April 2013 MBJ

The Monthly Newsletter for the Informed Health Care Professional

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The Medical Business

JOURNAL Brought to you by the Medical Management Institute | April 2013 | Issue 3 Volume 4

Inside this Issue CMS News Updates Are Doctors Selling Out? ICD-10 for Mental Behavioral Disorders MMI Member Updates Upcoming Hospital Coding Conference Guide to ICD-10-CM Certification Patient Protection & Affordable Care Act

AUTISM AWARENESS Autism Coding Revamp Autism Assessment in Young Children CPT速 Codes for Speech Language Pathology Audiology New & Revised Codes

mmi news updates It’s officially Spring! Products, ideas, and services are blooming and growing here at the Medical Management Institute. We have recently launched Spring Quarter, introduced you to some amazing new instructors, and will be announcing some exciting upcoming events. Please enjoy this April issue, dedicated to National Autism Awareness Month, and let us know what you think!

Booth #307 at the AAPC Conference Orlando, Florida

care diagnoses and procedures will be replaced with ICD-10 codes. ICD-10 will be a radical change, requiring extensive planning and training.

We are excited to announce that we will be hosting booth #307 at the AAPC Conference in Orlando April 14-17! We are looking forward to meeting great new people in the medical profession, and hopefully some future members. We will be giving out a ton of fun gifts, and even raffling out the chance to win a free iPad mini!

That is why the amazing instruction team at the Medical Management Institute is putting together a fully customizable ICD-10-CM certification training program, completely online! This program even includes ‘Implementation Insurance,’ guaranteeing no additional charges for continuing education should ICD-10 not be implemented on October 1, 2014.

Certification Programs on a New System Medical Coding, Management, & Auditing Re-introduce yourself to our online certification programs, now hosted on a brand new learning system called LearnerNation! This new system was built with you the user in mind, complete with interactive tools including flash cards, practice quizzes, and embedded videos.

Please go to page 7 of this April issue to view the customizable guide, or visit mmi-classes.com/ collections/icd-10 for more details.

Hospital Coding Conference in Atlanta, GA Become a Registered Hospital Coder!

We offer online certification training programs in the following fields:

Medical Coding • Graduates of this program have gone on to attain their CPC® (through the AAPC), RMC (through the ARHCP), and CCS-P® (through AHIMA)

Medical Management • Graduates of this program have gone on to attain their RMM (through the ARHCP)

Medical Auditing • Graduates of this program have gone on to attain their RMA (through the ARHCP) Visit mmi-classes.com/collections/programs for details on our certification programs.

ICD-10-CM Certification Program Online Program Coming Soon Effective October 1, 2014, the ICD-9-CM code sets used by medical coders and billers to report health mmi news updates

Please join us July 15-19 for our Hospital Coding Conference in Atlanta, GA, and become a Registered Hospital Coder (RHC)!

The first 3 days will cover Facility Coding (Inpatient & Outpatient), and the last two will cover Facility Billing. For more details, go to page 16 of this April issue, or visit mmi-classes.com/collections/ hospital-coding. *Note: This conference will be recorded, so if you can’t make these dates you can purchase an online version and become certified upon passing the online exam!*

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table of contents

mmiclasses.com

April 2013 2

MMI News Updates

4

CMS News Updates

5

Autism Assessment in Young Children

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CPT速 Codes for SpeechLanguage Pathology

7

Guide to ICD-10-CM Certification

6 12

8

Autism Coding Revamp

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Are Doctors Selling Out?

14

Patient Protection & Affordable Care Act

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Upcoming Hospital Coding Conference MMI Offers Security Procedure Manuals

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14 National Autism Aware n e ss M on t h

5, 6, 8, 18

ICD-10 & E/M Chart Audits through MMI

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MMI Secure

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Audiology New & Revised Codes

table of contents 3

CMS News Updates Reprinted from CMS.gov Bring Down Costs & Improve Quality of Care March 06, 2013

Protection Against Worst Insurance Practices February 22, 2013

Centers for Medicare & Medicaid Services (CMS) Acting Administrator Marilyn Tavenner and the National Coordinator for Health Information Technology Farzad Mostashari, M.D., today announced HHS’s plan to accelerate health information exchange (HIE) and build a seamless and secure flow of information essential to transforming the health care system.

The U.S. Department of Health and Human Services (HHS) today issued a final rule that implements five key consumer protections from the Affordable Care Act, and makes the health insurance market work better for individuals, families, and small businesses.

“Thanks to the Affordable Care Act, we are improving the way care is delivered while lowering costs,” said Acting Administrator Tavenner. “We are already seeing benefits, such as a reduction in hospital readmissions due to these reforms. Health IT and the secure exchange of information across providers are crucial to reforming the system, and must be a routine part of care delivery.”

This year, HHS will: Set aggressive goals for 2013: HHS is setting the goal of 50 percent of physician offices using electronic health records (EHR) and 80 percent of eligible hospitals receiving meaningful use incentive payments by the end of 2013.

Increase the emphasis on inter-operability: HHS will increase its emphasis on ensuring electronic exchange across providers. It will start that effort by issuing today a request for information (RFI) seeking public input about a variety of policies that will strengthen the business case for electronic exchange across providers to ensure patients’ health information will follow them seamlessly and securely wherever they access care.

Enhance the effective use of electronic health records through initiatives like the Blue Button initiative. Medicare beneficiaries can access their full Medicare records online today. HHS is working with the Veterans Administration and more than 450 different organizations to make health care information available to patients and health plan members. HHS is also encouraging Medicare Advantage plans to expand the use of Blue Button to provide beneficiaries with one-click secure access to their health information.

Implement Meaningful Use Stage 2: HHS is implementing rules that define what data must be able to be exchanged between Health IT systems, including how data will be structured and coded so that providers will have one uniform way to format and securely send data.

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cms news updates

“Because of the Affordable Care Act, being denied affordable health coverage due to medical conditions will be a thing of the past for every American,” said HHS Secretary Kathleen Sebelius.

“Being sick will no longer keep you, your family, or your employees from being able to get affordable health coverage.”

Under these reforms, all individuals and employers have the right to purchase health insurance coverage regardless of health status. In addition, insurers are prevented from charging discriminatory rates to individuals and small employers based on factors such as health status or gender, and young adults have additional affordable coverage options under catastrophic plans.

Today’s final rule implements five key provisions of the Affordable Care Act that are applicable to nongrandfathered health plans: 1.

2.

3.

4.

5.

Guaranteed Availability Fair Health Insurance Premiums Guaranteed Renewability Single Risk Pool Catastrophic Plans

ACA Saves over $6 Billion on Rx Drugs March 21, 2013 As the third anniversary of the Affordable Care Act approaches, Health and Human Services Secretary Kathleen Sebelius announced today more than 6.3 million people with Medicare saved over $6.1 billion on prescription drugs because of the health care law.

“By making prescription drugs more affordable, the Affordable Care Act is improving and promoting the best care for people with Medicare,” Secretary Sebelius said.

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Autism Assessment in Young Children

Kathy Dyson | March 21, 2013

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he significance of early detection of Autism Spectrum Disorders (ASD) is well documented. Numerous studies have highlighted the need to assess children as early as 12 months. As primary care physicians, whether a family physician or a pediatrician, it is important to know when and how to adequately assess young patients for ASD. Early symptoms of ASDs may be apparent by the age of 12 to 18 months, or sooner.

The Bright Futures guidelines require ASD Screening using a standardized test that has been proven effective at the 18 month and 24 month well checks. Most Medicaid programs and many commercial carriers are starting to audit for the use of a standardized tool.

One of the most commonly accepted and used standardized test is the ‘Modified Checklist for Autism in Toddlers’ or M-CHAT™(Robins, Fein, & Barton, 1999). M-CHAT is available for free download for clinical, research, and educational purposes. There are two authorized websites where the MCHAT and supplemental materials can be downloaded: • www.firstsigns.org or; • http://www2.gsu.edu/~wwwpsy/faculty/ robins.htm (from Dr. Robins’ website) The M-CHAT is designed for screening toddlers 16 to 30 months of age, to assess risk for autism spectrum disorders (ASD). The M-CHAT can be administered and scored as part of a well-child

check-up. The parent completes the 23 ‘Yes/No’ questionnaire, which can be scored in two (2) minutes. Scoring instructions can be downloaded from: • http://www2.gsu.edu/~wwwpsy/faculty/ robins.htm or; • www.firstsigns.org.

As stated by Dr. Robins, the primary goal of the M-CHAT was to maximize sensitivity, meaning to detect as many cases of ASD as possible.

Therefore, there is a high false positive rate, meaning that not all children who score at risk for ASD will be diagnosed with ASD. It can identify children who should be further evaluated by the pediatrician or referred for a developmental evaluation with a specialist.

The child fails the checklist when: • two or more critical items are failed, OR; • when any three items are failed This test is reimbursable by most Medicaid programs. Major carriers usually pay it, upon appeal. It should be billed with the well check as a 96110 – Developmental Screening, with interpretation and report, per standardized instrument form. Be sure to either file the original with the pass/fail indicator in the patient chart or scan it into the medical record.

The test should be linked to the well check if the child passes the screen. Otherwise, link the test to the Developmental coordination disorder or another appropriate diagnosis.

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autism assessment in young children 5

2013 New & Revised CPT® Codes for Speech-Language Pathology Jennifer Donovan | March 06, 2013

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he following are changes to CPT® codes that were effective January 1, 2013. Comments from the CMS have been included as commercial health plans may adopt Medicare’s coding rules.

Revised Codes Key: Deleted • 92613: Flexible Liberoptic endoscopic evaluation of swallowing by cine or video recording; physician interpretation and report only

With the removal of the term "physician" from these interpretation and report codes, Speech Language Pathologists (SLPs) who have not passed the endoscope, but have been asked to interpret the images, may be able to bill for their time using the following revised codes. SLPs should check with their local Medicare contractor or other third-­‐ party payers to make sure they may use these codes. An SLP who has performed the evaluation should use only the code for the endoscopic evaluation (CPT 92612, 92614, or 92616) and may not also bill the interpretation and report code.

• 92615: Flexible Liberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording; physician interpretation and report only

New Codes

• 92617: Flexible Liberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by vine or video recording (FEESST); physician interpretation and report only

Deleted Codes

6 new & revised cpt® codes for speech-language pathology

No speech-­‐language pathology codes have been added for 2013.

No speech-­‐language pathology codes have been deleted for 2013.

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Biller

Provider

(Pre-Requisite: Need to be licensed)

(Pre-Requisite: Registered Medical Biller)

Coder

ICD-10 Doc Requirements

ICD-10 Doc Requirements

ICD-10 Doc Requirements

ICD-10 Implementation Planning

Manager

Clinical Staff

ICD-10 Doc Requirements

ICD-10 Implementation Planning

ICD-10 for Qualified Health Care Professionals

Billing for ICD-10

Basic Coding for ICD-10

Advanced Anatomy & Physiology

Advanced Anatomy & Physiology

ICD-10 for Office Managers

Assessment of ICD-10 PreRequisites

Specialty Coding for ICD-10

Specialty Coding for ICD-10

ICD-10 for Office Staff

Certification Exam

Certification Exam

Office Readiness for ICD-10

ICD-10-CM CERTIFIED

Your Guide to Becoming ICD-10-CM Certified

Effective October 1, 2014, the ICD-9-CM code sets will be replaced with ICD-10 codes. ICD-10 will be a radical change, requiring extensive planning and training. MMI will be launching a fully customizable ICD-10-CM certification training program in the next coming months, which you can learn more about here: mmi-classes/collections/icd-10.

Your guide to certification is detailed below:

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How Autism Diagnoses Will Change in 2013 A look into the New Diagnostic Criteria (DSM 5) Jennifer Donovan | March 28, 2013

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hink about this; twenty years ago, 1 in 128 children was diagnosed with autism (or some form thereof). Ten years ago, it rose to 1 in 100. Today…1 in 88 are diagnosed with some form of an Autism Spectrum Disorder (ASD)! Therefore, whether you code ASDs directly or not, statistically someone in your family or someone close to you will be affected by these changes. Read on to be more informed when the subject will inevitably come up.

Meanwhile, new and related disorders and categories are listed, including, but not limited to:

Currently, the American Psychiatric Association (APA) is wrapping up revamps to the DSM, the diagnostic manual that names and describes the symptoms of mental, neurological and developmental disorders. Huge changes are afoot for ASDs when the new manual is released in May of this year at the APA annual meeting in San Francisco, CA. Some of these changes include the removal of the categories Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) and Asperger Syndrome. The new criteria for Autism Spectrum Disorder is quite different as well, and many people who were once included in that group may no longer fit the more specific criteria.

• Specific Language Impairment (A 04)

how autism diagnoses will change

• Intellectual Developmental Disorder (A 00) • Intellectual or Global Developmental Delay Not Elsewhere Classified (A 01) • Language Impairment (A 02) • Late Language Emergence (A 03) • Social Communication Disorder( A 05) • Speech Sound Disorder( A 06) • Childhood Onset Fluency Disorder (A 07) • Voice Disorder (A 08) For those who want to explore the entire proposed DSM-V, I highly encourage it. But for purposes of this article, check out some interesting criteria that follows. The emphasis is on perseverative and repetitive behaviors, and includes some very interesting verbage that seems to suggest that an

“...my best guess is that Aspergers Syndrome as a diagnostic description, even if it is not officially included in the DSM-5, is here to stay.”

-DSM-V Board individual with "general developmental delays" may not also be eligible for an autism diagnosis. Based on that, it seems my stepson, who has displayed significant language and social communication issues however doesn’t regularly display perseverative or repetitive behaviors, presently has a PDD-NOS diagnosis. But after the release of the new DSM, he will no longer fit into the autism category. Instead, he could wind up with a Social Communication Disorder (SCD) diagnosis.

The new DSM 5 criteria was previously proposed to include a number of new disorders such as SCD, which appears to include symptoms that are presently classified within the autism spectrum.

Here are the criteria for the new diagnosis: • Social Communication Disorder (SCD) is an impairment of pragmatics and is diagnosed based on difficulty in the social uses of verbal and nonverbal communication in naturalistic contexts, which affects the development of social relationships and discourse comprehension and cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability.

• The low social communication abilities result in functional limitations in effective communication, social participation, academic achievement or occupational performance, alone or in any combination.

• Rule out Autism Spectrum Disorder (ASD). ASD by definition encompasses pragmatic communication problems, but also includes restricted, repetitive patterns of behavior, interests or activities as part of the autism spectrum. Therefore, ASD needs to be ruled out for SCD to be diagnosed.

• Symptoms must be present in early childhood (but may not become fully manifested until social demands exceed limited capacities).

New Criteria for Autism Spectrum Disorder Must meet criteria A, B, C, and D: A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following: 1.

Deficits in social-emotional reciprocity, ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect, and response to total lack of initiation of social interaction.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging from poorly integrated verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.

3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers), ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: 1.

Stereotyped or repetitive speech, motor movements, or use of objects (such as simple motor stereotypes, echolalia, repetitive use of objects, or idiosyncratic phrases).

2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change (such as motoric rituals, insistence on same route or food, repetitive questioning, or extreme distress at small changes).

3. Highly restricted, fixated interests that are abnormal in intensity or focus (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).

4. Hyper or hypo reactivity to sensory input or unusual interest in sensory aspects of environment (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).

C. Symptoms must be present in early childhood (but may not become fully manifested until social demands exceed limited capacities) D. Symptoms together limit and impair everyday functioning.

Q & A with the APA and Autism Community The DSM draft drew newly 2,300 responders and over 15,000 comments. There’s no way to cover them all here, but in an effort to find out more about the proposed changes and their affect, we’ve compiled a Q&A including responses from the American Psychiatric Association (APA), the entity responsible for writing and publishing the DSM, DSM5.org, as well as questions posed from the autism community. Many APA responses were provided by Dr. King of the Neurodevelopmental Disorders workgroup and have been noted as such.

Q

Should the autism community anticipate a big shakeup in terms of services and therapies available, based on new diagnostic categories? What should we do to prepare? how autism diagnoses will change 9

•Dr. King: There should not be a shake up in terms of services and therapies.

None of us has control over what third parties choose to do regarding service qualification or delivery, and it should be emphasized that people and their needs aren't changing -- just the way we capture their diagnoses. In the past, when DSM has been revised, the new diagnostic criteria are attached to the closest Dr. Bryan H King, MD approximation of the previous disorder and its International Classification of Diseases (ICD) diagnostic code number. Existing evidence for treatment efficacy for these conditions continues to guide treatment decisions until new evidence emerges on treatment response for the newly defined disorders.

Q

Can a pediatrician bill as a supervising provider when medical staff is providing cognitive service for autistic/attention deficit, visual/sensory/auditory disorder, etc children – such as computers as the therapy tool? Medical staff are therapists, but credentialed teachers.

stereotyped behaviors isn't really changing. However, there is a desire to be able to more precisely describe individuals diagnostically than is currently possible with DSM-IV, and in some cases this may involve using more than one diagnosis.

• For example, by pulling language impairment out of the diagnostic criteria for autism, we will be able to better describe individuals with autism with or without significant language impairment, as opposed to giving them the same diagnosis. Similarly, the DSM-IV prevents the co-diagnoses of ADHD and autism, or of schizophrenia and autism. But we know that these conditions can co-occur, and DSM 5 will allow for this ability to better capture what is at issue for a given individual than merely "autistic disorder".

“...we believe that it is better to highlight the co-occurrence of physical problems with separate diagnoses rather than for them to disappear into the ASD diagnosis.”

-Dr Bryan H King, MD

• 96116 can be billed by a psychologist or physician. It can be used when conducting a neurobehavioral status exam to determine testing if any to be done (96118).

• Furthermore, PDD-NOS does not have associated diagnostic criteria, as it was originally intended to be used only sparingly for children who didn’t meet criteria for autism or Aspergers disorder. Because DSM-IV didn’t have a diagnostic category for children with social communication difficulties only, these children were often given a diagnosis of PDD-NOS. This was not equivalent to a diagnosis of autistic disorder, because it encompassed other developmental disorders as well. The new criteria could re-classify children whose deficits are limited to social communication (and who therefore are not part of the autism spectrum), as well as others, by broadening inclusion in the autism spectrum. The new criteria could also provide for more specific and accurate social communication diagnoses, potentially leading to more appropriate treatment.

Q

Q

• Only Physical Therapists, Occupational Therapists and Physicians can bill out 97xxx codes. They cannot be billed "incident-to". The therapist or physician must have direct one-on-one contact.

Q

When can 96116 or 97150 be applied?

•97150 is a group, so there would be more than one patient receiving therapy. It is not required that they receive direct one-on-one care from the physician, but they must be in constant attendance.

Based on the criteria in the proposed version of the DSM 5, it looks like the focus will be on stereotyped and repetitive behaviors, and that other related symptoms are being broken off into new and/or different categories.

It also looks like a child could easily wind up with multiple diagnoses. For example, a child with social and communications difficulties (which presumably could include lack of eye contact, etc.) could presently fit into the PDD-NOS category, with or without "the presence of repetitive behaviors and restricted interests." Would the new criteria mean they'd be re-categorized OUT of ASD and into the new SCD? • APA: Stereotyped and repetitive behaviors and unusual preoccupations or interests have been essential criteria for the diagnosis of autism from its earliest descriptions.

In the changes proposed in DSM 5, the focus on 10

how autism diagnoses will change

What happens to all those individuals diagnosed with Asperger Syndrome? Will this descriptive label really go away?

• DSM-V Board: None of us know the answer to this question for certain, but my best guess is that Asperger Syndrome as a diagnostic description, even if it is not officially included in the DSM-5, is here to stay. High functioning autism (HFA) has never been an official diagnostic descriptor sanctioned in previous or the current edition of DSM (DSM-IV) yet is a commonly used descriptor not only by us lay people but also by researchers who use it to define their study subjects.

Furthermore, Asperger Syndrome is more than a diagnostic label; it has become a cultural identifier for many of our students and adults who recognize

themselves as AS and have sought networks of support, friendship and collaboration within it.

Q

Assuming that a child has essentially the same symptoms that are now classified as PDD-NOS, ASD or PDD, do you anticipate that treatments will vary dramatically with the DSM V? That is - will ABA, developmental therapies, speech, OT, PT and social skills therapies remain the options of choice? Or do anticipate big treatment changes as a result of changes to the criteria?

• Dr. King: It is unlikely that treatments will vary dramatically as a result of the DSM 5. However, the current categorical (PDD-NOS, AD, PDD) approach actually gets in the way of the use of some treatments that may become more appropriately and widely used for persons with ASD. For example, an FDA approved treatment for a condition associated with Autistic Disorder is technically not approved or indicated for PDD unless that condition was specifically included in the labeling. We do not anticipate big treatment changes as a result of changes to the criteria.

Q

What is your "official" perspective on the physical issues related to ASD (seizure disorders, sleep issues, higher incidence of GI problems, etc.)? Do they fit into the diagnosis, or are they a whole separate issue to be addressed by a physician?

• Dr. King: We are not able to provide “official” perspectives on such issues; rather, we can only share what our work group experts believe to be, based on the science and clinical information, the most accurate and informative diagnostic picture at this time. In that vein, we believe that it is better to highlight the co-occurrence of physical problems with separate diagnoses rather than for them to disappear into the ASD diagnosis. Because

not everyone with autism has sleep issues, or GI issues, or epilepsy, it is important to call those out when they occur with a specific diagnosis rather than to suggest, for example, that epilepsy is just part of autism.

Q

How will this impact coverage for private services by insurance companies?

• DSM-V Board: Insurance companies in some states are being mandated to provide services for children with ASD. It is likely that these insurance companies will take a definitive stance in refusing to cover services such as ABA therapy for those who are not “ASD” under the new definition. However, consider that many (not all, but most) clients who don’t fall into the DSM-5 ASD category are less likely to need the ABA model of treatment as they have developed language and need to learn a more complex (synergistic) set of communication skills that are beyond the more linear stair-stepped approach offered by traditional ABA programs.

• Many insurance policies will consider covering a student who has mental health needs or social communication needs if the therapist can document the need for services and the benefit from services. However, insurance companies don’t cover anyone enthusiastically and they will try to find reasons (very often, not always) for refusing services. One significant issue is that insurance is very unlikely to cover as they transition into adulthood or live as an adult, as non-ASD neurodevelopmental disorders are not easily covered into adulthood, even though the patients show great benefit from treatment as they transition and live as adults.

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American Psychiatric Association, DSM5.org, ABC News, Age of Autism, Centers for Disease Control, World Health Organization

how autism diagnoses will change 11

Are Doctors Selling Out? Patients are the ones paying the price Kathy Dyson | March 16, 2013

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he days of going to our family physician and knowing that the health care provider we see is vested in our community and our families are almost gone. With all of the mandated programs, recovery audits, and penalties for not adopting sophisticated technologies, the smaller physician practices cannot survive. In fact, solo practitioners are at risk of extinction. Most physicians are selling their practices, some are merging with multispecialty physician led systems, but the largest numbers are selling them to hospitals.

With the implementation of the Affordable Care Act, there is already an anticipation of 16,000 or more too few primary care providers to meet the demands of the newly insured. In addition, physicians with many years of experience are retiring to avoid all of the technological changes.

Unfortunately, it is well known that once a physician sells their practice to a hospital, there is an immediate drop in productivity. This decline in patient visits and treatments is actually anticipated in the purchase value calculations for the practice. Therefore, the number of physicians

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are doctors selling out?

needed to fill the gap is even larger than earlier estimates indicate.

To fix health care and the fiscal challenges with our government programs like Medicare and Medicaid, we have to do something to encourage our experienced physicians to continue to care for patients, while getting the optimal performance for all physicians. Therefore, when doctors sell out, we in fact all lose. The quality and availability of healthcare diminishes with every sell that is finalized. In an environment where productivity needs to increase, our policies are actually forcing change that causes it to decrease.

The current strategy advocated by the Affordable Care Act is to move to Accountable Care Org-

“The new reimbursements schemes...also help to drive small physician practices out of business.�

anizations. These organizations can best be thought of as multi-specialty groups that take on financial risks by agreeing to something similar to capitation agreements for better outcomes with patient care. The goal is that by all working together, the number of duplicate labs and other tests will be reduced, saving the healthcare programs significant dollars. Without this kind of improvement, the entire financial base for Accountable Care fails.

Unfortunately, it is not just ACO’s inability to save money for the insurance programs that is a problem. Without bigger incentives than are currently being offered, there is no way to attract the required capital investment to make an ACO work. Therefore, the only groups that can create ACO’s are the larger hospital groups. While this may sound like a good approach, what happens is that there is no competition. The hospital becomes a monopoly; this actually drives costs up in an area.

The new reimbursements schemes favored by the Affordable Care Act also help to drive small

“So, while all of this seems like the doctor is selling out to hospitals, they are actually getting squeezed out by the Affordable Care Act.” physician practices out of business. The same outpatient procedure done in your privately owned physician office will be compensated at a lower rate than the same procedure done in a hospital-owned practice.

In the past, when hospitals and practice management companies bought up a lot of practices, mostly in the early 1990’s, this was a failure. Most doctors left the groups and reopened their own private practices. The hospitals say that this time it is different. They have learned how to provide incentive based

“...it is well known that once a physician sells their practice to a hospital, there is an immediate drop in productivity.” compensation to keep productivity at the same levels as prior to the purchase. This seems doubtful, given the political nature of most large hospital structures and the executive teams that run them.

Physicians are not easily managed employees, either. Unfortunately, this time around, when the system fails the doctors may not be able to go back to the prior format and won’t be able to raise the capital to open their own practice. Given the monopoly that hospitals will hold, the physician becomes the victim of reduced incomes as the reimbursements fall to the required levels to make the fiscal budget work.

So, while all of this seems like the doctor is selling out to hospitals, they are actually getting squeezed out by the Affordable Care Act. And the real losers in all of this will be the patient.

Patients will have to settle for physicians that are following a standard protocol of care dictated by the profitability goals of the hospitals and not the patient needs. Further, the physicians will become less available for providing care. And think about our physicians in 10 years. The folks going to medical school will not be our brightest and most compassionate students. Those students will be going into a field where their intelligence will be compensated appropriately and without the many extra years of study required to become a hospital-based physician.

Doctors are selling out, and usually to hospitals.

But in the end, it is the patient that can’t get quality care from a physician with roots in their community as a business owner. That is really the one that got sold out by the Affordable Care Act.

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What happens to all those folks that worked with the physician?

Many of their jobs are eliminated. Often the skills required to succeed in the hospital based environment are not the same skills valued in the physician owned practice. Some of them will not make the transition and many will not even be given the opportunity.

are doctors selling out? 13

Patient Protection and Affordable Care Act Focus on wellness Janet Salyer | March 27, 2013

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he Patient Protection and Affordable Care Act emphasizes wellness and the potential to lower health care costs if American’s focus on making better behavioral choices and becoming healthier. The Affordable Care Act (ACA) changes health insurance policies to include first dollar benefits for annual wellness exams and many preventive screenings and expands women’s preventive health care. The bill also expands Medicare, Medicaid and other government health insurance plans’ coverage of prevention. And the ACA expands the 2006 HIIPPA employer-based wellness programs.

ACA’s message is clear: Get Healthy, America!

One of the first changes implemented by the ACA was the Patient’s Bill of Rights that went into effective in Q4 2009. Among other benefits included in the Patients’ Bill of Rights was the provision that health insurance plans cover preventive care and age appropriate screenings

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patient protection & affordable care act

at no cost to the insured. This provision eliminated annual dollar limits on prevention care and eliminated copays, deductibles and coinsurance for prevention care. When the plan doesn’t charge the insured a copay, deductible, or co-insurance, this is commonly called “first dollar benefit.” The ACA did not apply to grandfathered plans, but all new health plans have to include this benefit for insureds.

In 2012, the ACA expanded coverage for women’s wellness and added many first dollar benefits for insured women. There are 22 of these preventive services available to women.

These expanded benefits include gestational diabetes screenings, support for breastfeeding, supplies, and counseling, and HPV DNA testing for women 30 and older. Breastfeeding support includes the training by a professional and counseling for breastfeeding during maternity and postpartum as well as the rental of

breastfeeding equipment. The ACA also provides first dollar benefits for many types of counseling including domestic and interpersonal violence, contraceptive education and counseling, sexually transmitted infections counseling, and HIV screening and counseling. These counseling sessions are available annually. Contraceptives, including all FDA approved contraceptive methods including sterilization procedures for all women with reproductive capacity are covered by health insurance as a first dollar benefit. No longer do women have a copay for contraceptives that are part of their plan’s formulary.

Many of the preventive screenings, such as a mammogram, may be either preventive or diagnostic. Insureds should be sure that their doctor agrees the visit is for prevention and files the claims accordingly. Diagnostic procedures will still have cost-sharing for insureds.

The women’s contraceptive benefit is controversial. As a result, the ACA allows group insurance offered by companies that are primarily established for religious reasons such as houses of worship and some other religious organizations to be exempt from the contraceptive mandate. But non-profits and organizations with close ties to religious organizations are not exempt.

Government insurance plans must also include more prevention coverage with no cost sharing to the insureds. The changes to Medicare include HIV, cancer, diabetes, and depression screening, tobacco-use cessation counseling, and behavioral therapy for obesity. Medicaid changes vary state to state since Medicaid is a state based program. States have the option of expanding the Medicaid program to include all individuals making 133% of the national poverty level. They may also offer benefit plans to include mental health services and prescription drugs. State Medicaid programs may also offer first dollar benefits for tobacco cessation and obesity related services. The ACA increases the Medicaid payments for primary care doctors to the Medicare level for 2013 and 2014. The Federal government will provide the funds to the states for these increased payment levels.

One of the initial changes for all these first dollar benefits is that premiums of private and government insurance will increase. While the goal of the ACA is to lower costs by prevention and early detection and treatment, actuarials disagree as to whether or not these benefits will reduce the overall cost of healthcare as we move into the PPACA implementation.

Discrimination is generally not allowed by the Health Insurance Portability and Accountability

Act (HIPAA). Employers cannot charge more based on an employee’s health history. But HIPAA made an exception for employer sponsored wellness programs. The 2006 ruling allows employers to have a 20% reward/penalty for employees participating in the employer sponsored wellness program.

Wellness programs have specific guidelines for employers to follow. There are five specific criteria for employer sponsored wellness programs. The program must provide a reward for meeting specific health-related goals, it must reasonably promote good health or prevent disease, employees who cannot attain goals due to a health condition must be given an alternate standard to attain the reward, the plan must inform employees about the availability of the alternate standards, and employees must be given a chance to qualify for the reward, or avoid the penalty, at least once per year. The PPACA increases the amount of the reward/penalty to 30% of the total employee-only premium , not just the employee’s portion of the premium. If family members are allowed to participate in the program, then the reward/penalty can be up to 30% of the employee and dependent coverage cost. In circumstances where tobacco cessation is included, the amount may be 50% of the total premium. The goal of these wellness programs is to encourage behavioral change. Behavioral changes are expected to lower the cost of healthcare over time.

The ACA requires employers with 50 or more full time or full time equivalent employees to provide health insurance for full time employees at a reasonable cost. The safe harbor ruling states that to be affordable, the employer cannot charge more than 9.5% total wages in box 1 of the employee’s W2. If an employer does not offer coverage and an employee gets a tax credit for health insurance, or if the employer offers coverage that is not deemed affordable and the employee receives a tax credit for health insurance, then the employer will be fined. It is unclear how the employer mandate to provide affordable coverage for each employee and the Wellness Program Initiative that allows employers to charge up to 30% of the employee’s premium will work together.

Many guidelines for implementation of the ACA have been released. Some guidelines are final and some are not. Health insurance coverage will continue to update as the guidelines are finalized. Prevention, wellness screenings, and healthy behaviors are key components to successfully reaching the ACA goal of making quality healthcare available at a reasonable cost for all Americans.

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patient protection & affordable care act 15

Facility Coding

Hospital Coding Conference July 15-19, 2013 in Atlanta, GA • Monday-Wednesday: Facility Coding, Inpatient & Outpatient • Thursday-Friday:

• Role of Chargemaster in Coding • Identifying the Correct Principal Diagnosis • Identifying Complications and Co-Morbidities • Determining Present on Admission Indicator • Using ICD-9 Volume 3 • Using Facility Modifiers • Observation and Inpatient Challenges

Facility Billing

Facility Billing

• Learn how to use UB-04 • Proper reporting of Condition, Occurrence and Value Codes • Role of Revenue Codes • Identifying Charging Errors and Omissions • Procedure/Device Edits • Cycle Billing and Overlap of Service Dates For more details on how to become RHC certified visit www.mmi-classes.com/collections/hospital-coding or call 866-892-2765

Security Procedure Manual

Only $499

Have you met stage 1 of meaningful use?

Core measure 15 requires a Security Procedure Manual to meet meaningful use, which the Medical Management Institute offers at the inexpensive price of $499!

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For more details visit mmi-classes.com/collections/consulting/products/manual

It is no longer “IF” you will be audited

...but “WHEN” • Concurrent and Retrospective Audits MMI offers concurrent and retrospective audits for a charge based payer population • On or Off-Site These audits can be performed in your office or remotely from our office. MMI can prepare an audit of approximately 25 patient charts to ensure compliance with Medicare (CMS) guidelines and to establish proper billing and documentation procedures to protect you and your practice from a Medicare audit.

E/M CHART AUDITS

ICD-10-CM CHART AUDITS

Learn more about MMI’s Chart Audits by visiting: mmi-classes.com/collections/consulting

Leave it to us, we will help you get secure MMI Secure will help your organization understand what steps to take in achieving compliance with HIPAA Security Regulations and Meaningful Use.

MMI Secure will provide an assessment comprised of tools,

reports and policies, and procedures so that your practice is up to date, safe, and secure.

MMI Secure reduces the complexity, fuss and presumptions of complying with the law.

Why do you need it? It’s simple. If you have electronic

patient health information (ePHI), you need to secure and protect it! Your practice is required to change and preserve compliance with the regulations set forth in both the HIPAA and the HITECH Acts.

How does MMI Secure differ? We help review and define policies and procedures with lead Physicians and Practice Managers. We help you with your network documentation and contingency and disaster recovery planning.

Assessment Advantages:

✓Peace of mind in knowing your practice has written proof of compliance

✓Assessment “Best Practices” considered ✓We help you avoid serious implications ✓We help you avoid firm fines ✓Our solution is simple and cost effective ✓Personalized security procedures manual, addressing HIPAA security requirements

To lean more about the immediate benefits of the MMI Secure Assessment or would like to get started today; Call MMI: 866-892-2765 Email MMI: MMIsecure@mmiclasses.com

MMI Secure 17

Audiology 2013 New & Revised HCPCS Codes in Honor of National Autism Month

I

n honor of National Autism Month, here are changes to Current Procedural Terminology (CPT® American Medical Association) and Health Care Common Procedure Coding System (HCPCS) Level II codes that were effective January 1, 2013.

Comments from CMS have been included as commercial health plans may soon adopt Medicare’s coding rules.

New CPT Codes New codes related to nerve conduction studies and intraoperative neurophysiologic monitoring has been added for 2013.

Nerve Conduction Studies These new nerve conduction study codes replace two H-reflex codes (see Deleted Codes).

• 95907: Nerve conduction studies; 1-2 studies • 95908: 3-4 studies • 95909: 5-6 studies

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• • • •

95910: 7-8 studies 95911: 9-10 studies 95912: 11-12 studies 95913: 13 or more studies

The numerical ranges included in the descriptors refer to the number of nerve conduction studies performed. Tests must be performed with separate electrodes for stimulating, recording, and grounding on only those specific nerves needed for the diagnosis in question. Waveforms must be reviewed on site in real time with reports by the examiner and interpretation by the physician or other qualified health care professional. Each type of nerve conduction study is counted only once on the same nerve.

Intraoperative Neurophysiologic Monitoring (IONM) These new IONM codes replace CPT 95920 (see Deleted Codes).

“Waveforms must be reviewed on-site in real time with reports by the examiner and interpretation by the physician or other qualified health care professional”

Deleted CPT Codes • 95920: Intraoperative neurophysiology testing, per hour (see 95940- 1, G0453) • 95934: H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle (see 95907-13) • 95936: record muscle other than gas-trocnemius/ soleus muscle (see 95907-13)

New HCPCS Level II Codes • 95940: Continuous intraoperative neuro-physiology monitoring in the o p e r a t i n g r o o m , o n e o n o n e monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) • 95941: Continuous intraoperative neuro-physiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure) (See Medicare Note) • G0453: Continuous intraoperative neuro-physiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure) (This is a Medicare-only code. See Medicare Note) These CPT codes are add-on codes to be listed in addition to the primary surgical procedure. They describe ongoing neurophysiologic monitoring, testing, and data interpretation distinct from the performance of specific types of baseline neurophysiologic studies performed during surgical procedures. Do not report these codes for automated monitoring devices that do not require continuous attendance by a professional qualified to interpret the testing and monitoring. Both 95940 and G0453 are billed in units of 15 minutes and should be listed in addition to the primary surgical procedure.

Continuous and immediate communication directly with the operating room is also required, and the codes include the ongoing monitoring time distinct from the performance of baseline studies.

CMS Note: 95941 may not be used for Medicare beneficiaries because it allows a provider to remotely monitor several patients at the same time. Because CMS allows a provider to monitor only one patient at a time, it created G0453, which covers continuous remote (outside the operating room) monitoring for one patient.

New codes related to frequency modulated (FM) and digitally modulated (DM) systems have been added for 2013.

• V5281: personal FM/DM system, monaural, (one receiver, transmitter and microphone) • V5282: personal FM/DM system, binaural (two receivers, transmitter and microphone) • V5283: personal FM/DM neck, loop induction receiver • V5284: personal FM/DM, ear level receiver • V5285: personal FM/DM, direct audio input receiver • V5286: personal blue tooth FM/DM receiver • V5287: personal FM/DM receiver, not otherwise specified • V5288: personal FM/DM transmitter assistive listening device • V5289: personal FM/DM adapter/boot coupling device for receiver, any type • V5290: transmitter microphone, any type

CMS Note: Although FM/DM systems are not a Medicare benefit, the codes will be instrumental for Medicaid and private insurance programs that supplement hearing aid and cochlear implants recipients, especially children, with the technology.

Revised HCPCS Level II Codes The following code was revised to include assistive listening device supplies not otherwise specified • V5267: hearing aid or assistive listening device/ supplies/accessories, not otherwise specified

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THE MONTHLY NEWSLETTER FOR THE INFORMED HEALTH CARE PROFESSIONAL

MBJ

ISSUE 3 VOL. 4

The Medical Business Journal is brought to you by the Medical Management Institute Editor in Chief Carleigh Benscoter

Contributors Kathy Dyson Jennifer Donovan Janet Salyer Scott Gottlieb

Layout & Design Carleigh Benscoter 20

The Medical Business Journal is a monthly source of up-to-date information on all issues affecting the healthcare industry. Its content ranges from medical coding and billing to healthcare reform legislature and beyond.

The MBJ is not affiliated in any way with the Department of Health and Human Services, Medicare, or the Centers for Medicare and Medicaid Services. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting or other professional services, and is not a substitute for individualized expert assistance. The CPT codes, descriptors, and modifiers are copyrighted by the American Medical Association. For more information, please call MMI at 866-892-2765.