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Published Online: 1 March 2016

How to Ensure Part D Coverage for Your Medicare, Medicaid Patients

Part D prescriptions will no longer be covered as of June 1 for patients of nonparticipating Medicare providers.
APA’s Practice Management HelpLine has gotten a number of calls from concerned APA members who received letters from Medicare stating that they must be either enrolled in or opted out of Medicare before June 1 if they want their Medicare patients to continue having their medications covered under Medicare Part D. The Centers for Medicare and Medicaid Services (CMS) recommends that physicians enroll or opt out of Medicare as soon as possible to avoid costly problems for their patients. Detailed instructions on enrollment and opting out are posted on CMS’s website.
The reason the psychiatrists received these letters is because they had been prescribing medications for Medicare patients but had no status with Medicare. They were neither enrolled as Medicare providers (either participating or nonparticipating) nor opted out of Medicare and had not entered into private contracts with their Medicare patients. Although Medicare has been covering prescriptions and referrals for their beneficiaries, it will no longer do so as of June 1. (The Medicaid program already imposed this limitation as of July 1, 2013.)

CPT Coding Q&As From Helpline

Q: I have a patient who is unable to come into the office because of physical health problems so I conduct her psychotherapy sessions via telephone. I do not provide medical evaluation and management unless I see her in person. Can I use the CPT code 90834 even though this code is generally used by nonphysician therapists?
A: You cannot use 90834 in this case; however, if you were seeing the patient in person, you would be perfectly correct in using this code when you provide psychotherapy with no medical evaluation and management. Since all of the psychotherapy codes are defined as being “face-to-face with the patient and/or family,” and in this case the therapy is being provided telephonically rather than in person, the only appropriate code to use is 90899, the code for an “unlisted psychiatric service or procedure.” When you use 90899, you should always identify what the unlisted service is.
Both Medicare and Medicaid now have an option for physicians and other health care providers allowing them to enroll solely to be able to order prescriptions and make referrals. However, physicians cannot file claims or bill patients for these services.
We at the HelpLine have been concerned about the calls we’ve received since Medicare sent out the notification letters because some of the psychiatrists who got the letters were accepting out-of-pocket reimbursement from their Medicare patients without being enrolled in or opted out of Medicare. Unless you are seeing patients pro bono, please note that it is a violation of federal law to receive reimbursement for care you provide to Medicare patients if you are not a Medicare provider or have not opted out. If you do not know your opt-out status, check the national listing of opted-out physicians. You can access complete information about opting out on APA’s website or contact the HelpLine directly. ■

Biographies

Ellen Jaffe is the manager of APA’s Practice Management HelpLine.

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Published online: 1 March 2016
Published in print: February 20, 2016 – March 4, 2016

Keywords

  1. Medicare
  2. Medicaid
  3. Opt out
  4. Medicare Part D
  5. Centers for Medicare and Medicaid Services
  6. APA’s Practice Management HelpLine

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