The Monthly Newsletter for the Informed Healthcare Professional Issue 11 Volume 2 November - December 2011 www.mbjonline.com
15 2012 Medicare Physician Fee Schedule:
The Final Rule Summary
13 5010 Upgrade Postponed.
Grace period granted. Warning: This does not delay implementation! What does that mean? Answers to your questions inside.
21
Member Exclusive
2012 CPT Summary. What’s in store for 2012.
30 Top 5 Best (and
Worst) States to Practice. We consider cost-of-living rates, tax burden data, malpractice climate numbers, and physician-density statistics. We’ve even included job opportunities that have been submitted this month.
Brought to you by The Medical Management Institute
Be Productive this Winter Season
Are you prepared for ACO and ICD-10?
Winter Quarter at MMI This quarter we focus on avenues that providers can take to increase their revenue while building their practice for the future. These classes will help you understand the incentive options out there and give you a glimpse into the future of the industry.
Jan 18. Meaningful Use Attestation Is the incentive worth the process?
Feb 1. Implementing and Optimizing an ACO (Accountable Care Organization)
Can your providers benefit as a working part of an ACO?
Feb 15. PQRS Reporting
Learn all there is to know about quality reporting and how it can increase your revenue while building quality patient care.
Feb 29. Implementing a new EHR
Help lessen patient suffering due to medical errors and the inability of analysts to assess quality. How to get the most out of your new EHR.
Mar 14. Next steps: ICD-10
Where are we now? With a year and a half to go- how prepared are you?
For more details visit
www.mmiclasses.com
The Medical Business Journal Contents
Features
Contents
13 Version 5010 Upgrade. Doesn’t let practices off the hook.
15 2012 Medicare Physician Fee
Schedule. The final rule summary.
18 Revenue Cycle Management.
6 A Year of Coding. The former
MBJ editor gives us insight on his first year in the industry.
12 Patients/Patience. The patient’s point of view from the waiting room.
How to cut costs.
20 ICD-10 Panic Kicks In. AMA
promises to try to push back ICD-10 implementation date.
Members
Only!
27 Accountable Care
Organizations. Health information technology is a must.
21 CPT Summary at a Glance. Available to MMI and ARHCP members only.
36 PLUS: MBJ Key Terms Puzzle.
Test your healthcare knowledge with a fun game!
30 Top 5 Best (and Worst) States to Practice. Available jobs in the healthcare industry are included.
5 Certification
Brought to you by
The Medical Management Institute
Crossing
Inside Every Issue CMS News Updates.............................................7
The Podium: Making the Most of the Election Year....................................................28
Letter from the Editor.........................................4 Health Nut: Sugar vs. Fat..................................17
Coding Corner...................................................33
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Letter from the Editor Medical Business Journal
Dear Readers,
Issue 11, Volume 2, November-December 2011
I don’t need to tell you how much the business of medicine has changed over the past few years, let alone the past few decades. You’ve lived through it- and because you still read publications such as The Medical Business Journal, you’re still as excited about the industry and its future as you were when you started in the business. So how did you do it? I would wager that you stayed on top of specialty and regulatory changes, as well as broad legislative topics, while educating yourself about how they affected you and your practice along the way. You likely adapted your business practices as you better understood what these changes meant to you, and your providers too, right?
Jennifer Donovan Rob Hassett, RMC Julia Scott, RMC Jennifer Donovan Ruby Ramos, RMC, RMM Maria Albo Carleigh Thomson Rob Hassett Carleigh Thomson
The Medical Business Journal is a monthly source of upto-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: (770) 709.6928.
Ultimately, the main effect of change isn’t necessarily the changes themselves, rather, it is how people react and adapt.
Legend of Acronyms in Issue 11.2
Happy Holidays to All!!! Sincerely, Jen Editor-in-Chief, Medical Business Journal
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Managing Editor: Copy Editor:
Layout and Design
Between coding changes, bundling issues, hospital ventures, insurance changes, the holidays and the family... hang in there. 2012 is right around the corner and the MBJ will be here to keep you informed of all the changes, offer tips to make life easier and help promote your business through ads and contributions from our dearest friends, you!
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Jennifer Donovan, RMC, CPC, RMM
Contributors:
Looking back, it can be said that a lack of education and certification requirements contributed to the industry’s darker days. That’s why I say make education and certification your New Year’s resolution. MMI is moving to a new platform that will make eLearning easier and more fun than ever before! Use your MMI gift card for yourself or pass it on to a friend to enroll in one of our comprehensive certification prep programs.
PS. I would like to personally invite you to “Like” us on our facebook page at www.facebook.com/MMIfan. Here you will find upcoming events, classes, and helpful resources to keep you informed and up-to-date in the healthcare industry.
Editor-in-Chief:
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ACO – Accountable Care Organization NCQA – National Committee for Quality Assurance HHS/DHHS – [Dept of] Health and Human Services OIG – Office of Inspector General CIA – Corporate Integrity Aggreement DME – Durable Medical Equipment SNF – Skilled Nursing Facility POV – Point of View PCP – Primary Care Provider CMS – Centers for Medicare and Medicaid Services HFCS – High Fructose Corn Syrup GI – Glycemic Index RMC – Registered Medical Coder ACA/PPACA – [Patient Protection and] Affordable Care Act
CC Certification Crossing
Keeping you updated in the industry news
To make MMI’s eLearning experience more user-friendly, the Institute has joined forces with a cutting edge programming company. In addition to instructor support, students have access to a system that allows them to learn in their own way. Set to launch in early 2012 so stay tuned. Are you already in an MMI class? No worries – you will receive access to the new platform to complete your studies in addition to your existing login so you can compare your work!
Maintain your certification with Continuing Education Units from MMI! January 18th marks the first day of the Winter Quarter Classes. This quarter we will cover Meaningful Use, Negotiating Contracts with Payors, Implementing and/or Optimizing an ACO, and more!
The Association of Registered Health Care Professionals is pleased to announce the new Registered Medical Auditor exam will launch May 2012. This new RMA exam will be administered in beta format with no immediate scoring. This addresses an immediate need in the field, and will help move professionals in the industry forward to achieve goals of RAC audits, ARRA, HITECH and other important initiatives with the ultimate goal of improving the quality of healthcare as a business.
www.facebook.com/MMIfan All ARHCP coding exams will become ICD-10 compliant in March 2013. Stay tuned for more information on ICD-10 exam updates throughout 2012.
CC
Swing by our Facebook page to keep informed of upcoming events and classes, helpful resources, or just to join in on the conversation. And if you “Like” us by March 1, 2012...we will put your name into a drawing for a chance to win a free iPad 2!! (Be sure to comment on our wall to let us know that you “Liked” us.)
Certification Crossing is a new segment by MBJ. This segment will act as a bulletin board; a place where you can go to find out about professional development, industry news, continuing education, announcements, upcoming events, and tools for success. This is the MBJ’s effort at keeping you updated and informed in the industry.
A Year of Coding
Christopher Meyers, RMC
One journalist’s experience in the industry Upon entering the world of medical coding, one is immediately impressed with how confusing it is. ICD-9, HIPAA, CPT, HCPCS, DRG, CMS, HHS… well these are just a random assortment of letters to an outsider. So, as a journalist with no medical experience whatsoever, I started the summer of 2010 just trying to make sense of all the acronyms. Once I got far into the list to reach CMS, or the Centers for Medicare and Medicaid Services, it was like opening up Pandora’s box. Like most Americans outside of the healthcare industry, I had no idea how deep it went. My advice to anyone who wants to get into medical coding (or anyone simply paying a physician’s bill) is to start here. CMS is the belly of the beast. Even if you don’t accept Medicare or Medicaid patients, CMS still has a direct effect on your billing practices. Think of CMS as the largest private insurer in the country. When they set their rates, most private in-
surers follow suit. Codes are often changed based on recommendations by CMS. The transition from ICD-9 to ICD-10 is their brainchild, and the move to electronic health records (EHRs) is heavily influenced by the incentives being offered. I would recommend that any forward-thinking coder check the CMS website every day for updates, because it isn’t always easy to tell where healthcare will be six months from now.
The RMC exam is hard, but passing it is a feeling like nothing in the world. It’s a validation that, yes, you can do this job. As much as it tells employers that you are worth your salt, it allows you to stop worrying for a minute and realize that you are actually getting the hang of this. Of course the education doesn’t stop there. Once you can actually code like a professional, you have to learn how healthcare is changing.
The actual logistics of medical coding are very simple—on the surface. You have a number for the diagnosis; let’s say a broken arm. Then you have a number for the treatment, or setting and casting the arm. Then you have one more number for the supplies used. On paper this may seem as simple as 1, 2, 3. But within this simplicity are so many variables that a successful coder really has to do their homework. For example, take the concept of a global period. Certain procedures will include supplies. Some procedures are bundled into payments that will pay one rate for a variety of procedures to treat the same condition. You need a good education in the fundamental principles of coding. I took a two-week crash course to prepare myself for the Registered Medical Coder (RMC) exam and a knowledgeable instructor is crucial. There is a process to coding, a process which is much more important than the specifics. You need to know how to get from documentation to reimbursement a lot more than you need to know how to set a broken arm. Yes, terminology is important, but that is really the language and not the conversation.
The Patient Protection and Affordable Care Act (PPACA) is changing the very foundation of healthcare… if it isn’t repealed. The ICD-10 is requiring doctors and coders to relearn entire workflows. Even the current ICD-9 is always evolving, adding new codes and deleting older ones. The only way to keep up is constant education. A career in medical coding also requires a career as a full-time student.
“ The RMC exam is
hard, but passing it is a feeling like nothing in the world.”
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Despite all the hard work required in the industry, opportunities abound. If you think of a doctor as being in the business of healing, coders are in the business of getting that doctor paid for healing. A single coder is often the first, and only, line of defense preventing an audit at a small practice. Without coders, the healthcare industry would collapse under the weight of its own financial complexity. It is a career that one should take great pride in. It’s a tough job, but someone has to do it… and make an honest living while they’re at it. Though I’m not sure what I will be doing, I commend each and every one of you for your dedication to the industry and wish you all great success as I move forward on to new pastures. Sincerely, Christopher Myers, RMC Former Editor-In-Chief, MBJ
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8 BERWICK RESIGNS. Is Tavenner
up for the challenge?
8 HCPCS 2012. What’s in store for
Level II Codes?
9 INCREASED MEDICARE COVERAGE FOR OBESITY SCREENING AND COUNSELING.
9 HHS INCREASES GRANTS
FOR AFFORDABLE INSURANCE EXCHANGES.
10 OVER $5 BILLION RECOVERED IN 2011. Semiannual report to Congress.
11 NEW AND IMPROVED CMS
WEBSITE.
Berwick Resigns Is Tavenner up for the challenge? Back in April 2010, President Obama nominated Dr. Donald Berwick, a pediatrician, to head the Centers for Medicare and Medicaid (CMS). Last July, after a Republican opposition and during a congressional recess, Obama appointed Berwick, giving him the job through the end of the year and the current session. Over the past 17 months, Berwick was said to have become a symbol of all that Republicans dislike in President Obama’s healthcare policies. Though his temporary recess appointment was due to expire at the end of the year, effective Dec. 2, 2011, Dr. Donald Berwick resigned from the position. The Senate sees this as a confirmation that the next Obama nomination will not get appointed. Dr. Berwick is a long-time advocate of patient safety. He is a respected member of the healthcare community and has had support from medical, trade, labor, and consumer organizations ranging from ACP, AARP, Wal-Mart, Consumer Union, and the AHA. During the Berwick era, he oversaw the beginning of the EHR Incentive pro-
“ Tavenner helped reduce Medicaid costs in intelligent ways” gram (currently 138,000 registered EPs and EH’s, paid over $527M in incentive payments) and helped implement a number of key provisions in the Affordable Care Act (ACA) pertaining to the Medicare and Medicaid programs. In October, CMS issued final regulations for accountable care 8
organizations (ACO), which are provider consortiums designed to better coordinate care received by Medicare patients, all while improving medical outcomes and lower costs. ACOs will receive a share of any money they save the Medicare trust fund. It has been said in a Medscape article, that “Unfortunately, he’s [Berwick] been a scapegoat for Republicans who are mad about the ACA”. Dr. Berwick steps down maintaining firm beliefs of the agency’s three aims: improving the experience of care, improving citizens’ health, and reducing the per capita costs of healthcare. Who’s up now? President Obama has nominated Berwick’s principal deputy, Marilyn Tavenner, RN, MHA to replace him. Ms. Tavenner is the Principal Deputy Administrator and Chief Operating Officer for CMS. She is an RN with 35 years of health care experience and was a hospital CEU and senior level management for Hospital Corporations of America after 20 years of nursing. In times of declining state revenues and a struggling economy, Tavenner helped reduce Medicaid costs in intelligent ways such as program improvements, focusing on preventative care and creative use of technology. Ms. Tavenner was also the secretary of the Virginia Department of Health and Human Resources under former Virginia Governor Tim Kaine. Ranking Republican on the finance Committee Senator Orrin Hatch has already stated that “Republicans on the Finance Committee look forward to examining her record and gaining an understanding of her views on Medicare and Medicaid and the president’s health law.” Only time will tell whether Tavenner is appointed, and what difference she can make.
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HCPCS 2012 What’s in store for level II codes More than 430 codes have been touched for 2012. Among them: • 285 added; one new modifier • 48 revised • 75 deleted 18 added, 8 deleted throughout 2011 that will not appear in your printed book or eBook of choice (depending solely, of course, on your book’s publisher) What about that new modifier? Modifier PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days has been added to help hospital identify those certain services that fall within the Medicare “3-day Payment Window”. The 3-day window policy requires a hospital to combine the charges and appropriate codes for any outpatient diagnostic and “related” non-diagnostic services(other than ambulance and maintenance renal dialysis) provided within the 3-day period immediately preceding an inpatient admission. Many codes have been deleted throughout the HCPCS II, especially in the C and Q sections. Among them: •C9272 is replaced by J0897 Injection, demosumab, 1mg •Q2040 is replaced by J0588 Injection, incobotulinumtoxin A, 1 unit •Q2042 is replaced by J1725 Injection, hydroxyprogesterone caproate, 1mg Among the near 300 added codes, there are a few C codes including C9287 for the lymphoma drug brentuximab vedotin and C9366 for the membrane/skin-allograft EpiFix. Nearly a dozen new drug/supply Q codes come for 2012 including Q0162 for the antin-
ausea drug ondansertron; Q2043 for sipuleucel-T, (therapeutic vaccine for prostate cancer); and 9 new Q codes to accompany the highly revised skin substitute section of the CPT for the associated supply of choice such as Alloskin and Talymed. Additionally a series of E codes have been added to describe a variety of accessories for manual and power wheelchairs; 4 new K codes for home suction pumps and supplies for wound healing; and revised G codes for telehealth consultations that apply to both inpatient and emergency department services. Along with these G code revisions, this sections contains the largest amount of changes for 2012. Over 200 additions to report quality indicators for Physician Quality Reporting System (PQRS).
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Increased Medicare Coverage for Obesity Screening and Counseling More obesity coverage could lead Medicare beneficiaries to less serious health problems.
On November 29, 2011, the Centers for Medicare & Medicaid Services (CMS) announced it was increasing coverage for treatments to reduce obesity. CMS Administrator Donald M. Berwick, M.D., said “Obesity is a challenge faced by Americans of all ages, and prevention is crucial for the management and elimination of obesity in our country.”
Based on the data, this added coverage is going to assist a great deal of people nation-wide. More than 30% of people with Medicare coverage are thought to be obese. Although this is clearly an increase in coverage, the move might actually relieve some of the burden on Medicare providers in the long run. Obesity is linked to many serious chronic diseases, resulting in
“ More than 30% of
people with Medicare coverage are thought to be obese” Medicare beneficiaries who need extensive and serious medical care down the road. By adding obesity screening and counseling as a preventive service, CMS could end up saving many Medicare beneficiaries from these complex and expensive treatments. Hopefully, simple face-to-face consultations with a healthcare professional can help some Medicare beneficiaries to make health-conscious decisions that stunt the growth of diseases like cardiovascular disease and diabetes. Not only will this mean more people are covered for preventive obesity care generally, but statistics show that this program has the potential to benefit racial and ethnic minorities. Many diseases tied to obesity have been proven to disproportionately affect minority populations; preventive care to combat obesity could be an effective answer to this problem. Here’s how the additional coverage works: Medicare beneficiaries who screen positive for obesity at a BMI of 30 or higher are covered for a counseling visit each week for a month, bi-
weekly visits for the next five months, and then monthly visits for the next six (as long as the beneficiary has lost at least 6.6 pounds in the first six months of treatment).
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HHS Increases Grants for Affordable Insurance Exchanges State-created exchanges are receiving funding so that they are ready to be up and running by 2014. On November 29, 2011, the Department of Health and Human Services (HHS) awarded grants to 13 states to assist them in creating Affordable Insurance Exchanges. These Exchanges are state-created, one-stop shopping for families and small businesses to find health insurance coverage at an affordable price. The theory is that several different companies are all in one spot trying to get people to sign up for coverage, leading to a decrease in price based on the increase in competition. Another hope is that the Exchanges require insurers to provide customers with easy-to-understand information about their services. This way, potential customers really understand the difference between insurers and are able to make an informed decision about their coverage. The Congressional Budget Office has estimated that the Exchanges will reduce premiums by 7 to 10%. In addition to providing funding of almost $220 million, HHS has provided information on their website states
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can use to determine the best way to build and implement their particular Exchange. More information has been added recently because January marks the beginning of state legislative sessions, where representatives will be able to debate the idea of their state Exchange and how to get it up and running. HHS didn’t just give this money away; states applied for these grants, so it’s clear that the idea of setting up these Exchanges with the help of government funding seems like a good idea to most states across the country. In fact, 49 states and the District of Columbia have received some type of planning grant for Affordable Insurance Exchanges. Rhode Island even received the first ever “Level Two” grant, given to states that have developed their Exchange more fully. These Level Two grants also provide funding over several years, where the Level One grants are just for a year. The important date to pay attention to here is 2014 – this is when the Affordable Care Act, which gave HHS the authority to administer grants for states to create and fully develop their Affordable Insurance Exchanges, goes into effect. If Congress, HHS, and CMS are right, this will be a good year for the individual and small business healthcare consumer to get a fair deal on health insurance coverage.
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Over $5 Billion Recovered in 2011 Semiannual report to Congress by OIG
healthcare fraud prevention and enforcement efforts. Back in January, the Department of Health and Human Services (HHS) issued a statement saying: “This is the highest annual amount ever recovered from people who attempted to defraud seniors and taxpayers.” When those statistics came out in early 2011, they struck fear in the hearts and minds of those with any intention to defraud the system. The numbers seemed pretty hard to beat – being that, according to CNN Money, that was the largest sum ever recovered in a single year. Well, the Health Care Fraud Prevention & Enforcement Action Team (HEAT) didn’t dissipate in 2011. In its Semiannual Report to Congress, the OIG announced expected recoveries of approximately $5.2 billion in audit and investigative receivables. This includes exclusions of 2,662 individuals and entities from participation in federal health care programs, 723 criminal actions against individuals and entities that engaged in crimes against HHS programs, and 382 civil actions, which included false claims as well as unjust-enrichment lawsuits filed in federal district courts, civil monetary penalties settlements, and administrative recoveries related to provider self-disclosure matters.
care Part A & Part B reviews and enforcement actions – which include, but are not limited to, skilled nursing facilities (SNF) billing, oncology services, and durable medical equipment (DME). HHS and the Justice Department jointly created HEAT back in 2009 with the original intent to prevent waste, fraud and abuse in CMS programs. They are certainly bringing their A-game. Corporate Integrity Agreements (CIAs) have also received special mention by the OIG. An instance was given where Church Street Health Management was penalized $230,000 because of non-compliance with requirements of its CIA with OIG by failing to implement training, develop and distribute policies and procedures, submit an independent review organization (IRO) report, and provide notice of government investigations.
“ The OIG announced
expected recoveries of approximately $5.2 billion in audit and investigative receivables.”
The OIG tips their hat to the special The efforts to protect the well-being efforts of HEAT in coordinating law of our healthcare system seem to be enforcement operations among fedpaying off. Let’s take a look back: eral, state, and local law enforcement In 2010, the government collected entities; overseeing prescription drug an astonishing $4 Billion through its investigations and reviews; and Medi10 www.mbjonline.com - Medical Business Journal
Inspector General Daniel Levinson expressed confidence that technology “has tremendous potential to enhance [the OIG’s] program integrity capabilities, citing tools such as data mining, predictive analytics, trend evaluation, and modeling” to better target oversight for HHS programs.
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Sources: [HHS Increases Grants: http://cciio.cms. gov/programs/exchanges/index.html, http://www.healthcare.gov/news/factsheets/2011/05/exchanges05232011a.html, http://www.hhs.gov/news press/2011pres/11/20111129a.html] [Medicare Coverage for Obesity: millionhearts.hhs.gov]
New and Improved CMS Website
Screenshot of new CMS Website.
If you’ve been reading the MBJ for any amount of time, you may remember a series called “Navigating a Sea of Information”, where former MBJ Editor, Christopher Myers, provided a compass and map of various government websites and resources. This effort was to help readers navigate through the labyrinth to find the useful information that lies within. This was such a hot topic because so many people had such a difficult time weeding through the chaos. Well CMS has taken some of that feedback from users to develop their new and improved site! Other than the overall look and feel, some improvements are:
•A significantly improved search engine •Indepth ACA Info •Real-time updates regarding important CMS developments and initiatives. •Content has been moved around for easier finding If you’ve been working with the CMS site for years and thought you finally figured it out, only to see they’ve changed it all – don’t worry. CMS will be launching an archived version soon so you can still access the same information without cluttering their new look.
Additionally, CMS has launched a brand new site Medicaid.gov, and Healthcare.gov will remain the primary site for consumer info. CMS states this is their first step only and they believe it will be well received by patients, partners, providers and staff, states and all others who utilize this site. If you haven’t already, check out the new look at www.CMS.gov. Feedback is encouraged at cmsideas.uservoice.com/forums.
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Patients/Patience
Keeping patients happy by understanding their point of view
Patient’s POV“From the Waiting Room”
they wait 5 minutes without screaming at every person on your staff whether they need an insurance card or would like to move seats.
Providers are being billed for patient wait time. What can you do to keep patients patient? You may remember a classic Seinfeld episode where George was charged for canceling his doctor’s appointment. He was, of course, livid…as his character often was. Later on in the same episode, the same doctor has to cancel her appointment with George due to a personal emergency. Well, George smirked and decided to try to charge his doctor for the same thing that he was charged for (ah…good ol’ cheap George). Well, if you think about it, most viewers understood where George was coming from…whether they were on the doc’s side or not. In this world, if you miss an appointment, you are subject to a no-show fee if within a certain window of the scheduled time. Well, if your patient has already signed in, they’re already in the window. So, what makes the doctor’s office so different? Understandably, there are reasons that can throw a doctor’s entire day off, including: the unpredictable nature of healthcare to patients misrepresenting the reason for their visit, to patients adding complaints, arriving late, to those just unprepared for their visit. Some patients are sicker than they think or need hospitalization. These doctors aren’t chatting by the water cooler and sipping Mai Thais. Nonetheless, what does that mean for the waiting patient?
Though there is a shortage of primary care physicians, there is still a need to keep as tight and honest a schedule as possible and, if the doctor is Earlier in the year, a freelance writer running behind, let the patient know. who waited over four hours in 1969 In addition to the PCP shortage, also has been all over CNN explaining consider the lowered reimbursement her process of shopping for her docand perpetually rising overhead; you’ll tor, scheduling only the first appointsee the number of patients increases ment of the day or first after lunch and daily. Time is the crux of the matter, billing her doctor for excessive waitbut if we can’t get a repairman or catimes (with full up-front disclosure, of ble guy to hold a 4-hour window, how course). Cherie Kerr, now 67, says: can we expect our doctors to? If a “Now it’s funny. They’ll always doctor spends 2 hours congive me a time when they sulting a patient on a newly know I’ll be the first aprevealed terminal illness pointment.” diagnosis, what are they What we need to resupposed to do, call member is this is a “times up”? We’ve got competitive business. to be fair. If patients bill We have to keep padoctors for wait times, tients happy. They are does that mean the docnot customers, this isn’t tor should bill the patient Wal-Mart, but they are paywho caused the wait in the ing consumers, whether Doctor caring for patient. first place? Or charge for filling through a private payer and out forms that insurance comco-pay, heath savings fund, or outpanies don’t pay for? Or after-hours of-pocket. Some offices are keeping advice? What if one day that patient track of patient wait times with an egg is you? Recent research shows PCPs timer and compensating those who spend 50% of their time performing wait too long with gift cards or frawork that is not reimbursable by the grant lotions; it’s an issue of mutual insurance company as they only pay respect. Some try to avoid gift-giving for face-to-face visits. by calling/texting their patients if they are running late. As a rule of thumb, a Patients can help by becoming more patient waits for approximately 10-20 involved in their own healthcare and minutes, rifling through old magazines as a result can come prepared for their or staring at a looping screen, before schedule appointment within a realisgoing stir crazy…and if they have any tic time frame. sort of pain, watch out! You’re lucky if
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Patients/Patience is a new segment by MBJ. This spot highlights the most talked-about trends from the patient’s point of view. We also include some helpful information for your patients to understand how we run the business of medicine. This is the MBJ’s first attempt to build the bridge between patient and providers. 12
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Version 5010 Upgrade Postponed Doesn’t Let Practices Off the Hook
Are you ready?
Just as suspected, the Centers for Medicare and Medicaid Services (CMS) Office of E-Health Standards and Services (OESS) announced that a grace period will be granted for its ASC X12 Version 5010 standards compliance enforcement, set for Jan. 1, 2012. Warning: This does not delay implementation! Providers are strongly encouraged to continue to prepare for this deadline. Only in the event that implementation cannot be met, a 90-day discretion period for all HIPAA covered entities is available. CMS says it will initiate enforcement on office-based physicians, health insurance plans and claims clearinghouses starting March 31, 2012. Although enforcement penalties may be delayed, failure to use 5010 may still mean no reimbursement. The decision was based on industry feedback from organizations and their trading partners who aren’t ready to finalize system upgrades to 5010 standards. According to a Medical Group Management Association (MGMA) members’ survey, only 35% had begun internal testing. ModernHealthcare.com states the same survey indicated that about 1 in 5 practices (approx. 22%) hadn’t even scheduled internal testing with their vendors. These results prompted MGMA to ask CMS to “immediately issue a comprehensive contingency plan” to allow health plans to continue processing non-compliant healthcare claims. Robert Tennant, senior policy advisor with the Medical Group Management Association (MGMA) said the news is a great start. “As you know, MGMA has been calling on CMS to issue a comprehensive contingency plan to avoid a potentially significant cash flow disruption on Jan 1,” Tennant told Physicians Practice via e-mail. “This message that enforcement would be delayed 90 days was a step in the right direction. However, we remain concerned that critical provider trading partners, including practice management system vendors and health plans, will not be ready by the compliance date.” MGMA is urging CMS to vigorously monitor each stakeholder group for their readiness to conduct compliant 5010 transactions, said Tennant. “We continue to be concerned about the ability of health plans to accept a 5010 claim that might not have all the content, but enough content to adjudicate a claim.” He further noted that “CMS has to look seriously about allowing 4010 claims for a considerable length of time. We strongly encourage the government to monitor the industry. If things don’t improve, they’ll have to look seriously about augmenting the decision they made today.”
Only 2 months away from the Version 5010 standard upgrade - for those who have waited until the last minute, well, here we are. Version 5010 is a mandatory and integral step toward successful ICD-10 implementation. It is required when electronically conducting certain administrative transactions, including claims, remittance, eligibility and claims status requests and responses. This 5010 upgrade is from the 4010/40101A, which cannot accommodate the use of the ICD-10 code set.
What actions do you take to test now? Providers: Submit claims properly. Providers should begin submitting as many claims as possible prior to the January 1st deadline. A low backlog of claims will reduce the financial stress on your office and assist with cash flow after the transition. Test your Version 5010 standards. Providers can test their systems through CMS’s Medicare Fee for Service program, which is already accepting test and production claims in Version 5010 as it prepares for the transition’s GO LIVE date. Check partner readiness. Keep in mind the upgrade affects both providers and vendors so it is very important that you are aware of your vendors’ transition status.
Here’s why: If your vendor is behind schedule, encourage them to take action immediately so they can be prepared to handle your claims once Version 5010 officially goes into effect. Even if you are ready to transition, if your vendor isn’t, you will be unable to complete your transition. If your vendor is on track to implement, use them as a benchmark to compare your own level of readiness. Payers’ services can be utilized similarly. They can be consulted to help develop your timeline. You should check now with your payers to see what plans they have in place to handle incoming claims and whether temporary alternatives (e.g., direct data entry) will be available. It is imperative to make optimal communication efforts between providers, plans, clearinghouses, trading partners and vendors.
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Version 510 Upgrade Postponed Clearinghouses: Clearinghouses can be helpful to those who have fallen behind on their Version 5010 implementation plan. They can take your 4010 codes and translate them to 5010, which allows you to submit Version 4010 to payers even after the transition. A clearinghouse may only be a temporary solution, but a huge help to consider for your transition.
Credit: This close to the effective date, if you foresee a delay in your ability to submit Version 5010 claims, you may want to consider establishing a line of credit with your financial institution to help with any cash flow interruptions. Remember, the enforcement date is delayed, but your reimbursement flow may still be interrupted. Particularly with regard to small payers and some small Medicaid carriers, this means that physician groups and hospitals might have to continue to file some claims in the
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5010 format and some in the current 4010 format, unless clearinghouses can translate the claims back to 4010. The CMS urged all practices to continue working with vendors and partners to become compliant with the new HIPAA standards and to run tests that will determine their readiness to accept the new standards beginning Jan. 1, 2012. Additionally, respondents in a recent MGMA survey estimated that converting to HIPAA 5010 could set them back $16,575, and 45.2 percent of practices said that they had not yet started the implementation of software upgrades necessary for HIPAA 5010, even though 53.4 percent said that they were fully aware of the upcoming mandates. CMS’s OESS said that it will continue to accept complaints associated with Version 5010 during the 90-day period beginning Jan. 1, 2012. If requested, those subject to complaints must provide “evidence of either compliance or a good faith effort to become compliant with the new HIPAA standards during the 90-day period.”
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2012 Medicare Physician Fee Schedule The Final Rule Summary CMS posted the full Medicare Physician Fee Schedule (PFS). The provisions of the rule will be effective January 1, 2012 unless stated otherwise. Comments on those issues subject to comment are due by January 3, 2012.
Conversion Factor CMS has calculated the 2012 conversion factor (CF) to be $24.6712. That ‘s a 27.4% cut in the current conversion factor of $33.9764 ,which expires on Dec. 31, 2011. The CF must be viewed as a work in progress, because Congress has acted every year since 2003 to stop the cuts proposed by the notoriously flawed sustainable growth rate (SGR) formula.
Why so flawed?
The conversion factor represents a 27.4% reduction in the fee schedule. Congress has voted to stop this cut every year for nearly the last decade. Therefore, while we expect them to do so again, the critical factor is that the reduction will be placed UNLESS Congress acts on this between now and Jan. 1 (sound familiar – we’ve heard the same song and dance for, you guessed it, almost 10 years).
CMS states in the Final Rule Summary, they expect a 2012 CF identical to the 2011 CF. The President’s budget calls for an extension of the 2011 CF through Dec. 31, 2013, however legislation must go through the motions to enact this proposal or to maintain the current CF.
Is your specialty at risk…again?
Across the board, E/M services will
see increases of approximately 1%. Gastroenterological procedures are viewed to remain the same, but the total impact of the changes in the rule, on average, will vary depending on the mix of services provided. The change in the weights assigned to physician work, physician expense (PE) and professional liability insurance (PLI) components, and other changes in the proposed rule, come in to play.
vanced imaging, provided in the same session. This policy is based on the assumption that there are efficiencies in labor, supplies and equipment when more than one imaging procedure is performed. The policy was extended to the PE or therapy services (PT, speech and occupational therapy). A 20% reduction is applied to the PE of the second additional therapy code reported for the same day.
What the RUC?
CMS proposed to apply a 50% reduction to the professional component (PC = modifier 26) of multiple advanced imaging services (MRI, PET, CT, etc) performed in the same session based on the rational that there are efficiencies when multiple images are interpreted as well. The Final rule, CMS decided to proceed with this change buy has reduced the MPPR adjustment to a 25% reduction.
CMS directed the AMA’s RUC (Relative Value Committee) review of relative values assigned to various categories of services. In the proposed rule, CMS stated the RUC should review the physician work and practice expense values for all the E/M codes along with a number of high volume/ high expenditure services which had not been reviewed [by RUC] in the last 6 years. Originally CMS requested a reexamination of E/M codes, but they dropped the request after the majority of commenters indicated it was not likely to be productive since the codes were recently reviewed. Additionally, commenters urged CMS to recognize some of the non face-to-face services provided by primary care and other physicians who provide care to chronically ill patients such as telephone calls and team conferences. CMS responded it will continue to explore the valuation of E/M services and other refinements to the physician fee schedule (PFS).
Multiple Procedure Payment Reductions Currently a 50% multiple procedure payment reduction (MPPR) is applied to the technical component (TC) of ad-
The CMS is still considering more options discussed in the proposed rule to extend the application of the MPPR in the future to include applying the MPPR to the TC for all imaging codes, not just advanced imaging (including radiology, audiology, cardiology, neurology, etc)
Geographic Practice Expense Index The GPCI (GPCI – pronounced like ‘gypsy’) is a CMS calculated adjustment that applies to both the work and practice expense related value units for each code to reflect differences in labor, rent and other cost elements. GPCI changes are still being finalized including how it is applied to payment for physician services. A technical change to how the GPCI applies to office rents, purchased ser-
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2012 Medicare Physician Fee Schedule
vices and employee compensation. Implementation of a provision of the ACA establishing a PE index of 1.0 in several so-called frontier states – Montana, Wyoming, North Dakota, South Dakota and Nevada. A PE index of 1.0 would be equivalent to the national average. The actual GPCI in these states would be less than 1.0 so this change raises payments in these states. Elimination of the statutory floor on the GPCI the authority for which expired to protect lower cost and rural areas. If the GPCI changes at a rate of +/- 1% tor 2%), removing the floor in some areas will lead to substantial reductions in payment.
Annual Wellness Visit CMS covers annual wellness visits for beneficiaries as mandated by the ACA. The law also covers a personal prevention plan, which includes a health risk assessment (HRA). CMS increased the payment for AWV to reflect the additional time required to administer health risk assessment. They’ve adopted the following criteria for HRA: •Collects self-reported information about the beneficiary. •Can be administered independently by the beneficiary or administered by a health professional prior to or as part of the AWV encounter •Takes into account the communication needs of under-served populations, persons with limited English proficiency, and persons with health literacy needs, •Takes no more than 20 minutes to complete •Addresses, at a minimum, demo16
graphic data, including but not limited to age, gender, race and ethnicity; self-assessment of health status, frailty, and physical functioning, psychosocial risks, including but not limited to depression/life satisfaction, stress, anger, loneliness/social isolation, pain, or fatigue; behavioral risks, including but no limited to tobacco use, physical activity, nutrition and oral health, alcohol consumption, sexual practices, motor vehicle safety (seat belt use), and home safety and activities of daily living (ADLs), including but not limited to dressing, feeding, toileting, grooming, physical ambulation (including balance/risk of falls), and bathing
2012 Physician Quality Reporting System (PQRS) CMS proposes to redefine a group practice for the reporting option as 25 or more eligible professionals (EPs). CMS also proposes to reduce the number of options for 6-month registry-based measures reporting. Since implementation, in the formerly known as PQRI program, PQRS has continually evolved due to statutory updates enacted by Congress. CY 2012 can bring bonus payments of 0.5% of total allowed charges for services provided during the reporting period. An additional 0.5% is available for those participating in a maintenance of certification (MOC) program as well. MOC is required for board certification by recognized physician specialty organizations. EPs who choose not to participate in satisfactorily submission of quality data, will be assessed penalties beginning 2015. Initial penalties will be 1.5% and rise to 2.0 in CY 2016.
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eRx Program The eRx program is moving to the penalty phase. Participation is required in CY 2012 to avoid a 1.5% payment reduction in 2013. The incentive payment is based on the total allowed charges for services under Medicare Part B - for 2012 it is 1.0% and 0.5% in 2013. For EPs who do not participate or are not successful in participating will receive reduced Medicare payments equal to: -1% in 2012, -1.5% in 2013, and -2.0% in 2014. To avoid these penalties eRS measures must be reported 25 times between 1/1/2011 and 12/31/2011 or 10 times between 1/1/2013 and 6/30/2013. Group practices of 25-99 must report 625 times and group practices of 100 or more must report 2500 or more times between 1/1/2012 and 6/30/2012.
Medicare EHR Incentive Program CMS will now allow EPs participating in the Medicare EHR Incentive Program to report clinical quality measures (CQMs) in 2012 by attesting to the CQMs utilizing CMS certified EHRs or by participating in the voluntary PQRS-Medicare EHR Incentive Pilot. For individuals participating in the pilot, measures can be submitted through a PQRS EHR data submission vendor or from a certified PQRS EHR via a web portal. CMS has approved 44 EHR Incentive Program measures, to date.
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Small bits of information that may affect your health in a big way
Sugar vs. Fat: What’s worse?
Have you ever noticed when you read nutrition labels that foods are either high in fat and low in sugar, or low in fat and high in sugar? Unless, of course, you fancy the fat-free food diet lines – those generally score zero across the board…taste included.
Statistics: Sugar:
(Class: Carbohydrate). Calories: 4 calories per gram (approx. 1 tsp). In nature: Fruits, grains and other plants. Synthetic: Candy, soda and quick-foods.
Fat: (Class: Fat). Calories: 9 calories
per gram. In nature: Nuts, Meat, and Dairy. Synthetic: French, fries, potato chips, and many other forms
It all depends on the source.
Sugar: Foods such as yogurt, supple-
ment bars, fruits, the sugar may be derived from natural resources – in yogurt, even the milk it contains is also a source of sugar. When reading labels, also be aware of added sugars. Though labels don’t list “bad” sugar versus ”good” sugar, you can still break the code from the ingredients list. Food labels always list ingredients in the order of greatest weight contained within the product. You can ascertain most of the sugars are from natural fruits if they’re listed first or second. Natural sugars like honey have a much lower glycemic index (GI) than artificial variations. Synthetic sugars increase the GI number, which causes the sugar to rush into the system and affect the body like a drug by exaggerating hormonal responses, especially insulin. You may be familiar with insulin – when the body has trouble producing it, its known as the disease diabetes. Type II diabetes is fastest growing disease in the world.
Fat: When it comes to fat, you can use a similar method when reading labels. If the main source of fat is from animal products (e.g., dairy, meat, and poultry) then you want to choose a low-fat option because all of these fats derived from animals are high in saturated fat. You want to limit saturated fats in order to maintain good heart health. However, fats from healthy sources such as plants (nuts, oils, seeds) are good for you as long as you keep an eye on the overall calorie count. Keep in mind that fat from coconut oil or palm oil is also high in saturated fats and should be limited or avoided. As previously mentioned, fat is dense. It’s a double-edged sword – lots of calories for its size, but it’s an essential nutrient that helps us feel satiated, or full. This is the very reason why our body craves it when we’re hungry – and the more of it we eat, the more our bodies want it. And since our bodies don’t need much of it, it makes it really easy to overeat. When we eat more food than our bodies can put to good use, our body stores it in adipose tissue (i.e., fat tissue), but its not really fat as in the kind we eat, we get adipose tissue from too much protein, sugar, carbohydrates, and alcohol. Think about it: most “delicacies” are laden with fat. As a society, we’ve found ways to consume just the bad parts of fat – like butter, margarine, and lard – which are completely unnecessary for survival! Ever hear the saying “Some eat to live; I live to eat” – maybe its time to find a happy balance. Life’s about balance no matter which side your bread is buttered.
All things considered, sugar is more dangerous. The FDA has required that trans fats be listed on the side of every food label while sugar, sugar alcohol, artificial sweeteners,
and glucose syrups can be labeled with less stringent regulation. Many fats such as nuts, olives, seeds, avocados and fish are essential for optimal health and nothing in sugar is needed for human survival. A product that contains 100% sugar, can still be marketed as 100% fatfree when in fact sugar alters the body’s PH levels which makes an all-sugar food worse than a no-fat food. Fat has been linked to polycystic ovarian syndrome (PCOS) and fibromyalgia, but excessive sugar leads to insulin resistance problems. Sugar, in its cheapest and lowest quality form comes in high fructose corn syrup (HFCS) and is now found in items that aren’t even sweet – such as salad dressings and peanut butter. Though HFCS has the same amount of calories as regular sugar, HFCS can only be broken down by the liver, whereas natural sugars can be absorbed anywhere in the body. In the 80’s and 90’s we were trained to fear fat; “fat makes you fat” they said; fat-free food products popped up everywhere…remember Olestra? However, this is a new day and age. Due to heavy lobbying, effective marketing, deregulation, and public misconception, sugar is by far the more dangerous of the two. Education and motivation are your two best lines of defense.
New Rules to Follow
1. Read your ingredients labels;
not to be confused with the nutrition part of the label. If the first two ingredients are not whole and/or natural sources, pass . (e.g., whole wheat, organic = good; enriched, synthetic, high fructose = bad)
2. Fill up on fruits and veggies before you eat your meal. This will help you
refrain from overeating and provide a nice base of roughage for digestion.
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Revenue Cycle Management
How to cut costs
Dealing with Rising Operational Costs in the Medical Office Ruby Ramos of “Complete Reimbursement Solutions, LLC” has two tips on how to deal with rising operational costs
1st tip: Re-negotiate your inventory contracts.
Checking the inventory.
This will allow you to review what you are ordering, how often you are ordering the item, and how much you are spending for it. Once you have that information you must call your account manager and re-negotiate a lower rate. This method has been very successful in many of my practices. You will be surprised what you can get from companies you never thought would have a discount program.
2nd tip: Avoid late fees and interest fees. Paying late fees can be very costly to a practice. Some managers don’t realize how costly it can be until the end of the year figures and then you realize that it adds up. Another thing that will decrease expenses is to avoid charging on your business credit card because you accumulate interest fees. Instead of using the credit card go for the no interest payment plans. There are many companies that have this option.
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Ruby Ramos, RMC, RMM, is the Administrator for Allied Surgical Group and James Street Ambulatory Surgical Suite in Morristown, NJ. Ruby has been in the field for 15 years and is a member of the Association of Registered Health Care Professionals (ARHCP) and the American Medical Billing Association (AMBA). Her practice specialty is general surgery/oncology. www.reimbursementsolution.com rubyr@reimbursementsolution.com
ICD-10 Panic Kicks In AMA Pushes Back on Implementation Date At its semi-annual policy-making meeting, the AMA states that one of its goals is “to work vigorously to stop implementation” of the International Classification of Diseases 10th Revision family of diagnostic and procedural codes. An interesting stand from a once mighty organization that has done nothing but continuously shrink for the last decade to a membership representing less than 20% of practicing physicians. The AMA explained, citing a 2008 case study, that the average three physician practice will spend nearly $83K to transition and implement ICD-10; these costs skyrocket to more than $285,000 for a 10-physician group. So should they be spending additional money on efforts that will do nothing to help them implement and become compliant? AMA
claims it is a massive and expensive undertaking that will bring little benefit to physicians, and will only be a disruption to the implementation of EHRs and demonstration of meaningful use. In an Oct. 26 statement released by the Medical Group Management Association (MGMA), only 4.5 percent of study respondents rated their 5010 implementation status as complete while 40 percent said that their implementation status is less than onequarter complete. OESS made the decision to push back the Version 5010 enforcement period after industry feedback revealed that with only about 45 days remaining before the Jan. 1, 2012 deadline hits, many practices have not and likely
would not reach compliance. Version 5010 will provide a greater functionality to healthcare claims and is also a prerequisite to transitioning to the ICD-10-CM and ICD-10-PCS code set, which will become mandatory Oct. 1, 2013. Shortly after survey results were released, the American Medical Association (AMA) House of Delegates voted to try and halt ICD10 code implementation, due to the significant burdens that will be placed on practices. It was estimated that a 10-physician practice could be forced to fork over $285,195 to complete the implementation phase of the ICD-10 code set. “ICD-10 does nothing to improve care of patients”, said one Mobile, Alabama delegate.
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CPT 2012 Summary Preview for ARHCP Members and MMI Alumni Only More than 500 changes come with the upcoming New Year. This includes minor additions to the Evaluation and Management Services Guidelines which are intended to bring forth clarity to the “three-year rule” (HCPCS II includes a new modifier to help as well; more on pages 8 & 9). The three-year rule applies to, you guessed it, new patient vs. established. The guideline changes emphasize that a new patient is one who “has not received any professional services from the physician or another physician of the exact same specialty or subspecialty who belongs to the same group practice, within the past three-years”. The CPT 2012 further defines professional services to mean “any face-toface services rendered by a physician and reported by a specific CPT code, or codes.” To visualize a patient’s status, the CPT 2012 brings back the Design Tree, which did not change for 2011, but was not included in the year’s book.
At-a-Glance Peek For MBJ readers only, we bring you an at-a-glance peek on page 24-26, to show what 2012 brings -- effective Jan. 1st If you haven’t purchased your book yet, please see page 32 for purchasing information.
CPT Modifiers Two new modifiers are added to Appendix A,
but don’t be alarmed if you won’t see them listed on the inside cover. We can only imagine that this is the AMA’s effort to bring CPT users to the full definitions as to break the habit of quick-find procedures that steer you away from proper modifier usage. This is just one journalist’s opinion, of course.
Modifier 33 Though not brand new, this is the first appear-
ance in the book. The modifier was created in 2011 to denote the service is a covered annual wellness visit. By covered, they mean this modifier is appended when reporting a preventative service “in accordance with a US Preventative Services Task Force A or B rating in effect” and “other preventative services identified in [legislative or regulatory] preventative services mandate”. For example, Medicare’s IPPE (G0402) and annual wellness visit (G0438 and G0439). Modifier 33 is not intended to be applied for separately reported services that are specifically identified as preventative (e.g. screening colonoscopy, G0105 or G0121; screening mammography, 77057), instead the modifier PT Colorectoal screening test converted to diagnostic test or another procedure to the diagnostic colonoscopy code to indicate the procedure started off as a preventative service.
(For a more detailed description, see the April 2011 issue of the MBJ – New Preventative Services Modifier)
Modifier 92 Alternative Laboratory Platform Testing Though
it may not look new, this modifier is used when: • Lab tests are performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable, analytical chamber; • The test does not require permanent dedicated space; • The test is designed for carry or transport to the vicinity of the patient for immediate testing at that particular site. Medicare payors will use modifier 92 to indicate point-orservice HIV testing (86701-86703 and 87389) only. CMS transmitsl 2277, modifier 92 went into effect on Oct. 1, 2011 for this reason. Being that modifier 92 was introduced in 2008, CMS will allow you to apply it retroactively to claims filed on or since Jan. 1, 2008.
Category I Most CPT 2012 changes will be found in this section of the CPT. That’s over 200 new codes, over 180 deletions and more than 130 revisions. Zero changes occurred in only the Anesthesia (00100-01999) and Urinary System (50010-53899) sections.
Evaluation and Management Initial Observation Care codes
99218, 99219 and 99220 include additions of “reference times”. The 99220 descriptor now specifies, “Physicians typically spend 70 minutes at the bedside and on the patient’s hospital floor or unit.” This language clarification allows providers to report the initial observation care codes using time as the key component when counseling, or coordination of care dominates the encounter. Prolonged Services 99354-99335 (office or outpatient) and 99356-99357 (inpatient or observation) were given instructions for physicians or other qualified health care professional to indicate these add-on services specify total faceto-face time with the patient, and non face-to-face services on the patient’s floor or hospital/nursing facility unit during the same session. Time does not have to be continuous, but only one prolonged service code may be reported per day. Prolonged services without direct patient contact (9935899359) also received guidelines in 2012 to highlight that these add-ons may be provided on another date, but the initial must have been face-to-face, though time need not be referenced. Additional guidelines also precede the Inpatient Neonatal and Pediatric Critical Care (99468-99476) and Initial and
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CPT 2012 Summary Continuing Intensive Care Services (99477-99480) codes to emphasize what these services include and how the codes should be applied.
Integumentary One of the highlights of the AMA symposium
this year was this section on the changes regarding the skin replacement/skin substitute codes. You will see many codes in range 15300-15431 are gone and replaced by a smaller list of simpler codes. Rationale behind this being that no matter the choice for supply of the graft, the procedure to apply is the same. Among these simpler codes is 15271 application of skin substitute 25 sq cm or less wound surface are and +15272…each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure). The skin substitute supply may be reported separately, of course. To describe biologic implant for soft tissue reinforcement, the CPT created add-on code 15777 Implantation of biologic implant (eg acellular dermal matrix) for soft tissue reinforcement (eg, breast, trunk). (List separately in addition to code for primary procedure). Keep an eye on this section as many other code descriptors received minor revisions.
Musculoskeletal Many code descriptors received revisions
in this section as well either to clarify the intent of the service or through added parentheticals to draw attention to bundled services. For example: Below range 22520-22522, note the parenthetical which indicates bone biopsy as in included service when performed. Two new codes (22633 and 22634) join us for arthrodesis via combined posterior and posterlateral technique with posterior interbody technique as well as a new manipulation code (26341) for Dupuytren’s contracture.
Respiratory All
“removal of lung” codes in range 3244032491 have been revised. There are six new codes for thoracotomy (32096-32098, with biopsy; and 32505-+32507, with wedge resection), and a brand new category of a dozen codes (32601-32674) has been established for VATS (video-assisted thoracic surgery. Additionally, close to a full page of instructions under “Lungs and Pleura” and parentheticals throughout this section have been added.
Cardiovascular For those of you with the AMA’s Professional
CPT, you will see lots of green in this section. Additional pages of instructions for code application as well as a quick reference chart to help with code selection for insertion, implantation and removal of a pulse generator and the components involved. Nearly 20 codes have been revised, nine have been added, including combo codes to report renal catheterization and angiography (36251-36254) which in22
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clude radiological supervision and interpretation. More instructions have been added to the “Cardiac Assist” subsection to clarify the replacement of ventricular assist device pump (33981-33983).
Digestive Few changes sprinkle this section.
Of them, several parentheticals to clarify proper code selection. Three new codes were added (49082-49084) which describe abdominal parcentesis to replace deleted codes 49080 and 49081.
Reproductive Systems Codes in the Male and Female sections remain untouched, but parentheticals have been added throughout these sections including instructions to see the Integumentary section regarding non-biodegradable contraception implants and removal with subsequent insertion.
Nervous System New code range 64633-64636 replace deleted range 64622-64627 for destruction of paravertebral facet joint by neurolytic agent. The new range specifies location and the number of joints injected. Additionally, parentheticals and instructions have been added and codes throughout received revisions to clarify intent or application of the code.
Eye/Ocular Adnexa and Auditory Only three minor changes for 2012 in these two sections : • An added parenthetical for proper use of 65280 and 65285; • Fitting of contact lens for treatment of disease; and • Deleted code 69802
Radiology There is lots of anxiety about this section for 2012.
Though there are many changes, the most significant are: New codes to report intra-operative radiation treatment delivery (77424, 77425); Intra-operative radiation treatment management (77469); New instructions for radiation management is now reported in units of five fractions or treatment sessions, regardless of the actual time period in which the service is furnished; Atherectomy codes (75992-75996) have been deleted and replaced with directions to utilize Category III codes. For example, in 2012, instead of using 75995 for Transluminal peripheral atheretomy, open or percutaneous, including radiological supervision and interpretation; visceral artery (except renal), each vessel, report Category III code 0235T.
Path/Lab Lots of green text in Path and Lab!
2012 brings a brand new section for molecular pathology (Mo-Path). Along with two full pages of instructions and over five pages
CPT 2012 Summary of new codes – Tier 1 (81200-81383), Tier 2 (81400-81408). Mo-Path procedures involve analysis of nucleic acid to detect variants in genes that may be indicative of germline or somatic conditions, or to test for histocompatibility antigents. The specific gene that is analyzed is the basis for the code reported. Parenthetical notes have been added for HIV-1 and HIV-2 testing code 86703 (single result) for clarification of code selection for alternative testing. Example, HIV-1 antigen(s) with HIV-1 and HIV-2 antibodies (87389), and notes regarding when to apply modifier 92 with 8670186703 and 87389. Codes 88312, 88313 and +88314 have been revised, and parentheticals added regarding special stain tests.
Medicine Immunization codes receive descriptor revisions
and added instructions to clarify usage by vaccine component, rather than per injection. Codes 91010 and +91013 replace 91011 and 91012 for Esophageal motility studies. Code 92070 has been deleted and replaced by two new codes, 92071 and 92072, for contact lens fitting to treat disease. Instructions fill a full page regarding sleep medicine testing and new codes have been added as well to report needle electromyography, per extremity. Hydration codes also received additional instructions to clarify the meanings of “initial ,” “subsequent, “ and “concurrent” infusions.
Category II & III Codes Over
50 codes have been added to these two areas of the CPT 2012. Many parentheticals throughout Category I direct readers to these codes for proper reporting. Among these changes are: Self-care education provided to patient (4450F); Referred to an outpatient cardiac rehabilitation program (4500F); Intramuscular autologous bone marrow cell therapy (0263T0265T); Percutaneous laminotomy/laminectomy (0274T, 0275T); And many, many more! Category II codes are a set of codes for supplemental tracking that can be used for performance measurements (PQRS codes). Category III codes describe emerging technologies, and also allow for tracking and collection of specific data. If available, Category III codes are to be used before an unlisted Category I code.
An at-a-glance listing of CPT 2012 changes can be found on the following pages. The Medical Management Institute will be covering specific information regarding 2012 changes in Specialty Updates Classes throughout their Winter 2012 Quarter Sessions. To be added to the list for your choice of specialty, contact the Institute today!
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2012 Anatomy 101 Course At The Medical Management Institute
Learn the Basics Learn the basics of Human Anatomy for medical coders
Enroll Now Enroll for this course online (www.mmiclasses.com) or over the phone (866-892-2765)
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2012 CPT Updates and Changes [At-AGlance]
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2012 CPT Updates and Changes
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2012 CPT Updates and Changes
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Accountable Care Organizations Health Information Technology is a Must The National Committee for Quality Assurance (NCQA) recently launched an accreditation program for accountable care organizations (ACOs). NCQA now emphasizes health IT in its requirements for accreditation. If you speak to any hard-core EHR incentive or even meaningful use advocates, you will get two things: the defined difference between EHR and EMR and proud mention and promotion of ACOs. Its hard to think forward to an ACO without thinking about how it will work and what will make it run smoother…and that is optimal health IT. NCQA sees this point and under the “care management” section of the seven domains in the accreditation program, they require ACOs to show that such an “organization collects, integrates and uses data from various sources for care management, performance reporting and identifying patients for population health programs.”. Additionally, an organization must also “provide resources to patients and practitioners to support care management activities.” Another domain of criteria, “care coordination and transitions,” requires that as an ACO, an “organization facilitates timely exchange of information between providers, patients and their caregivers to promote safe transitions.” NCQA also accredits health plans and recognizes patientcentered medical homes, is providing three accreditation levels for ACOs. Level 1: Recognizes organizations that are in the process of forming ACOs. Level 2: Designates organizations with the best chance of achieving the “triple aim” of lowering costs, improving quality, and enhancing the patient experience Level 3: After achieving level 2, ACOs must also show strong performance or improvement on the triple aim goal and then they may receive Level 3 accreditation. Group practices, physician networks, hospital/provider partnerships, hospitals and their employed or contracted providers, publicly governed entities, and health plan-provider partnerships all can form ACOs that are eligible for NCQA accreditation. Among the first to commit to the ACO effort are the Billings Clinic in Montana and Health Partners in Minneapolis.
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The Podium
How the healthcare industry and political government mesh
Making the Most of the Election Year As the holiday season approaches it is easy to forget that January will kick off the politically charged 2012, determining the future direction of healthcare in the United States. As Republicans and Democrats fight it out, implementation of the healthcare bill is currently being challenged by a number of states. The outcome of this debate will lead to a policy that can directly impact our practices and guidelines in the healthcare industry. As healthcare administrators, we have a responsibility to inform our political leaders by not only showing up on election day, but by taking the time to communicate directly with elected officials to discuss the potential impact of this legislation.
Find your Local Congressmen
You can use the websites www.sentate.gov or www.house. gov to find your local congressman. Research their websites and find out which legislators may be interested in your outlook. Congressmen want to please their constituents, especially during an election year, so you are likely to get a response to your efforts if you contact representatives in your district. Once you have determined who to contact regarding your problem, you must reach out to your elected officials and make your concerns known. Letters are typically the preferred method of communication with legisla28
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tures and offer a great opportunity to present your problem in a clear and concise matter.
Write an Effective Letter
Listed below are some general tips from Congress.org on how to write and effective letter: http://www.congress.org/congressorg/issues/basics/ • Your purpose for writing should be stated in the first paragraph of the letter. If your letter pertains to a specific piece of legislation, identify it accordingly. e.g., House bill: H. R. ____, Senate bill: S.____. • Be courteous, to the point, and include key information, using examples to support your position. • Address only one issue in each letter; and, if possible, keep the letter to one page. Also, when addressing your letter, it is customary to refer to Senators and Representatives as “The Honorable” followed by their full name. For the Salutation, you would use “Dear Senator” or “Dear Representative” depending on the situa-
The Podium tion. It is important to use proper headings and salutations even when sending emails to enhance your creditability as a citizen. Speaking of email - while electronic mail is gaining in popularity, it is important to note that correspondence by email do not have the same impact as a traditional letter and it can be very difficult to convey tone. It is always a good idea to start with a traditional letter for maximum impact when reaching out to an elected official.
Meet with an Elected Official
If your letter generates enough interest, you may be able to arrange for a face-to-face meeting with your elected official. This is a unique opportunity to offer insights on how the healthcare bill might affect the way you do your job in the future. Regardless of whether you support the legislation or not, it is important as professionals that we assert our concerns to Congress so they can make informed decisions. If you have the opportunity to meet a local Congressman, remember these tips:
“ It is important to acknowledge little milestones along the way to keep up morale and reach our ultimate goal.”
At the meeting: Keep your presentation as brief as possible and discuss only the following: the problem you want to solve, possible solutions and reasons why the official should support your proposal. Be ready to answer any questions about your issue with factual information. It is critical that you stay current on any late-breaking developments affecting your issue. You may want to take the time to type up your main talking points so if you run out of time the official can review them at a later date. You should practice your talking points prior to the meeting, especially if you are going as part of a group. Be respectful of the official’s time and recognize nonverbal cues that the meeting has ended. Avoid temptation to ask for additional items or photographs. After the meeting: Always follow up any face-to-face meeting with a handwritten thank you note. This gives you an opportunity to reiterate your key points and provide your contact information. Keep in brief and regular contact via email with the decision maker’s staff and acknowledge any action that has taken place on behalf of your issue. With certain exceptions, sweeping changes to public policy are just not possible. However, it is important to acknowledge little milestones along the way to keep up morale and reach your ultimate goal. [The above list
of tips on meeting a local Congressman was adopted from Mark Block, Director of external relations for Newsweek.---(Graham, 2010, 137-139).]
As healthcare employees, we have a responsibility to inform our policy makers how the laws they pass affect us!
Before the meeting: In addition to your background research, make sure that you know the correct names, spellings, and pronunciations of all officials and staff members that you will be interacting with. When you schedule your meeting, request the least amount of time necessary to go over your entire issue. Make sure you are dressed appropriately for meeting with an elected official. It is best to avoid clothing with any tears, tank tops and open toe shoes (e.g., flip-flops) when initially meeting with a government official. Do not bring any gifts to the meeting—it puts elected officials in an uncomfortable situation and is generally frowned upon in government. Keep your group small—bring only essential members who are important for getting the message across.
It is easy to get caught up in the routine of our everyday lives and forget how important we are to our government system. So as the holidays wind down, please remember to become informed about the current legislation and take the time to express your view on how we can better perform our services. We are a valuable resource for lawmakers and they ultimately want to know what their constituents think (especially during an election year) so take the opportunity to weigh in on this important issue!
Z
Sources: [Graham, Bob. (2010). America The Owner’s Manual: Making Government Work for You. Washington: CQ Press.] [Mark Block, Director of external relations for Newsweek.---(Graham, 2010, 137-139).] [This piece was based on the original work of Maria J. Albo as published in the The Basics of American Government (2011). Alexander, Ross and Carl D. Cavalli, eds. North Georgia Press: Dahlonega, GA.]
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Top Five Best (and Worst) States to Practice Whether you are looking to relocate or are just curious, this guide will enlighten you on the best and worst states to practice in regards to cost-of-living rates, tax burden data, malpractice climate numbers, and physician-density statistics along with some job opportunities that have been submitted this month.
The Top 5 Best States to Practice (In no particular order): Alabama: Cost of Living Index (92.74), Tax Burden per Capita ($2,967), Medical Board Disciplinary Actions per 1,000 Physicians (2.69), Physicians per 100,000 Residents (218.2)
Idaho:C-O-L Index (93.04), Tax Burden per Capita
($3,276), Medical Board Disciplinary Actions (2.72), Physicians per 100,000 Residents (168.8)
Mississippi: C-O-L Index (9267), Tax Burden per
Capita ($2,678), Medical Board Disciplinary Actions (2.62), 30
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Physicians per 100,000 Residents (177.9)
South Dakota: C-O-L Index (98.53), Tax Burden per Capita ($3,042), Medical Board Disciplinary Actions (2.6), Physicians per 100,000 Residents (219.1)
Texas: C-O-L Index (91.04), Tax Burden per Capita
($3,197), Medical Board Disciplinary Actions (2.61), Physicians per 100,000 Residents (214.2)
Healthcare Professionals Birmingham, AL
Full-time Position: Office Medical Assistant II A Company: Children’s Health System To Apply: Visit www.chsys.org
Tupelo, MS
Full-time Position: Coding Supervisor Company: North MS Medical Center To Apply: Visit www.nmhs.net/tupelo
Hauser, ID
Part-time/Full-time Position: Day shift Coder Company: Northern Idaho Advanced Care Hospital To Apply: Visit www.niach.ernesthealth.com
Yankton, SD
Part-Time Position: Human Services Dispatcher Company: South Dakota Bureau of Personnel To Apply: Visit www.bop.sd.gov
Denison, TX
Full-Time Position: Inpatient and Outpatient Medical Coder Company: Supplemental Health Care To Apply: Visit www.supplementalhealth care.com
The Top 5 Worst States to Practice (In no particular order): Connecticut: C-O-L Index (130.22), Tax Burden per
Physicians per 100,000 Residents (421.4)
DC: C-O-L Index (139.92), Tax Burden per Capita
Capita ($6,751), Medical Board Disciplinary Actions (2.28), Physicians per 100,000 Residents (316.3)
Maryland: C-O-L Index (124.81), Tax Burden per
Capita ($6,157), Medical Board Disciplinary Actions (3.03), Physicians per 100,000 Residents (395.9)
Capita ($7,256), Medical Board Disciplinary Actions (1.69), Physicians per 100,000 Residents (376.4) ($6,076), Medical Board Disciplinary Actions (2.57), Physicians per 100,000 Residents (807.2) Capita ($5,218), Medical Board Disciplinary Actions (2.11),
New Jersey: C-O-L Index (128.47), Tax Burden per New York: C-O-L Index (128.29), Tax Burden per
Z
Sources: [States to practice: http://www.physicianspractice.com/best-states-to-practice] [Job Listings:http://csjobbank.jobamatic.com/a/jobs/find-jobs/ q-medical+coder]
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Coding Corner Yo u ’ v e g o t Q u e s t i o n s , We ’ v e G o t A n s w e r s
The Editor-in-Chief sits down to answer some of your tough coding questions.
Q:
We have a bariatric surgeon that does the gastric band adjustment and we bill CPT S2083. Insurance companies are now denying and taking back money if they had paid so we started using 43999 (unlisted code) and put that it was for gastric band adjustment. Blue Cross Federal called us today stating S2083 no longer exists and they will not pay for 43999. The representative told us that there are codes but would not tell us what they were. Can you help shed some light on the subject?
A:
Of course, the contract with the payor may come into play here, but generally there are three types of surgical procedures that are distinguished as follows: 1. Vertical banded Gastroplasty (CPT 43842) and other forms of Gastroplasty (43843) - procedures designed to restrict food intake by limiting gastric volume. A 15-ml gastric reservoir is created by one of several stapling techniques. The small gastric reservoir empties through a narrow channel on the lesser curvature of the stomach to the residual stomach. The channel is reinforced with a prosthetic material to ensure a channel circumference of 4.5 to 5 cm. This operation is attractive because it preserves gastroduodenal continuity and avoids the potential for micronutrient deficiencies. 2. Gastric Bypass (CPT 43846, 43847) and Laparoscopic Gastric Bypass (CPT 43644 and 43645) - procedures that also limit the gastric reservoir capacity by the creation of a 15 ml stapled gastric pouch. However, the stapled pouch is connected by a 10-mm anastamosis to a 40-cm Roux-en-Y jejunal limb, thus bypassing the distal stomach,
duodenum, and very proximal jejunum. This procedure combines gastric restriction with emptying of semisolid gastric contents into the jejunum, which seems to exert further additional limitation of food intake. 3. Laparoscopic placement of an adjustable gastric band (Lap-Band), (CPT 43770) which is a silicone implant in the shape of a ring, with an adjustable balloon. The band is placed just below the esophagogastric junction, and the balloon is connected to a reservoir under the skin. The degree of gastric restriction can be adjusted by accessing the reservoir through the skin and adding or removing saline (CPT 90772 or HCPCS S2083) I believe the third bullet is what you are looking for. Remember, when it comes to insurance representatives, its not that they refuse to help with coding just to upset you. Liability-wise, they are not permitted to give coding advice or give any indication that can lead to payment. Useful information can be found in your contract with that particular payor.
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Coding Corner
Q:
Should present-on-admission (POA) queries stay in the record and become a part of the permanent medical record?
A:
I believe all queries should become a permanent part of the record. I think when they are incorporated as part of the record they provide a logical rationale for how certain diagnoses begin to appear in the record. Let’s say a specialist places a query for specificity and subsequently the physician documents a more specific diagnosis.
• The query did not seek to obtain an initial documentation of a diagnosis
You will have to raise this topic with management and compliance staff to see what works best in your facility. One facility made the POA query form a permanent part of the record and used only in the following circumstances:
• Is the wording “compliant”? • Is it “non-leading”? • Will your queries be audited on a routine basis for compliance and how will that be tracked? • Do you have detailed written query policies and procedures and if not do you have a plan to develop them?
• A provider already documented the diagnosis at least once • The query only asked if the condition was POA
Q:
My doctor wants to start billing 99406 for tobacco cessation counseling. Can this be billed in addition to the regular E/M visit? If so, I’m assuming a modifier would need to be applied; would that be 25? Also, I tried to find an allowable for that code and if I am doing this correctly I came up with $14.46 as maximum charge from the Medicare website.
A:
Yes, you would report 99406 (3-10 mins of counseling) with modifier 25 if another distinct encounter occurred during the same visit -- be sure your Doc documents time since this is a time-based code. The reimbursement is pretty low, but your doc can report it up to 8 times/year per patient.
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Before making your queries a permanent part of the record you will have to consider:
Q:
If a patient has regular Medicare, how often can they have a visual fields threshold 92083 performed, and it get covered?
A:
Regarding CPT 92083, I didn’t find any firm restrictions for submitting this code, but it appears to be on an annual basis unless the situation dictates otherwise (generally determined by supporting documentation upon request).
Coding Corner Coding Conversation
RMC:
Can a laboratory report surgical pathology codes 88302-88309, 88311-88399 and 89049-89240 with modifier 76 for repeat procedures? We are set up to currently deny. We have told them [lab] we expect to see modifier 91, which they are not accepting. I have been searching the Internet and not finding consistent answers. I cannot find an answer on the CMS website either.
MBJ:
Modifier 76 is for a repeat procedure (generally used by providers who perform clinical care) and modifier 91 is for a repeat clinical dx lab test (this is what a lab should use as it is specific to lab tests). It sounds like you understand the difference, it’s just getting the
lab to understand it is the problem. You may want to forward them the full definition of each of the modifiers to support the recommendation. If you have a contract with them that outlines the use of the modifier, that may clear things up for them too.
RMC:
You and I are on the same page here. The lab is stating the surgical pathology procedure codes are “procedures” and therefore should be payable with modifier 76. They are telling us that modifier 91 is incorrect for these types of procedure codes. I have explained this multiple times for the different labs, but they continue to argue.
MBJ:
According to the College of American Pathologists (CAP), they state in memorandum A-99-41, the following: “Modifier -76 is used to indicate that a procedure or service was repeated in a separate operative session on the same day by the same physician.”
The -76 modifier indicates that an initial procedure code has not been mistakenly reported twice and therefore would not be appropriate to report multiple surgical pathology specimens. Furthermore, I found many insurance companies will auto-deny with a 76 or 77 modifier as they are deemed inappropriate for path codes.
Outcome from RMC:
Just wanted to give you an update on this topic. After much discussion here, it was decided that we would not allow the modifier 76 on surgical pathology codes. The documentation you sent to me helped tremendously! Z
Q’s via email (cc@mmiclasses.com), phone (866-892-2765), or our facebook page (www.facebook.com/MMIfan). We love to give you A’s!
Send us your
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MBJ Key Terms Puzzle
Print out this puzzle to have a little fun while testing your MBJ knowledge. ( We d i d t h e f i r s t o n e f o r y o u ! )
Word Bank ACO ARHCP AUDIT BERWICK CHANGES CIA CMS COUNSELING EHR ERX GRACEPERIOD HEALTHNUT HIT HITECH IMPLEMENTATION MGMA MMI MPFS NCQA OBSERVATION OIG PODIUM PQRS RAC REVENUE SCREENING TECHNOLOGY
After you find all of the words, the message will reveal itself through the letters that are left.
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 2 0 1 2 ! 36
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