Transcript Economics 101: An Overview of General Terminology and Concepts

Economics 101: An Overview of General
Terminology and Concepts
Katie Keysor
Director, Economics & Health Policy
Economics & Health Policy Department Staff
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Angela Kim, Senior Director
Pamela Kassing
Diane Hayek
Katie Keysor
Gloria Garcia
Stephanie Le
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Anita McGlothlin
Laura Pattie
Gloria Bland
Evelyn Gilbert
Rynzelle Spraggs
2 Vacant Positions
Cindy Moran, Assistant Executive Director
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ACR Commission on Economics
 Geraldine McGinty, MD, MBA, Chair
 Katie Keysor, Staff
 Pam Kassing, Staff
 19 Committees/Subcommittees
 4 Networks
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Committee
Staff
Chair(s)
Body Imaging Committee
Gloria Garcia
David Paushter
Breast Imaging Committee
Laura Pattie
Ellen Mendelson
Coding & Nomenclature Committee
Diane Hayek, Gloria Garcia, Laura Pattie
Daniel Picus (Chair)
Timothy Crummy (Vice Chair)
Economic Issues in Academic Radiology Committee
Pam Kassing
James V. Rawson
Future Trends Committee
Pam Kassing
David C. Levin
Frank J. Lexa (Co-Chair)
GSR Committee
Kathryn Keysor
Robert S. Pyatt
HOPPS/APC Committee
Pam Kassing
James V. Rawson
Interventional & Cardiovascular Radiology Committee
Gloria Garcia
Sean Tutton
Managed Care Committee
Kathryn Keysor
Mark O. Bernardy
Medical Physics Committee
Anita McGlothlin
Michael D. Mills
Neuroradiology Committee
Laura Pattie
Robert M. Barr
William Donovan (Co-Chair)
Nuclear Medicine Committee
Laurie Pattie
Gary Dillehay
Pediatric Radiology Committee
Anita McGlothlin
Richard M. Benator
Practice Expense Committee
Stephanie Le/Angela Kim
Ezequiel Silva
Radiation Oncology Committee
Anita McGlothlin
Louis Potters
Reimbursement Committee
Stephanie Le/Angela Kim
William Donovan
Ultrasound Committee
Stephanie Le
John S. Pellerito
Utilization Management Committee
Kathryn Keysor
Christopher Ullrich
Value Added Sub Committee
Stephanie Le/Angela Kim
Ezequiel Silva
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ACR Commission on Economics - Networks
 Carrier Advisory Committee (CAC) Network
 Radiology
 Robert Zeman, MD (Chair)
 Shawn Conwell, MD (Vice-Chair)
 Radiation Oncology
 Richard Hudes, MD
 Donald Schwartz, MD
 Managed Care Network
 Mark Bernardy, MD (Chair)
 Medicaid Network
 Raymond Tu, MD (Chair)
 Radiology Integrated Care (RIC) Network
 David Rosman, MD (Chair)
 Jack Farinhas, MD (Vice-Chair)
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Alphabet Soup
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ACO – Accountable Care Organization
ADIS – Advanced Diagnostic Imaging Services
APC – Ambulatory Payment Classification
CAC – Carrier Advisory Committee
CPT – Current Procedural Terminology
CERT – Comprehensive Error Rate Testing
CF – Conversion Factor
CMD – Contractor Medical Director
CMS – Centers for Medicare and Medicaid Services
More Alphabet Soup
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DOS – Date of Service
DRA – Deficit Reduction Act
EHR – Electronic Health Record
E/M – Evaluation and Management
GPCI – Geographic Practice Cost Index
HCPCS – Healthcare Common Procedural Coding System
HHS – Health and Human Services
HIT – Health Information Technology
HOPPS – Hospital Outpatient Prospective Payment System
IPAB – Independent Payment Advisory Board
…And More
ICD-9,10 – International Classification of Diseases
IDTF – Independent Diagnostic Testing Facility
LCD – Local Coverage Determination
MAC – Medicare Administrative Contractor
MCC – Managed Care Committee
MCN – Managed Care Network
MedCAC – Medicare Evidence Development and
Coverage Advisory Committee
 MedPAC – Medicare Payment Advisory Commission
 MFS – Medicare Fee Schedule
 MEI – Medicare Economic Index
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…And More Still
MPPR – Multiple Procedure Payment Reduction
NCD – National Coverage Determination
NCCI – National Correct Coding Initiative
NPI – National Provider Identifier
PC, -26 – Professional Component
POS – Place of Service
PPACA – Patient Protection and Affordable Care Act
of 2010
 PPIS – Physician Practice Information Survey
 PPS – Prospective Payment System
 PQRI – Physician Quality Reporting Initiative
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…Last one
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RAC – Recovery Audit Contractor
RBM – Radiology Business Management Company
RBMA – Radiology Business Management Association
RCCB – Radiology Coding Certification Board
RVU – Relative Value Unit
RUC – Relative Value Update Committee
SGR – Sustainable Growth Rate
TC – Technical Component
And many others…
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Economics: From New Technology to Coverage
New
Technology
(published
evidence)
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CPT Code
Code
Valuation
Coverage
CPT Coding Background
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CPT = Current Procedural Terminology
“Codes”
Number assigned to services provided to patients
Evolve over time (new, revised, eliminated)
Developed, owned, and copyrighted by AMA
CPT Editorial Panel (17 members)
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Blue Cross and Blue Shield Association (1)
American Hospital Association (1)
American’s Health Insurance Plans (1)
Centers for Medicare and Medicaid Services (1)
Health Care Professionals Advisory Committee (2)
Physicians (11)
 Appointed by AMA Board of Trustees
 Radiology is NOT guaranteed a seat!
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Source: Duszak, “The CPT Process and How It Influences Our Economic Future”
Types of CPT Codes
 Category III
 “Emerging Technology”
 Intended to be used for data collection to substantiate
widespread use
 Category I – high evidence threshold
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Distinct service/procedure
FDA approved
Widely performed (in USA)
Substantial US peer reviewed literature
How to Choose a CPT Code
 Pre- 2001 CPT Instructions:
 Select the code that most accurately identifies the
service performed
 2002 CPT Instructions:
 Select the code that accurately identifies the service
performed
 Do not select a code that merely approximates the
service provided
 If no accurate code exists, then use an unlisted code
Once FDA approved, and modest clinical
trial data exists…
 Level III CPT code is likely to be approved…
 Once there’s level III code, Medicare Administrative
Contractors (MACs) may choose to develop local coverage
determinations (LCDs) and private payers may offer some
limited coverage
 This may precede CMS consideration of whether or not a
national policy is needed
 Example: coronary CTA, diagnostic CTC
 Level III codes are valued locally
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ACR Coding Products
ACR Coding Guides
Ultrasound (2013)
Nuclear Medicine (2013)
Radiation Oncology (ASTRO/ACR - 2013)
Interventional Radiology Update (SIR/ACR - 2013)
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ACR Coding Products
 Newsletters:
 ACR Radiology Coding SourceTM
 Bimonthly electronic newsletter on coding &
reimbursement
 Feature article
 Medicare and third party payer issues
 Q&A
 CEUs available toward RCCB certification
ACR Coding Products
Clinical Examples in Radiology
 AMA-ACR Coding Publication (2005)
 Published quarterly
 Real dictations with expert analysis
 Documentation challenge
 Test case
 Q&A
 Semi-annual bulletin articles to address timely topics
R
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Resource
Based
Relative
Value
Scale
American Medical Association
Specialty Society
R
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C
Relative Update Committee
Value Scale
Total RVU
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Work (PC)
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Practice Expense (TC)
ACR
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RUC
CMS
Refinement
Panel
CMS
FINAL
Medicare Physician Fee Schedule (MFS)
 How radiologists get paid for their work and
practice expense for their offices
Medicare Physician Fee Schedule
 Proposed Rule published in late June/early July
 Final Rule published in late October/early November
 Monitor the impacts of adjustments to the MFS for
increases and decreases in physician work, practice
expense and malpractice RVUs
 Other CMS payment policy decisions (e.g. MPPR,
interest rate, utilization rate, etc.)
 Analyze these effects and write formal comments to
CMS on areas of concern
Multiple Procedure Payment Reduction
 No credible data justifies these proposals
 Permanently devalues Radiology relative to
other physician services
 2013 CMS rule: 25% PC MPPR reduction across
group practices
 $100 Mil savings – redistributed to others
 Independent of any other “adjustments”
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Hospital Outpatient Prospective Payment
System (HOPPS)
 HOPPS mandated by Balanced Budget Act (BBA) of 1997
 April 7, 2000 CMS issued final rule on HOPPS
 HOPPS went into effect August 2000
 Previously Medicare paid for services performed in
hospital in a variety of methodologies based on
reasonable costs
Prospective Payment System
 Less granular than Medicare Physician Fee Schedule
 Belief that prospective payments incent efficiency
 Other examples: DRG payments to hospitals for
inpatient admission
 Payments calculated annually based on hospital charges
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Ambulatory Payment Classifications
 Service divided into ambulatory payment classifications
(APC)
 Each APC encompasses services that are clinically
similar and require similar resources
 All services within an APC are generally paid at same
prospectively-fixed rate.
 Payment determined by hospital charges submitted to
CMS
2 Times Rule
CMS considers the items and services within a
group as NOT comparable if the highest median
cost for an item or service within a group is more
than two times greater than the lowest median
cost
Proactive Work with CMS
 Work with The Moran Company to analyze new bundled
CPT codes based on predecessor codes
 Meet with CMS staff in person to provide
recommendations prior to publication of Final Rule
 CMS is appreciative of the information and generally
accepts recommendations
CMS COVERAGE
DECISION
LCD
(CAC)
NCD
What is a MAC?
Medicare Administrative Contractor
15 Jurisdictions
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Local Coverage Determination (LCD)
 Most Medicare coverage decisions are made at the local
level through LCDs
 No LCD does not mean there is no coverage
 MACs are required to post draft coverage policies for
comment and hold Carrier Advisory Committee (CAC)
meetings to discuss the policies
 ACR CAC Networks
 Screening coverage must be through a National
Coverage Determination
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National Coverage Determination - NCD
“reasonable and necessary for the diagnosis or treatment of an illness or injury
within the scope of a Medicare benefit. “NCD’s are made through evidencebased process… with public participation. In some cases CMS’ own research is
supplemented with an outside technology assessment and/or consultation with
MEDCAC” (eg internal decision cardiac flow add-on code for cardiac MRI)
MedCAC
Provide independent, expert guidance…
“Up to 100 experts in clinical and
administrative medicine, biological and
physical sciences, public health
administration, patient advocacy, health care
data management and information analysis,
health care economics,and medical ethics…”
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US Preventive Services Task Force
“...independent panel of private sector experts in prevention and primary
care…conducts rigorous impartial assessments of the scientific evidence…
for effectiveness of screening, counseling, and preventative medications”
Private Payer Coverage – Influences
 Medicare
 Often, Medicare coverage or non-coverage equals private payer
coverage or non-coverage, but not always
 Blue Cross Blue Shield Association Technology Evaluation Center
(TEC)
 United States Preventative Services Task Force (USPSTF)
 Increasing influence on Medicare coverage decisions
 Some payers now cite the USPSTF in their coverage decisions
 Radiology Benefits Management Companies (RBMs)
 Most say that they use ACR Practice Guidelines and
Appropriateness Criteria, but do not have transparent processes
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Blue Cross Blue Shield Association Technology
Evaluation Center (TEC)
 The TEC uses five criteria to evaluate new technologies
 The technology must have final approval from the
appropriate governmental regulatory bodies.
 The scientific evidence must permit conclusions concerning
the effect of the technology on health outcomes.
 The technology must improve the net health outcome.
 The technology must be as beneficial as any established
alternatives.
 The improvement must be attainable outside the
investigational settings.
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Private Payer Decisions
 Little to no transparency
 Not required to publish draft policies for public comment
 Relationships are key!
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ACR Networks
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CAC
Managed Care
Medicaid
Radiology Integrated Care (RIC)
General, Small, and Rural Practices
The Networks are the eyes and ears of the ACR!
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James Moorefield Economics Fellowship
 Two week program
 Learn about activities of the College, and specifically
about economics.
 Provide clinical feedback on various projects
 Two interns per year
 Applications accepted February-April
QUESTIONS???
[email protected]