Tuesday webinar about HIEs at noon CT on Tuesday, July 16. This will allow you to ask questions and learn more about the Texas approach. Information about the webinar and registration is available in the TMA Education Center

For more information about HIEs or other health information technology issues, contact TMA's HIT Department by telephone at (800) 880-5720 or by email

TMA Helps You Meet New Meaningful Use Rules

Physicians participating in the Medicare or Medicaid meaningful use incentive programs will have to meet increasingly more difficult criteria in 2014 when Stage 2 begins. The new requirements will apply to physicians who started the meaningful use program in either 2011 or 2012. Those who began in 2013 won't move to Stage 2 until 2015.

There are some significant changes for Stage 2 meaningful use, thus TMA offers a two-page snapshot of the criteria physicians should review as they prepare. 

As a reminder, all participants must upgrade their electronic health records (EHRs) to a Stage 2 certified version regardless of which meaningful use stage the practice is in. Because of the mandatory EHR upgrade, all meaningful use participants, regardless of participation year, are allowed a 90-day reporting period in 2014, as opposed to the full year reporting period previously required in years 2 through 5.   

TMA recognizes the complexities of the program and has developed numerous resources to help you and your staff. Check out TMA's Tech Tuesday webinar series developed to help you with HIT challenges. Federally funded health information technology regional extension centers around the state will provide in-office consulting for your practice. 

For more information about the electronic health record incentive program or other health information technology issues, contact TMA's HIT Department by telephone at (800) 880-5720 or by email.   

 TMAIT Action Ad 4.13 


ICD-10 Seminar Now Available on Demand

Did you miss TMA's recent seminar on preparing for ICD-10, ICD-10 Now! How and Why? Did you attend one of the sessions but would like a review? The seminar is now available as an on-demand webinar through the TMA Education Center.

This two-and-a-half-hour webinar takes a detailed look at everything you need to know and do to prepare for ICD-10. The presentation begins with an overview of ICD-10, then delves into real-world explanations of how to assess your practice's readiness and to plan for and implement a successful transition. Remember, being ready for ICD-10 will take time to work out; some changes will take more than a year to resolve.  

The seminar is a good foundation for TMA's next ICD-10 seminar, coming this fall to cities around the state. Achieving ICD-10 Implementation Success will be a live, interactive session that gets down to the brass tacks of making the change to ICD-10. Registration opens July 29.

ACIP Updates MMR Vaccination Guidelines

The Advisory Committee on Immunization Practices (ACIP) has new guidelines for preventing measles, mumps, rubella, and congenital rubella syndrome.

The revisions include:

  • All patients aged 12 months and older with HIV infection who don't have severe immunosuppression should be vaccinated against measles, mumps, and rubella (MMR).
  • Patients with perinatal HIV who received their MMR vaccination before antiretroviral therapy began should be revaccinated with two doses.
  • The use of immune globulin administered intramuscularly (IGIM) is recommended for infants from birth to 6 months who've been exposed to measles. In immunocompetent patients, the recommended dose of IGIM has increased.
  • Intravenous immune globulin is recommended for severely immunocompromised people and for pregnant women who have been exposed to measles but who don't have evidence of immunity.

August is National Immunization Awareness Month, a great time for a TMA Be Wise — ImmunizeSM vaccination or educational event. You can help kids prepare to head back to school or college with a shot clinic. Or educate families that vaccinations are important, safe, and effective – and needed across the lifespan.

Start planning your back-to-school Be Wise — Immunize event. Check out the new Be Wise Quick Start Manual for step-by-step tips to plan your event. 

Be Wise — Immunize is a service mark of the Texas Medical Association.

TMA Wise Choice for Choosing Wisely Grant

The ABIM Foundation awarded TMA a $50,000 grant to advance the Choosing Wisely campaign among Texas physicians. Choosing Wisely is leading a national conversation about doing the right thing at the right time for the right patient, and avoiding unnecessary care. TMA is one of only five state medical associations to receive a grant from the ABIM Foundation.

"It is important for physicians to take a leadership role in reducing waste and improving quality for their patients," said TMA President Stephen L. Brotherton, MD.

The campaign's goal is to promote conversations between physicians and patients about using the most appropriate tests and treatments. To help stimulate these conversations, leading medical specialty societies created lists of evidence-based practices that might be unnecessary or overused.  

"Every patient is unique," said Dr. Brotherton. "The practices identified are not meant to be absolutes but guidelines that include indications when a test or procedure may be appropriate. The campaign is not about cookie-cutter medicine but about starting a conversation between a patient and his or her physician about the best method of care."

As a member of the initiative, TMA will work with Texas physicians, state specialty societies, and county medical societies to educate doctors about the campaign's recommendations.

"With these funds, we plan to help our physicians promote Choosing Wisely in their practice, and foster meaningful discussions between doctors and patients to help patients choose the care that is truly necessary and beneficial," said TMA Foundation President G. Sealy Massingill, MD. The foundation, TMA's philanthropic arm, applied for the grant and will manage grant-funded activities, as well as educate individuals, businesses, and community groups about the value of the campaign.

Support for the grant program comes from the Robert Wood Johnson Foundation.


 PC Action Ad July 13 



TMA Foundation Grant Deadlines Coming

The TMA Foundation (TMAF) is accepting applications for its 2013-14 Medical Community Grants and Medical Student Leadership Grants programs. TMA county medical societies and alliance and medical student chapters may apply for support for short-term, high-impact health improvement initiatives.

Medical society and alliance chapters have until July 31 to apply for up to $7,500. Medical student chapters have until Aug. 30 to apply for up to $3,000.

You can get more information and download the applications on the TMAF website.

This Month in Texas Medicine

The July issue of Texas Medicine explains accountable care organizations and what they mean to you, tells you why electronic health records can be a hassle but worth the trouble, and details the benefits of TMA's new medication reconciliation tool. It also describes how physician and emergency medical personnel responded to April's deadly explosion in West and reports on what happened at TexMed 2013 in San Antonio in May.

Check out our digital edition.

Texas Medicine RSS Feed

Don't want to wait for Texas Medicine to land in your mailbox? You can access it as an RSS feed, the same way you get the TMA Practice E-Tips RSS feed.

E-Tips RSS Feed

TMA Practice E-Tips, a valuable source of hands-on, use-it-now advice on coding, billing, payment, HIPAA compliance, office policies and procedures, and practice marketing, is available as an RSS feed on the TMA website. Once there, you can download an RSS reader, such as Feedreader, Sharpreader, Sage, or NetNewsWire Lite. You also can subscribe to the RSS feeds for TMA news releases and for Blogged Arteries, the feed for Action.

This Just In ...

Want the latest and hottest news from TMA in a hurry? Then log on to  Blogged Arteries.  

TMA Education Center 

The TMA Education Center offers convenient, one-stop access to the continuing medical education Texas physicians need. TMA's practice management, cancer, and physician health courses are now easier than ever to find online. 

Physician Health and Wellness, Ext. 1342   

Getting Older: Beats the Alternative! 
9/20-21 Montgomery 

Healthy Physicians: Healthy Patients 
9/7       Houston 
10/26   San Antonio  

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Last Updated On

January 27, 2016