2019 Focus Newsletter by TEAM

Pennsylvania Ophthalmology News FALL 2019

PRESIDENT’S MESSAGE by David Silbert, MD, FAAP

The PAO needs you...and the others Pennsylvania Academy of Ophthalmology

In September I became the 18th president of the Pennsylvania Academy of Ophthalmology (PAO). The PAO traces its roots back to 1943, when it was incorporated as the Pennsylvania Academy of Ophthalmology and Otolaryngology, and 1990 when it split from otolaryngology. As ophthalmologists in Pennsylvania, we have a great deal to be proud of. We have worldclass facilities throughout the state and outstanding training programs in Philadelphia, Pittsburgh, Hershey and Danville. Every year we graduate 26 ophthalmologists from residency programs in the Commonwealth, and countless fellows. While some graduates stay in the Commonwealth, many leave Pennsylvania for other states where they feel practice will be easier or they believe the environment is better for physicians in general. The only thing we can reliably forecast is that the landscape in medicine will continue to change and will continue

to challenge us. Nothing exemplifies this more than CMS’s recent revaluation of cataract surgery, decreasing compensation by 15% for the surgery and 3-month global period. While drug companies value their drugs based on the value they add to an individual’s life, the cost they save society, or return on investment, our work is valued as piecework. The more efficiently we perform our work, to save sight and improve lives, the less we are paid. Although we have many challenges in ophthalmology, Medscape recently found ophthalmology to be among the happiest specialties in medicine second only to dermatology. We would like to keep it that way. The bulk of our PAO members are private practice physicians, but what we do is relevant to all ophthalmologists including academics. Ophthalmology is one of the few specialties where most physicians are still independent. While hospitals are currently purchasing many physician practices, this is still rare in ophthalmology. There are clouds on the horizon, however; as venture capital firms once again have begun purchasing ophthalmology practices, promising to simplify our lives, but certainly limiting the ophthalmologist’s autonomy. The complexities of running a practice are increasingly taking the fun out of medicine. So what can the PAO do to help our members with these challenges? How can we help our academic colleagues? continued on page 4

LEGISLATIVE UPDATE by Andy Goodman of Milliron Goodman Pennsylvania legislative voting is fast approaching, and it is important to understand what issues the Academy faces as we move into the fall. As always, we need you to act and be an advocate for your patients and profession. Optometric scope of practice expansion is back again as Senate Bill 391. This bill passed the Senate last year, died and was reintroduced. Optometric scope expansion into medicine is a top priority of organized optometry in the Commonwealth and nationwide. Act now before SB 391 begins to move. The bill would expand optometric scope of practice into surgery, medical imaging, systemic disease, a reduction of checks and balances and other concerning areas. On the flip side, the Academy is working on pediatric vision screening legislation. Representative Rosemary Brown introduced House Bill 1342 which would mandate all children before starting kindergarten receive a vision screening. In addition, this legislation would also make changes to the current vision screening schedule for children grades 5-12 by having them screened every two years instead of the current standard which is every year. This piece of legislation is vitally important to ensure that Pennsylvania’s children have healthy vision. The PAO supports House Bill 1342. We are again working on introducing the Definition of Ophthalmic Surgery legislation. This legislation would set a concrete definition of ophthalmic surgery. This definition would clear any ambiguity of what is or is not surgery. The bill would go a very long way to protect our patients, making sure only properly trained physicians perform ophthalmic surgery. With the information of what the PAO is working on this session it is important to take the next step and become an advocate. What does it mean to be an advocate? In the most basic sense, an advocate is someone who goes out and educates people about a specific issue area. But when it comes to advocating on behalf of a profession such as Ophthalmology, that basic definition does not properly encompass the importance of our advocates. An advocate for the PAO goes above and beyond sharing

information and educating; they act as champions of not only our profession but also our patients and their safety. If we don’t advocate for our patients and profession no one will. We need you to be the advocate. Are you willing to become a PAO advocate? Do you want to be a “Champion” of patient safety and our profession? We are reinvigorating the PAO Legislative Champions Network, which is a group of advocates who are willing to go out and advocate for our profession and patients. If you would like to join, please either fill out and return the form that has be sent to you via the mail or email Tyler@ millirongoodman.com. Finally, the PAO is holding at-home advocacy days the first two weeks in November and will focus on having meetings with your legislators in their district office. We need advocates to meet with their state Representative and Senator on Senate Bill 391, House Bill 1342 and the Definition of Ophthalmic Surgery legislation. If you are interested or need help organizing your meeting please feel free to reach out to Tyler Burke from Milliron Goodman at Tyler@millirongoodman.com or 717-232-5322.

2019 PA HOUSE SESSION SCHEDULE October

21, 22, 23, 28, 29, 30

November

12, 13, 14, 18, 19, 20

December

9, 10, 11, 16, 17, 18

2019 PA SENATE SESSION SCHEDULE October

21, 22, 23, 28, 29, 30

November

18, 19, 20

December

16, 17, 18

Wake Up Time – Relationships Matter We all share a deep concern over the dangerous consequences any optometric surgery proposal brings for our patients and profession. As you know the PAO and ophthalmologists from across the state won this year for you and the patients of Pennsylvania by stopping last session’s SB 668, a giant expansion of optometric scope of practice into surgery as well as systemic treatment. That bill would have allowed… • YAG capsulotomy • Laser peripheral iridotomy • A wide variety of eyelid surgeries

• Injections (other than intraocular) • Corneal crosslinking and much more

If you truly care about patient safety and our profession please keep reading. We very narrowly stopped that bill but it’s back now, in essence unchanged, as SB 391. The recipe we must follow for political success is simple but depends upon getting help: Personal relationships with legislators and financial support for those that are patient safety champions. We either develop these, or ultimately we, and the patients of Pennsylvania, will lose. Optometrists constantly build relationships with their legislators and that is how they get these bills introduced over and over across the country. How many of you have answered the call to help and set up an appointment to meet with your legislators during

our Advocacy Weeks at Home effort (first two weeks of October)? Did you pay any attention to that email? Do you think that someone else will continue to be able to do this for you? Are you thinking that these bills have been repeatedly introduced and stopped by the PAO without your help, so it will all be fine again? I am in all seriousness telling you that, without the involvement and help of more ophthalmologists, ultimately we will lose. The work and commitment of the minority cannot continue to make up for the lack of action of the majority. With help though, we can and will successfully defend our profession and patient safety. • Call our lobbyists at Milliron and Goodman (717) 232-5322 to help you set up an appointment with your legislators. We’ll provide you with all of the information you need. • Invest in your profession by answering the call to contribute to the PA Eye PAC or contribute to and support a fundraiser for a legislator when we ask. • This is how we build the RELATIONSHIPS THAT MATTER. It’s critical that far more ophthalmologists in Pennsylvania join the patient safety and surgical standards battle or we and our patients will suffer the consequences of inaction. Thank you for your interest and commitment to patient safety and our profession. Please talk about this with your partners and friends – Every ophthalmologist must help.

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PRESIDENT’S MESSAGE continued from page 1

The PAO is working on a digital platform for practice administrators. The platform, PAO Connect, will allow administrators whether in small practices, large groups or academic departments, to ask questions of each other and upload and download to the platform useful materials pertinent to running a practice in Pennsylvania. We hope this platform will help ophthalmology administrators in Pennsylvania work with each other and become resources for each other. The PAO is exploring partnership opportunities with ophthalmic management groups to develop services tailored to our members whether private practice or academic. By allowing practice to be more rewarding, it might encourage new ophthalmologists training in the state at our stellar training programs to consider joining existing practices or even to open their own practices rather than leaving the state. By making running a practice easier we might be able to further engage young ophthalmologists with their profession and the PAO. This might also lead to better options for retiring ophthalmologists to transition their practices to younger doctors. The PAO is working with the Pennsylvania Medical Society (PAMED) to see how ophthalmologists could fit in to their newly launched Care Centered Collaborative, a clinically integrated network (CIN). PAMED’s Care Centered Collaborative currently has contracts covering over 100,000 lives and has signed up over 150 physicians in its first round of membership. We all know ophthalmologists are critical to the success of yearly diabetic eye exams. Our question is whether it is feasible for ophthalmologists to participate in the CIN to enhance completion of Diabetic Eye exams and to develop a meaningful way for our members to participate in value-based contracting. We are exploring the development of a Pennsylvania Ophthalmology Job Bank, which could be used to list available positions in ophthalmology practices. Hopefully this would make it easier for practices to recruit ophthalmologists and optometrists to existing practices. The year 2020 is a once-in-a-lifetime opportunity to focus patients, the public, and the media on the importance of eye care. Over the next year, the Pennsylvania Academy of Ophthalmology (PAO) will work with the American Academy of Ophthalmology (AAO) on a yearlong public information campaign that puts ophthalmology front and center as the eye health authority. PAO plans to contact local media with news releases over the course of the year. We will need ophthalmologists willing to be quoted as we send news releases to local news outlets in your area. If you are interested in helping with any of these initiatives or have suggestions, please reach out to me at president@ paeyemds.org. Of course no PAO president’s address would be complete without commenting on legislative issues.

In October, PAO partnered with Temple University to promote and co-market their alumni conference. It benefited

Temple by bringing additional ophthalmologists to their conference with 70 ophthalmologists registering to attend. It allowed PAO a platform to discuss advocacy issues with residents, attending and practicing ophthalmologists. We next plan to co-market with the Pittsburgh Ophthalmology Society (POS) their spring meeting Friday March 25th and would like to duplicate this throughout the Commonwealth. Optometrists are continuing to push for expanded scope of practice and surgical privileges. Their bill last year passed the PA Senate, but we were able to hold it back in the House of Representatives. Optometry, however, is back, introducing SB 391. A companion bill will likely be introduced into the PA House soon. In turn we have introduced Senate Bill 853 to define ophthalmic surgery. Optometry has successfully pushed their agenda by forging relationships with legislators and obfuscation. Consider the implications of Optometric Surgery. Do we want our patients subjected to inadequately trained optometrists performing YAG capsulotomy, laser PI, cosmetic Botox injections, and a host of other surgical procedures, as well as expanding their scope into the diagnosis and treatment of systemic diseases? The answer is an emphatic no! House Bill 1342, introduced by Representative Rosemary Brown, would set standards and enhance vision screening in schools. The PAO strongly supports this initiative. Senator David Zimmerman recently proposed a bill in the PA Senate, backed by optometry, which would mandate Eye Health Exams for all children at set intervals in public schools. This is not supported by the PAO and is not consistent with American Academy of Pediatrics (AAP), AAO or AAPOS recommendations. The PAO has personally met with Senator Zimmerman to encourage him to introduce a companion senate bill to HB 1342, which we feel would be a far more constructive approach to prevent amblyopia and enhance vision in children. We need every Pennsylvania ophthalmologist to contact and meet his or her state legislators. Logic is on our side, but legislators have to hear from you, your administrators and colleagues face to face. Tyler Burke (tyler@millirongoodman.com) from Milliron Goodman, our lobbyists, can help you set up a meeting with your legislators and provide you taking points. We will have a local advocacy week in your districts in November. Tyler can help you set up an appointment with your legislators, PLEASE contact him. Finally, we need every ophthalmologist to make a meaningful contribution of $1000 or more to our PAC so we can be competitive with the optometry PAC that routinely outraises us by 2-3 fold. Over the next few years with your help, PAO would like to partner with you our members to make your lives easier and make your professional lives more rewarding. In turn we ask for your help. We are looking for members who wish to become more involved. Please let me know if you would be interested in working on a committee on legislative issues, practice management, education or on a young ophthalmologist (YO) committee. You can contact me at president@paeyemds.org

Coding Corner MEDICAREâ&#x20AC;&#x2122;S COMPREHENSIVE ERROR RATE TESTING (CERT)

By:Joy Newby, LPN, CPC | Newby Consulting,Inc. The information below can assist physicians in determining which services should be reviewed in a self-audit. The Centers for Medicare & Medicaid Services (CMS) calculates the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. Each year, CERT evaluates a statistically valid stratified random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules. The objective of the CERT program is to calculate the Medicare FFS program improper payment rate. The CERT program considers any payment that should not have been made or that was paid at an incorrect amount (including both overpayments and underpayments) to be an improper payment. It is important to note that the improper payment rate does not measure fraud. It estimates the payments that did not meet Medicare coverage, coding, and billing rules. The fiscal year (FY) 2018 Medicare FFS program improper payment rate is 8.12 percent, representing $31.62 billion in improper payments, compared to the FY 2017 improper payment rate of 9.51 percent or $36.21 billion in improper payments. The 2018 reporting period for this improper payment rate is July 1, 2016 -June 30, 2017. The error rate is the lowest since 2010. Part B providers improper payments were $10.5 billion for a 10.7% error rate. Part B errors represent 33.1% of the overall error rate. The CERT program notifies the MACs of improper payments identified through the CERT process. The MACs then repay underpayments and recoup overpayments.

Assignment of Error Categories

Medical review professionals review the claim and submitted documentation to decide whether the claim was paid or denied appropriately. These review professionals include nurses, medical doctors, and certified coders. Before reviewing documentation, the CERT program examines the CMS claims systems to check for (1) Medicare beneficiary eligibility, (2)

duplicate claims, and (3) Medicare as the primary insurer. When performing claim reviews, the CERT program checks for compliance with Medicare statutes and regulations, billing instructions, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and provisions in the CMS instructional manuals. The reason for the improper payment determines the error category for the claim. There are five major error categories.

No Documentation

Claims are placed into this category when the provider or supplier fails to respond to repeated requests for the medical records or when the provider or supplier responds that they do not have the requested documentation.

Insufficient Documentation

Claims are placed into this category when the medical documentation submitted is inadequate to support payment for the services billed. In other words, the CERT contractor reviewers could not conclude that the billed services were provided, were provided at the level billed, and/or were medically necessary. Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order or a form that is required to be completed in its entirety.

Medical Necessity

Claims are placed into this category when the CERT contractor reviewers receive adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage and payment policies.

Incorrect Coding

Claims are placed into this category when the provider or supplier submits medical documentation supporting (1) a different code than that billed, (2) that the service was performed by someone other than the billing provider or supplier, (3) that the billed service was unbundled, or (4) that a beneficiary was discharged to a site other than the one coded on a claim.

Other

Claims are placed into this category if there is an improper payment and it does not fit into any of the other categories (e.g., duplicate payment error, non-covered or unallowable service, ineligible Medicare beneficiary). Part B Excluding Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Medicare provides coverage for medically necessary services such as laboratory tests, physician services, ambulance services, and procedures under the Part B benefit. Medicare pays for these services only if the beneficiary’s medical record contains sufficient documentation of the patient’s medical condition to support the need for the services. In addition, all documentation requirements outlined in Medicare policies must be present for the claim to be paid.

Evaluation and Management Services

Evaluation and Management (E&M) services are visits and consultations by physicians and other qualified Non-Physician Practitioners (NPPs) to Medicare beneficiaries. The improper payment rate for E&M services was 14.3 percent, accounting for 10.9 percent of the overall Medicare FFS improper payment rate The type of service, place of service, patient’s status, content of the service, and the time required to provide the service determine the category of E&M service. The key components that determine the correct E&M service code are: • History (includes information such as the nature of presenting problem, past history, family history, social history, review of systems); • Physical examination; and • Medical decision making (includes such factors as the number of possible diagnoses and management options that must be considered; the amount and complexity of the medical records, diagnostic tests, and other information that must be obtained, reviewed, and analyzed; the risk of significant complications, morbidity, and mortality, the beneficiary’s comorbidities that are associated with the presenting problems; and the possible management options).

Incorrect coding and insufficient documentation caused most of the improper payments for E&M services. Often the physician submitted medical documentation that supported a different E&M code than the one billed. Many other claims were found to have insufficient documentation errors because the submitted records lacked a physician signature. For other claims, physicians provided services in settings other than their own offices and did not submit records maintained by hospitals or other facilities.

E&M: Office Visits – Established

Most improper payments for office visits with established patients were due to incorrect coding. The servicing provider specialties of Internal Medicine, Family Practice, and Cardiology comprise 48.9 percent of improper payments for office visits with established patients. Example A provider billed for Healthcare Common Procedure Coding System (HCPCS) code 99214 (office or other outpatient visit requiring two of three key components: detailed history, detailed examination, and medical decision making of a moderate complexity). The beneficiary was seen for a follow-up visit for chronic knee pain. There were no changes in medication or management and the beneficiary was asked to return for follow up in three months. The submitted documentation did not meet the requirements for 99214 but met the requirements for 99213. HCPCS 99213 requires two of three key components: expanded problem focused history, expanded problem focused examination and medical decision making of a low complexity. The CERT program downcoded the claim and scored it as an improper payment due to incorrect coding.

Examples of Projected Improper Payments and Type of Error by Type of Service, Each Claim Type Part B Services

Projected Improper Payments

Percentage of Service Type Improper Payments by Type of Error

Improper Payment Rate

No Doc Insufficient Medical Doc Necessity

Improper Coding

Other

Percent of Overall Improper Payments

Other drugs

$1,092,458,318

9.1%

0.0%

65.8%

0.00%

1.1%

33.2%

3.4%

Office visits established

$1,050,386,680

7.1%

5.7%

24.5%

2.0%

66.4%

1.5%

3.3%

Minor procedures – other (Medicare fee schedule)

$587,274,834

15.0%

1.9%

91.6%

2.4%

3.7%

0.4%

1.8%

Minor procedures musculoskeletal

$392,674,133

29.1%

0.0%

86.7%

13.3%

0.0%

1.2%

Office visits – new

$344,549,782

12.7%

0.0%

10.9%

0.0%

86.0%

3.1%

1.1%

Other tests – other

$246,371,070

13.4%

5.9%

91.1%

0.3%

2.7%

0.0%

0.8%

$111,630,382

6.6%

0.0%

96.8%

0.0%

0.1%

3.1%

0.3%

Eye procedure cataract removal/lens insertion

Top Root Causes of Insufficient Documentation Errors in Part B • Documentation to support medical necessity was not submitted. Missing/Inadequate

Mark your calendar for upcoming events:

• A valid provider’s order, or element of an order, was not submitted. Missing/Inadequate Orders • Valid provider’s intent to order (for certain services) was not submitted. Missing/Inadequate Orders • Documentation to support the services were provided or were provided as billed was not submitted. Inconsistent Records • Documentation of result of the diagnostic or laboratory test was not submitted. Missing/Inadequate Records • A signature log of medical personnel to support a clear identity of an illegible signature was not submitted or the provider’s written attestation of the unsigned or illegible signature was not submitted. Missing/Inadequate Records

Pennsylvania Academy of Ophthalmology

May 13, 14, 15

2020

PRSRTD STD U.S. POSTAGE PAID HARRISBURG PA PERMIT NO. 922

Pennsylvania Academy of Ophthalmology 777 East Park Drive PO Box 8820 Harrisburg, PA 17105-8820

2020 PAO Board of Directors President David Silbert, MD, FAAP President Elect Sharon L Taylor MD, FACS Immediate Past President Robert L Bergren MD Secretary/Treasurer Gautam Mishra MD Secretary, Legislation & Representation Kenneth P Cheng MD Chair, Bylaws Committee Michael J Azar MD Secretary, Membership Sonia Mehta MD

Co-Secretary, Medical Practice/ Payment Systems Scott M Goldstein MD Chair, Nominating Committee Drew J Stoken MD FACS

Emeritus, Bylaws & Rules Thomas B Souders MD

PAC Committee Mark C Maria MD

Emeritus, Secretary Legislation & Representation Joseph W Sassani MD MHA

AAO Councilor Robert L. Bergren, MD

Instruction/Education Committee Bozho Todorich MD PhD

AAO Councilor David I Silbert MD AAO Councilor Sharon L Taylor MD, FACS AAO Alternate Counselor Scott M Goldstein MD

Secretary, Public & Professional Information Robert Bergren, MD.

AAO Alternate Counselor Francis J Manning MD

Secretary, Public Health David I Silbert MD

Member-at-Large Edward H Bedrossian, Jr. MD FACS

Co-Secretary, Medical Practice/Payment Systems Joel D Brown MD

Member-at-Large Roger P Zelt MD FACS

Member-at-Large David S Pao MD

PAO NEW MEMBERS Victoria M Addis MD Christina M Lippe, MD Deepam Rusia, MD Nora Siegal, MD, Phd Yoshihiro Yonekawa, MD