Transcript AES 2010 Practice Management Course December 7, 2010

AES 2010
Practice Management Course
December 7, 2010
Gregory L. Barkley, M.D.
Comprehensive Epilepsy Program
Henry Ford Hospital
Detroit, MI
Associate Professor of Neurology
Wayne State University
Outline

Consultation Codes

2011 Medicare Conversion Factor and SGR

October 2010 ICD-9 coding changes of interest

2011 CPT Codes

PQRI update

Gearing up for ICD-10 on October 1, 2013
Miscellaneous: Please note, I have removed the cell slice images
from this set to keep the file size smaller. Images are at:
http://www.nytimes.com/slideshow/2010/11/29/science/20101130-brain-1.html
Deadline extended until Dec 10.
We specifically need
members from:
Alaska, Arizona, Arkansas
Colorado, Connecticut
Delaware, Kansas
Kentucky, Maine
Mississippi, Nebraska
Nevada, North Dakota
Rhode Island, South Carolina
South Dakota, West Virginia
Melissa Larson
Manager, Advocacy Development
AAN Professional Association
Ph: 651.695.2748
FAX: 651.361.4848
[email protected]
www.aan.com\advocacy
Consultation Codes Are Gone Forever
•
CMS stopped paying for consultations, 9924x and 9925x
–
In 2007, > 28 million claims
–
Money from Consultation codes redistributed to other
physician codes to maintain budget neutrality
•
Other payers stopped paying for consults during 2010
•
An attempt this year by AAN and other societies to get
reconsideration of consult codes was rejected
•
CMS commented: "in most cases there is no substantial
difference in physician work between E/M visits and services
that would otherwise be reported with CPT consultation
codes."
Coding an outpatient New Patient visit
(3/3 or Hx, PE, and MDM)
History
Exam
Decision
Time
Code
elements making (minutes)
HPI 1-3 facts
1-5
Straightforward
10
99201
HPI 1-3 facts
ROS 1 fact
6
Straightforward
20
99202
HPI 4 facts
ROS 2, PSFH 1
12
low
30
99203
HPI 4 facts,
ROS 10, PSFH 3
25
moderate
45
99204
Coding an outpatient Established
Patient visit (2/3 MDM + Hx or PE)
History
Exam
elements
Decision
making
Time
(minutes)
Code
-
-
Minimal or
none
5
99211
HPI 1-3 facts
1-5
Straightforward
10
99212
HPI 1-3 facts
ROS 1
6
low
15
99213
HPI 4 facts,
ROS 2, PSFH 1
12
moderate
25
99214
HPI 4 facts,
ROS 10, PSFH 3
25
high
40
99215
9922x Coding an inpatient Initial
Care Day (3/3)
History (CC
always needed)
Exam
elements
Decision
making
Time
(minutes)
Code
(wRVU)
HPI 4 facts,
1 PFSH,
2-9 ROS
12 Neuro
SSE or
5-7 systems
Straight-forward or
low
30
99221
(1.89)
HPI 4 facts,
3 PFSH,
10 ROS
Full Neuro
SSE (25) or
8 Systems
Moderate
(2 Chronic with 1
exacerbation)
50
99222
(2.57)
HPI 4 facts,
Full Neuro
High
70
99223
9923x Coding an inpatient
Subsequent Day Care (2/3)
History
Exam
elements
Decision
making
Time
(minutes)
Code
(wRVU)
HPI 1-3 facts
1-5
straight-forward or
low
15
99231
(0.76)
HPI 1-3 facts
ROS 1 fact
6
moderate
25
99232
(1.39)
HPI 4 facts
ROS 2 facts
12
high
35
99233
(2.00)
Counseling and Coordination of Care
Counseling is a discussion with patient or family about diagnoses,
test results, recommended tests, prognosis, treatment
alternatives, compliance, risk factor reduction, and patient and
family education.
Coordination of care is arranging for care with other health care
providers. This includes any type of such activity.
Counseling and Coordination of Care
•
•
•
•
This can be used in place of the above HX-PE-MDM.
It uses time to set LOS
The documentation should state:
–
Minutes spent face-to-face
–
That more than 50% of time was counseling and/or coordinating
care,
–
Give some general idea of what counsel/coord. care.
Time is:
–
Face-to-face with patient (outpatient)
–
•
At bedside and on unit/floor (inpatient).
No history or exam elements are needed except, of course, for real patient
care purposes!
Emergency Room Care
•
•
•
•
•
Most ER services provided by neurologists and neurosurgeons are
as “consultants”
Use Established Patient (99211-99215) codes for Medicare
patients seen by anyone in your group in the past three years
Otherwise use Outpatient New Patient (99201-99205) codes
If the patient is admitted to the hospital, then use the initial hospital
day codes (99221-99223)
Critical Care services provided in ER, e.g. tPA or status epilepticus
management:
–
Use Critical Care codes 99291 - 99292
Critical Care
•
•
•
99291 first hour of critical care (31-74 minutes)
99292 each additional 30 minutes
Coded by time for bedside and unit physician work for an unstable, critically ill
patient
–
Not for consultant's time
–
Need not be continuous in any location
•
Generally cannot bill other E/M on same day.
•
Exceptions are if an E & M is performed at one time, then a crisis occurs and
critical services are performed.
•
Make sure you document times carefully so you do not appear to be combining
times of routine care with critical care times or procedure times.
•
Not every day in the ICU is critical care!!!
–
Patients awaiting transfer to GPU are not critically ill
•
Critical care can be provided anywhere including in the clinic
•
You must document time spent and what you did in your note
A Very Short Primer on American
Health Care Financing:
$2.5 trillion spent on health care in 2009. Private insurance covered
59% of Americans. Government programs paid for 53% of direct
health care costs and 62% if tax exemptions counted. More than 50
million Americans without health care coverage.
Private insurance policies
- Largely paid for by
employers
- Usually small, but
increasing, out-of-pocket
costs borne by individuals
- Thousands of companies
offering tens of thousands of
individual policies
- Range minimal coverage
for catastrophic illness to
full coverage
Medicare Trust Fund
- Elderly and those qualifying for
Medicare disability
-For outpatient care, covers 80% of
professional fee schedule for visits
and procedures + APC for technical
charges
- In 2006 outpatient medications
were covered
- For inpatient care, covers 80% of
fee schedule for professional costs +
DRG for technical costs
- Covers 55% of psychiatric care
charges (Chapter 5 of ICD-9)
In 2007, U.S per capita health care spending was
$7,290, 2.5 times the OECD average and 16% of
GDP
U.S. government alone already pays more than total costs in nearly all
other countries
Health Care Spending is 16% of GDP
To Control US Debt

Only options are to:

Cut Medicare spending


2010 Accountable Care Act reduces Medicare
spending by $350 Billion over 10 years

Cut Defense spending

Cut Social Security spending

Raise taxes
Reality is that all of the above are necessary
Social Security
P. Krugman, NYTimes 12/06/2010
2011 Medicare Proposed Conversion
Rate issued 11/02/2010, 2023 pages

In the final rule, the Medicare Conversion Factor will be $25.5217
starting 01/01/2011
–
30% drop compared to 2010 to meet SGR law
–

Conversion factor law override from 06/01/2010 until 11/30/2010
was $36.8729
–


Comment period is open until January 3, 2011
A 2.2% increase from 2009 and averted a 21.5% cut
Legislation proposals in Congress to override remain contentious at
this time
–
On 11/18/2010, Senate passed a one month extension of
current pay scale
–
House passed same bill on 11/30/2010
Rescaling of RVU weights (-8.2%) and (+0.5%) budget neutrality
change due to RVU changes mandated by law, so CF likely to be
$34.00 if Congress overrides
2011 Medicare Conversion Rate
12/06/2010, 8:17 PM
To: [email protected]
From: [email protected]
Re: SGR Agreement
Dear MEM Members:
The Senate Finance committee just announced a one year delay of the
SGR cuts. The deal will be fully paid for. Details to come.
Michael J. Amery, Esq.
Legislative Counsel
American Academy of Neurology
202-506-7468
SGR Annual Override..
• Does not fixed flawed formula and increases the
decrease needed the next year, currently $210-279 B
$210-279 B
AMA
2011 ICD-9 Code Changes

On October 1 of each year, the ICD-9 code changes occur

There are new codes as well as new index terms.
–


Index terms can be used by coders to map to a specific code
New index terms for epilepsy I presented at the ICD Coding and
Maintenance Committee Meeting on 9/25/2008, my presentation is at:
http://www.cdc.gov/nchs/icd/icd9cm_maintenance.htm
Epilepsy, epileptic (idiopathic) 345.9
Note: use the following fifth-digit subclassifications with categories 345.0,
345.1, 345.4-345.9
0
1
without mention of intractable epilepsy
with intractable epilepsy
pharmacoresistant (pharmacologically resistant)
poorly controlled
refractory (medically)
treatment resistant
2011 ICD-9 Code Changes

345 Epilepsy and recurrent seizures


780 General symptoms


Delete Excludes: progressive myoclonic epilepsy (333.2)
780.3 Convulsions
New code 780.33 Post traumatic seizures

Excludes: post traumatic epilepsy (345.00-345.91)
2011 ICD-9 Code Changes

225 Benign neoplasm of brain and other parts of nervous system


Revise Excludes: neurofibromatosis (237.70-237.79)
237 Neoplasm of uncertain behavior of endocrine glands and nervous
system

237.7 Neurofibromatosis

Delete von Recklinghausen's disease

New code 237.73 Schwannomatosis

New code 237.79 Other neurofibromatosis
2011 ICD-9 Code Changes
Codes in Red are in Chapter 5, reimbursed at 55% vs. 80%

278.0 Overweight and obesity

New code 278.03 Obesity hypoventilation syndrome


Pickwickian syndrome
307 Special symptoms or syndromes, not elsewhere classified

Revise 307.0 Stuttering Adult onset fluency disorder

Add Excludes: childhood onset fluency disorder (315.35)


Revise stuttering (fluency disorder) due to late effect of
cerebrovascular accident (438.14)
Add fluency disorder in conditions classified elsewhere (784.52)
2011 ICD-9 Code Changes
Codes in Red are in Chapter 5, reimbursed at 55% vs. 80%

315 Specific delays in development

315.3 Developmental speech or language disorder

New code 315.35 Childhood onset fluency disorder


Cluttering NOS

Stuttering NOS
Excludes: adult onset fluency disorder (307.0)



fluency disorder due to late effect of cerebrovascular
accident (438.14)
fluency disorder in conditions classified elsewhere (784.52)
315.39 Other

Delete Excludes: stammering and stuttering (307.0)
2011 ICD-9 Code Changes

337 Disorders of the autonomic nervous system



Revise Use additional code to identify the cause, such as: fecal
impaction (560.32)
488 Influenza due to certain identified influenza viruses


337.3 Autonomic dysreflexia
488.0 Influenza due to identified avian influenza virus
New code 488.09 Influenza due to identified avian influenza virus with other
manifestations

Avian influenza with involvement of gastrointestinal tract

Encephalopathy due to identified avian influenza

Excludes: "intestinal flu" [viral gastroenteritis] (008.8)
2011 ICD-9 Code Changes

488.1 Influenza due to identified novel H1N1 influenza virus



New code 488.19 Influenza due to identified novel H1N1 influenza
virus with other manifestations

Novel H1N1 influenza with involvement of gastrointestinal tract

Encephalopathy due to identified novel H1N1 influenza

Excludes: "intestinal flu" [viral gastroenteritis] (008.8)
721 Spondylosis and allied disorders

721.4 Thoracic or lumbar spondylosis with myelopathy

721.42 Lumbar region
Delete Spondylogenic compression of lumbar spinal cord
2011 ICD-9 Code Changes

724 Other and unspecified disorders of back

724.0 Spinal stenosis, other than cervical

Revise 724.02 Lumbar region, without neurogenic claudication

Add Lumbar region NOS

New code 724.03 Lumbar region, with neurogenic claudication

742 Other congenital anomalies of nervous system


742.8 Other specified anomalies of nervous system
Revise Excludes: neurofibromatosis (237.70-237.79)
2011 ICD-9 Code Changes

781 Symptoms involving nervous and musculoskeletal systems

Revise 781.8 Neurologic neglect syndrome

Add Excludes: visuospatial deficit (799.53)


New code V13.63 Personal history of (corrected) congenital malformations
of nervous system
V49 Other conditions influencing health status


V49.8 Other specified conditions influencing health status
New code V49.86 Do not resuscitate status
2011 ICD-9 Code Changes

784 Symptoms involving head and neck

784.5 Other speech disturbance

Revise Excludes: stammering and stuttering (315.35)

Delete that of nonorganic origin (307.0, 307.9)

New code 784.52 Fluency disorder in conditions classified elsewhere

Stuttering in conditions classified elsewhere

Code first underlying disease or condition, such as:

Parkinson’s disease (332.0)

Excludes: adult onset fluency disorder (307.0)

childhood onset fluency disorder (315.35)

fluency disorder due to late effect of cerebrovascular accident
(438.14)
2011 ICD-9 Code Changes

799 Other ill-defined and unknown causes of morbidity and mortality
New Subcategory 799.5 Signs and symptoms involving cognition

Excludes: amnesia (780.93)

amnestic syndrome (294.0)

attention deficit disorder (314.00-314.01)

late effects of cerebrovascular disease (438)

memory loss (780.93)

mild cognitive impairment, so stated (331.83)

specific problems in developmental delay (315.00-315.9)

transient global amnesia (437.7)

visuospatial neglect 781.8
2011 ICD-9 Code Changes

799 Other ill-defined and unknown causes of morbidity and mortality

New code 799.51 Attention or concentration deficit

New code 799.52 Cognitive communication deficit

New code 799.53 Visuospatial deficit

New code 799.54 Psychomotor deficit

New code 799.55 Frontal lobe and executive function deficit

New code 799.59 Other signs and symptoms involving cognition
2011 ICD-9 Code Changes

992 Effects of heat and light


992.0 Heat stroke and sunstroke
Add Use additional code(s) to identify any associated complication of heat
stroke, such as:

Add alterations of consciousness (780.01-780.09)

Add systemic inflammatory response syndrome (995.93-995.94)
2011 Practice Expense (PE)
Changes
•
Second year of 4 year transition on PE methodology
–
CMS is using results of 2009 AMA Physician Practice
Information Survey
•
•
–
www.ama-assn.org/go/ppisurvey
Neurology $73 PE/hr, $127.21Total PE/hr; Overall
increase 3%
• Neurosurgery $81 PE/hr, $132.52 Total PE/hr;
Overall increase 2%
Assume that imaging equipment such as CT and MRI
are used 90% of the time instead of current 50%
–
Other equipment remains at 50% usage for now
–
Work defined as 150,000 minutes/year (48 hour work
week)
2011 MFS for Neurology Services*
*RVUs, excluding the conversion factor
• 95812, EEG 41-60 minutes
–
Total RVUs: 9.31, +28%
–
Practice Expense: 8.16, 33%
–
Professional: 1.60, +8%
–
Physician Work (wRVU): 1.08, No change
• 95813, EEG > 1 hour
–
Total RVUs: 10.48, +21%
–
Practice Expense: 8.64, 26%
–
Professional: 2.54, +7%
–
Physician Work (wRVU): 1.73, No change
2011 MFS for Neurology Services*
*RVUs, excluding the conversion factor
• 95816, Awake EEG
–
Total RVUs: 8.39, +26%
–
Practice Expense: 7.22, 31%
–
Professional: 1.60, +8%
–
Physician Work (wRVU): 1.08, No change
• 95819, Awake and Asleep EEG
–
Total RVUs: 9.62, +32%
–
Practice Expense: 8.47, 38%
–
Professional: 2.54, +7%
–
Physician Work (wRVU): 1.73, No change
2011 MFS for Neurology Services*
*RVUs, excluding the conversion factor
• 95822, Sleep EEG
–
Total RVUs: 7.84, +33%
–
Practice Expense: 7.22, +31%
–
Professional: 1.60, +8%
–
Physician Work (wRVU): 1.08, No change
• 95824, EEG for Brain Death
–
Total RVUs: 0.00, No change
–
Practice Expense: 0.00, N/A
–
Professional: 1.12, +8%
–
Physician Work (wRVU): 0.74, No change
2011 MFS for Neurology Services*
*RVUs, excluding the conversion factor
• 95827, Overnight EEG
–
Total RVUs: 16.52, +33%
–
Practice Expense: 15.31, +36%
–
Professional: 1.60, +8%
–
Physician Work (wRVU): 1.08, No change
• 95829, Surgery Electrocorticogram
–
Total RVUs: 44.12 +20%
–
Practice Expense: 37.71, +29%
–
Professional: 9.11, +8%
–
Physician Work (wRVU): 6.20, No change
2011 MFS for Neurology Services*
*RVUs, excluding the conversion factor
• 95950, Ambulatory Cassette EEG
– Total RVUs: 7.99, +18%
–
Practice Expense: 6.38, +22%
–
Professional: 2.25, +9%
–
Physician Work (wRVU): 1.51, No change
• 95951, 24 Hour Video EEG
– Total RVUs: 0.00, *Carrier-defined technical expense
–
Practice Expense: *Carrier-defined technical expense
–
Professional: 9.14, +8%
–
Physician Work (wRVU): 5.99, No change
2011 MFS for Neurology Services*
*RVUs, excluding the conversion factor
Codes presented at RUC 04/2010 by M. Spanaki
• 95953, 24 hour computerized digital EEG, unattended
– Total RVUs: 12.19, +6%
–
Practice Expense: 7.56, +8.78%
–
Professional: 4.63, 1.76%
–
Physician Work (wRVU): 3.08
• 95956, 24 Hour attended EEG without video
– Total RVUs: 29.82, 49.92%
–
Practice Expense: 24.6, 57.19%
–
Professional: 5.22, +23.11%
–
Physician Work (wRVU): 3.61
2011 MFS for Neurology Services*
*RVUs, excluding the conversion factor
• 95954, EEG with administration of drugs
– Total RVUs: 9.15, +26.56%
–
Practice Expense: 5.8 RVUs, +41.12%
–
Professional: 3.35 RVUs, 7.37%
–
Physician Work (wRVU): 2.45
• 95955, EEG during surgery
– Total RVUs: 4.96, 25.89%
–
Practice Expense: 3.48, 35.41%
–
Professional: 1.48, 8.03%
–
Physician Work (wRVU): 1.01
2011 MFS for Neurology Services*
*RVUs, excluding the conversion factor
• 95957, EEG Digital Analysis
– Total RVUs: 10.01, +27.68%
–
Practice Expense: 7.05 RVUs, +41.12%
–
Professional: 2.96 RVUs, 8.03%
–
Physician Work (wRVU): 1.98
• 95958, EEG monitoring, functional mapping (Wada Test)
– Total RVUs: 13.39, 20.20%
–
Practice Expense: 7.08, 34.35%
–
Professional: 1.48, 8.03%
–
Physician Work (wRVU): 4.24
2011 MFS for Neurology Services*
*RVUs, excluding the conversion factor
• 95961, Electrode stimulation, brain, first hour
– Total RVUs: 7.41, +16.88%
–
Practice Expense: 2.93 RVUs, +33.79%
–
Professional: 4.48 RVUs, +7.95%
–
Physician Work (wRVU): 2.97
• 95962, Electrode stimulation, brain, each additional hour
– Total RVUs: 6.67, +14.21%
–
Practice Expense: 1.8, +33.33%
–
Professional: 4.79, +8.13%
–
Physician Work (wRVU): 3.21
2011 MFS for Neurology Services*
*RVUs, excluding the conversion factor
• 95970, Analyze neurostimulator, no programming
– Physician Work (wRVU): 0.45
• 95975, Cranial neurostimulation, complex analysis and programming
– Physician Work (wRVU): 1.70

2009 AAN MEG Payment
Policy
In 2008, AAN MEM Payment Policy Subcommittee decided to
develop a model payment policy for MEG due to difficulties in getting
MEG payments by insurers
– Saty Satya-Murti, William Sutherling, and Gregory L. Barkley
wrote the policy
– Joel Kaufman, M.D. & Katie Kuechenmeister lead AAN efforts
– Passed by AAN Board of Directors on May 8, 2009
– Sent by AAN MEM to major insurance companies
– http://www.aan.com/globals/axon/assets/5641.pdf

ACMEGS developed a similar policy in 2009
– Anto Bagic, Michael Funke, & John Ebersole wrote the policy
– JClinNeurophys 26 (4) p290-293, 2009

Model payment policy, letters, & meetings changed insurance
coverage by major providers
Secrets to success in dealing
with insurance companies

Data, data, data, especially evidence-based

The AAN & ACMEGS statements are referenced in the
MEG policy review.

I am certain that the AAN MEG policy review was a crucial
piece of information in this change in policy
– Several of the points in the AAN payment policy
statement are restated in the AETNA review

Personal Contacts and establishing relationships with the
decision-makers were also key factors
CIGNA MEG Payment Policy #0248
For 12/15/2009 to 12/15/2010, “CIGNA does not cover
magnetoencephalography (MEG) or magnetic source
imaging (MSI) for any condition because they are
considered experimental, investigational or unproven.”
The AAN MEM Payment Policy Subcommittee
(PPS) met with CIGNA representatives in
September 2010
 CIGNA requested a letter regarding their policies
 AAN Response letter sent November 12, 2010 by
Joel Kaufman, Chair of AAN PPS
 CIGNA has not yet posted MEG policy for 2011

2011 Medicare MEG Medicare Fee Schedule

95965 Spontaneous MEG for epileptic spike mapping
– 2011 Professional 12.34 Total RVUs (7.99 wRVUs)
• 2010 11.83 Total RVUs (+8.0%) Payment ?
– 2011 Technical (APC 067) $3408.69 (-4.6 %)

95966 Evoked magnetic fields
– 2011 Professional 6.16 Total RVUs (3.99 wRVUs)
2010 5.72 Total RVUs (+8,0 %) Payment ?
– Technical (APC 066) $977.12
• 2010 $962.61 (+1.5 %)

95967 Each additional evoked magnetic field procedure
– 2011 Professional 5.34 Total RVUs (3.49 wRVUs)
• 2010 4.92 Total RVUs (+9.0 %) Payment ?
– Technical (APC 066) $977.12
• 2010 $962.61 (+1.5 %)
* When one procedure is performed with another, payment would be
reduced by 50%
* Charges to private insurance are set by each laboratory and cannot
be compared due to US antitrust (price-fixing) laws
MEG Practice Expense
Payment Rate
 The
Affordable Care Act (ACA) requires that
CMS establish the equipment utilization rate
for CT, MR and PET at 75 percent. CMS had
previously set the equipment utilization rate for
this equipment at 90 percent, phasing in
reduced payments over four years. This may
result in changes to payment rates for CT and
MR services.
 May affect MEG technical pricing since MEG
grouped in imaging APCs
2010 e-Prescribing
•
PQRI revision for e-Rx
–
For 2011, only have to report at least 25 uses of
e-Rx to qualify for PQRI payment
–
Failure to register for e-Rx in first half of 2011
and do not qualify for an exemption will face
penalties in 2012.
–
AAN has signed on to a letter of protest
–
Physicians who participate in 2011 EHR cannot
participate in e-Rx incentive program
PQRI
(Physician Quality Reporting Initiative)
http://www.cms.hhs.gov/apps/media/press/factsheet.asp?
•
AAN has developed 8 epilepsy measures lead by N. Fountain
and P Van Ness
–
Approved by AMA Physician's Consortium for
Performance Improvement
–
Currently under review by National Quality Forum
(NQF)
–
If NQF approves, then will be submitted to CMS for
possible inclusion in the PQRI
–
Being developed by AAN for Maintenance of
Certification program as a module
CPT Medicare Payment Relative to Site
of Services
Professional Component
Technical Component
Inpatient
Use -26 modifier;
Paid to physician
Single DRG payment
made to hospital to cover
all technical expenses
for that admission (IPPS)
Outpatient medical center
(includes EDs)
Use -26 modifier;
Paid to physician
APC payment made to
medical center (HOPPS)
Outpatient, private office
Global bill
Submitted for professional
and technical components
Global bill
Submitted for
professional and
technical components
Paid to physician
Paid to physician
Mapping of Seizure/Epilepsy DRG
Documentation
Seizure, psychogenic
nonepileptic seizure,
spells
Recurrent seizures,
Epilepsy, Seizure
disorder
Specific epilepsies
Psychogenic
conversion disorder
Principle
Diagnosis
Secondary
Diagnosis
MS DRG
v25
780.39
(other
101 Sz w MCC
100 Sz w/o MCC
345.8y
101 Sz w MCC
100 Sz w/o MCC
convulsions)
(other
recurrent seizures)
345.xy
300.11
(Conversion
disorder)
780.39
880
Acute
Adjustment Reaction
2011 Hospital Outpatient Prospective
Payment System (HOPPS)

Published 11/24/2010
–
782 pages in the Federal Register
–
http://edocket.access.gpo.gov/2010/pdf/2010-27926.pdf

Payment for the technical portion of CPT codes done on Medicare
Outpatients

Some outpatient procedures with HOPPS values have no payment
assigned in MFS for doctors billing global
–
95951 24 hour video EEG is “carrier priced”
–
95965 MEG is “carrier priced”

Payment for technical portion of Medicare inpatients is bundled into a
single DRG payment

Payment for technical fees in outpatients in private offices is in the
Medicare Physician Fee Schedule
•
Billing “global” in private offices
2011 HOPPS APC 0213
•
APC 0213 Level 1 Sleep, EEG, and CV studies
–
95812 EEG 41-60 min
–
95812 EEG > 1 hour
–
95816 EEG awake and drowsy
–
95819 EEG awake and asleep
–
96822 EEG sleep and/or coma
–
95827 EEG all night recording
–
95958 EEG monitoring/function test
•
2010 APC rate is $162.06
•
2011 APC rate will be $166.64
•
Increase of $4.62 or 2.83%
2011 HOPPS APC 0209
•
APC 0209 Level II sleep, EEG, & CV
–
95950 ambulatory cassette EEG
–
95951 24 hour video EEG
–
95953 ambulatory digital EEG
–
95956 24 hour EEG without video
–
MSLP and polysomnograms
•
2010 APC Rate is $770.55
•
2011 APC Rate will be $780.77
•
Increase of $10.22 or 1.33%
2011 HOPPS APC 218
•
APC 218 Level II Nerve and Muscle Tests
–
95970 Neurostimulation, analysis with no
programming
–
95954 EEG monitoring with drug administration
•
2010 payment is $80.65
•
2011 payment will be $80.78
•
Increase of $0.13 or 0.16%
2011 HOPPS APC 216
•
APC 216 Level III Nerve and Muscle Tests
–
95961 Cortical Stimulation, 1st hour
–
95962 Cortical Stimulation, each additional hour
•
2010 payment is $180.86
•
2011 payment will be $186.17
•
Increase of $5.31 or 2.94%
2011 HOPPS APC 0692
•
APC 0692 Level III Electronic Analysis of Devices
–
95971 Analyze neurostim, simple
–
95972 Analyze neurostim, complex
–
95973 Analyze neurostim, complex
–
95974 Cranial neurostim, complex
–
95974 Cranial neurostim, complex
–
95978 Analyze neurostim brain, 1st hour
–
95979 Analyze neurostim brain, each 1 hour
–
95982 Low gain neurostim subseq w/ reprogram
•
2010 payment is $107.85
•
2011 payment will be $110.95
•
Increase of $3.10 or 2.87%
2011 MEG HOPPs

Technical payments for MEG studies in hospitalbased outpatient care facilities
– Does not apply to free standing MEG sites
• Carrier priced
– Does not apply to MEG studies done on inpatients
• Technical fees bundled to DRG
2010 HOPPS APC 0067
•
APC 0065 Level III Stereotactic Radiosurgery, MRgFUS, and
MEG
–
95965 MEG, spontaneous
•
2010 payment is $3571.78
•
2011 payment is $3408.69
•
Decrease of $163.09 or 4.57%
•
Caught by the change in assumption of work hours for
equipment costing more than $1 M. Decrease of $394.54 in
past two years.
•
New MEG cost reporting may help
–
MEG and EEG were combined on Line 54 of the Medicare
Cost Report
–
Now MEG is moved to a new line, 54.01
2011 HOPPs APC 0065

Level I Stereotactic radiosurgery, MrgGUS, and MEG
– 95966 MEG Evoked Response
–
95967 Additional MEG Evoked Response

2010 payment is $962.61

2011 payment will be $977.12

Increase of $14.51 or 1.5%
Update on HFHS Transition to
ICD-10 Coding System
Kickoff: December 9, 2010
Nov 18th , 2010
ICD-10-CM/PCS
(Clinical Modification/Procedure Coding System)
Final Rule: HHS published on Jan 2009
Compliance Date: October 1st, 2013
• ICD-10-CM/PCS will enhance accurate payment for services rendered and facilitate
evaluation of medical processes and outcomes.
• ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control
and Prevention for use in all (inpatient and outpatient) U.S. health care treatment settings.
Diagnosis coding under this system uses 3–7 alpha and numeric digits and full code titles, but
the format is very much the same as ICD-9-CM
• ICD-10-PCS – The procedure classification system developed by the Centers for Medicare &
Medicaid Services (CMS) for use in the U.S. for inpatient hospital settings ONLY. The new
procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system
uses 3 or 4 numeric digits.
• A number of other countries have already moved to ICD-10, including:
–
–
–
–
–
United Kingdom (1995);
France (1997);
Australia (1998);
Germany (2000); and
Canada (2001).
65
HIPAA X12 5010 Electronic Transaction Changes
• All HIPAA X12 Electronic Transactions with payors (e.g., eligibility
verification, claims, remittance advise) have to be upgraded from
current 4010 version to newer 5010 version
• This will enable payors to request more information in the future
electronic transactions
(adding extra lanes to electronic freeway system to carry more
information)
• This change has to be operational by Jan 1 2012 and it is a prerequisite for ICD 10 CM/PCS changes
66
ICD-9-CM - Shortcomings
• Shortcomings of ICD-9 include:
– ICD-9 is outdated, with only a limited ability to accommodate new procedures
and diagnoses;
– ICD-9 lacks the precision needed for a number of emerging uses such as payfor-performance and biosurveillance. Biosurveillance is the automated
monitoring of information sources that may help in detecting an emerging
epidemic, whether naturally occurring or as the result of bioterrorism;
– ICD-9 limits the precision of diagnosis-related groups (DRGs) as a result of very
different procedures being grouped together in one code;
– ICD-9 lacks specificity and detail, uses terminology inconsistently, cannot
capture new technology, and lacks codes for preventive services; and
– ICD-9 will eventually run out of space, particularly for procedure codes.
67
Expected Benefits from usage of ICD 10 codes
• Adoption of the ICD-10 code sets is expected to:
– Support value-based purchasing and Medicare’s anti-fraud and abuse
activities by accurately defining services and providing specific diagnosis and
treatment information;
– Support comprehensive reporting of quality data;
– Ensure more accurate payments for new procedures, fewer rejected claims,
improved disease management, and harmonization of disease monitoring and
reporting worldwide; and
– Allow the United States to compare its data with international data to track
the incidence and spread of disease and treatment outcomes because the
United States is one of the few developed countries not using ICD-10.
68
Next Generation of Coding
Structural Changes
S.
No.
ICD-9-CM
ICD-10-CM / PCS
1.
Minimum of 3 digits, maximum of 5 digits, decimal
point after the third digit
Minimum of 3 digits, maximum of 7 digits, decimal point after
the third digit
2.
Numeric, except for supplementary codes — V
codes and E codes
Alphanumeric, with all codes using alphabetic lead character; V
and E codes have been eliminated and incorporated into the
main code set
3.
Structure of injuries designated by wound type
Structure of injuries designated by body part (location)
4.
Diagnosis: 13,000 Codes
IP Procedure: 4,000 Codes
67,000 ICD-10-CM Codes
87,000 ICD-10-PCS Codes
Mapping – ICD-9 To ICD-10
One to One: One old code to one new code . 3,458 codes or 24.52 % of all ICD-9 DX codes
Single Entry: One old code to one of many new code. 9,600 codes or 68.07 % of all ICD-9 DX codes
Combination Entry: One old code is split into multiple new code. 629 codes or 4.46 % of all ICD-9 DX codes
No Match: All new codes. 416 codes or 2.95 % of all ICD-9 DX codes
69
Difference between ICD-9 and ICD-10
ICD-9-CM
Mechanical complication of other vascular device, implant and
graft
1 code (996.1)
ICD-10-CM
Mechanical complication of other vascular grafts
156 codes, including
T82.310 – Breakdown (mechanical) of aortic (bifurcation) graft
(replacement)
T82.311 – Breakdown (mechanical) of carotid arterial graft (bypass)
T82.312 – Breakdown (mechanical) of femoral arterial graft (bypass)
ICD-9-CM
Angioplasty
1 code (39.50)
ICD-10-PCS
Angioplasty codes
854 codes
Specifying body part, approach, and device, including:
047K04Z – Dilation of right femoral artery with
drug-eluting intraluminal device, open approach
047K0DZ – Dilation of right femoral artery with intraluminal device,
open approach
T82.318 – Breakdown (mechanical) of other vascular grafts
047K0ZZ – Dilation of right femoral artery, open approach
T82.319 – Breakdown (mechanical) of unspecified vascular grafts
T82.320 – Displacement of aortic (bifurcation) graft (replacement)
T82.321 – Displacement of carotid arterial graft (bypass)
047K34Z – Dilation of right femoral artery with drug-eluting
intraluminal device, percutaneous approach
047K3DZ – Dilation of right femoral artery with intraluminal device,
percutaneous Approach
T82.322 – Displacement of femoral arterial graft (bypass)
T82.328 – Displacement of other vascular grafts
70
ICD-10 Example
Fracture of wrist
• Patient fractures left wrist
• A month later, fractures right wrist
• ICD-9-CM does not identify left versus right
(requires additional documentation to clarify during claim
adjudication)
• ICD-10-CM describes left versus right, Initial encounter, subsequent
encounter, routine healing, delayed healing, nonunion, or malunion
71
Potential Risks of Transition to ICD10
• Training and Education – ICD10 codes are based on human anatomy
and physiology will require significant mind set change for coders to
get used to new system
• Business Process – Potential significant shift in roles and
responsibilities between clinicians and coders to handle the
complexity of ICD 10s
• Information Technology – Significant risk in modifications to several
systems to accommodate new code sets
• Financial/Reimbursement – Transition from ICD 9 to ICD 10 can
result into temporary delays in cash flow from payors due to
technology implementation glitches
72
ICD 10 Potential Impacts to HFMG
Operations
• Significant process changes in the areas of
documentation, coding and charge capture
• May result in extensive training for Physicians,
Coders and other care-givers
• MediPac revenue cycle systems will be modified to
address transition to ICD 10
• OMR and TCAP systems have to be replaced with
newer technology to handle the complexity and
explosion of ICD 10 codes
74
OMR Considerations
• HFMG Clinic Coding model: Physician Model
enabled by branching technology logic (CAC) vs.
Centralized Coder model
• Handheld devices with future integration with
CarePlus(NG)/CPOE solution
75
HFHS ICD-10 Project Phasing
Phase 1 – Impact Assessment & Planning
•
•
•
•
•
Develop project management structure
Engage Steering Committee and Business Unit Operational Teams
Assess Process Implications
Assess IT Systems impact
Create Multi-Year Capital and Expense budget to address the change
Phase 2 – Process Redesign and IT System Changes
• Process Redesign-Current and Future State
• Detailed analysis, design and build of IT changes
• Create testing plans to validate process redesign and IT system changes
76
HFHS ICD-10 Project Phasing
Phase 3 – Testing and Implementation Planning
• Internal Testing and Training
• External Testing (Payors, Regulatory Reporting)
• Operational Readiness and Implementation Planning
Phase 4 – End User Training and Go-Live
• Finalize IT system changes and certify testing
• Finalize process changes and certify operational readiness
• Complete intensive coding professional education
Phase 5 – Post Go-Live Support
• Monitor coding accuracy for reimbursement, coding productivity and continue
with appropriate coding professional training
77
HFHS Project Phasing and Tentative Timeline
2010
Q3 Q4
Phase 1 - Impact
Assessment & Planning
Q1
2011
Q2 Q3
Q4
Q1
2012
Q2 Q3
Q4
Q1
2013
Q2 Q3
Q4
Jan 1, 2012 - Version 5010
EDI Transaction Compliance
Phase 2 - Process Redesign
and IT System Modifications
Oct 1, 2013
ICD 10
Compliance
Phase 3- Testing and
Implementation Planning
Phase 4- End User Training
and Go-Live
Phase 5 - Post Go-Live
Support
78
Key components of level of service
History
• Chief complaint (CC)
• History of present illness (HPI)
• Past medical, family, social history (PFSH)
• Review of systems (ROS)
Examination
• Neurological single system exam
or general multi-system exam
Medical
Decision
Making
• Number of diagnoses or number of
management options
• Complexity of data
• Risk of morbidity and mortality
You Get Credit for Trying...
•
Sometimes, you cannot do a full H & P no matter what
–
•
History
–
•
Document your attempt and what happened
Patient aphasic, lethargic, in coma, won't answer,
demented, etc.
PE
–
Patient aphasic, uncooperative, limb amputated,
strict bedrest, etc.
•
Do not write “unable to obtain”
•
Forgetting one bullet point on a New Patient visit has
major consequences in billing: drops to a level 1 visit
Tips for documenting history
• CC always required
• ROS is very important
– must document pertinent positives, may be in HPI
– “all other systems negative” permitted
– ROS deficiency a major reason for not meeting criteria for
highest level of service
• ROS and PFSH
– staff may record, and physician note
– may use previous ROS and PFSH, revise
as needed
• If history not obtainable, document why
History of Present Illness (HPI)
1997 E &M Guidelines allow for the option of
documenting the status/acuity of chronic problems
and/or inactive problems to complete the History of
Present Illness.
IMPORTANT: You must document the chronic or
inactive problem that you are addressing during
the visit and detail the current status/acuity of the
problem
Documenting the neurological
examination
• CPT™ defines 25 individual elements (“bullets”) of the
neuro exam, in 4 main groups
–
–
–
–
constitutional, eyes, cardiovascular
higher integrative functions or mental status
cranial nerves
musculoskeletal, motor, and sensory
• CPT™ specifies the numbers of elements that must be
documented for each level of service
• You must comment on these elements (“WNL” not
acceptable)
Medical Decision Making (MDM)
Documentation Tips
• Document the test(s) that you have reviewed (summarize what you have
reviewed) and ordered
• Document discussing test(s) with the physician who performed the test.
For example discussing with the cardiologist the interpretation of an
echocardiogram
• Document the review of old records. Remember you must summarize
what you have reviewed.
• For Example: Patient was admitted a month ago for __________.
Course of treatment included ____and patient was discharged with
home health care and continue with _________.
IF IT IS NOT DOCUMENTED IT IS NOT DONE
Medical Decision Making (MDM)
Medical decision making refers to the complexity of
establishing a diagnosis and/or selecting a
management option. It can be broken down into three
components.
– Number of diagnoses or management options
– Amount and complexity of data to review (Previous
documentation tips support this component)
– Risk of complication and/or morbidity or mortality
2002 CMS Regulations on Supervision
of Residents and Students
• Effective date November, 22, 2002
• Resident means an individual who participates in an
approved graduate medical education (GME) program
• Receiving a staff or faculty appointment or participating in a
fellowship does not by itself alter the status of “resident”.
• A student is never considered to be an intern or a resident.
Medicare does not pay for any clinical service furnished by
a student. (Medicare pays hospitals and medical schools
large sums of money in other ways.)
Medicare Teaching Definitions
• Critical or key portion means that part (or parts) of
a service that the teaching physician determines is
(are) a critical or key portion(s).
• Documentation may be dictated and typed, handwritten or computer-generated, and typed or
handwritten.
• Documentation must be dated and include a legible
signature or identity.
Payment Definitions
• For purposes of payment, E/M services billed by teaching
physicians require that they personally document at least the
following:
– a. That they performed the service or were physically present during
the key or critical portions of the service when performed by the
resident; and
– b. The participation of the teaching physician in the management of
the patient.
• When assigning codes to services billed by teaching
physicians, reviewers will combine the documentation of both
the resident and the teaching physician.
• Documentation for the service must support the medical
necessity of the service.
Examples of Acceptable Notes
• “I was present with resident during the history and
exam. I discussed the case with the resident and agree
with the findings and plan as documented in the
resident’s note.”
• “I saw the patient with the resident and agree with the
resident’s findings and plan.”
• “See resident’s note for details. I saw and evaluated the
patient and agree with the resident’s finding and plans
as written.”
• “I saw and evaluated the patient. Agree with resident’s
note but lower extremities are weaker, now 3/5; MRI of
L/S Spine today.”
Examples of Unacceptable Notes
•
•
•
•
•
•
“Agree with above.”
“Rounded, Reviewed, Agree”
“Discussed with resident. Agree.”
“Seen and agree.”
“Patient seen and evaluated”
A legible countersignature or identity alone.
E/M Service Documentation Provided
By Students.
• Any contribution and participation of a student to
the performance of a billable service (other than the
review of systems and/or past family/social history
which are not separately billable, but are taken as
part of an E/M service) must be performed in the
physical presence of a teaching physician or
physical presence of a resident in a service meeting
the requirements set forth in this section for
teaching physician billing.
E/M Service Documentation Provided
By Students.
• Students may document services in the medical record.
• Documentation by a student that may be referred to by the
teaching physician is limited to the review of systems and/or
past family/social history.
• The teaching physician may not refer to a student’s
documentation of physical exam findings or medical decision
making in his or her personal note.
• The teaching physician must verify and redocument the
history of present illness as well as perform and redocument
the physical exam and medical decision making activities of
the service.
DISCHARGE DAY
•
On the day of discharge, code as follows:
– 99238 for a total staff time of 30 minutes or less
–
•
99239 for a total staff time of more than 30 minutes
You must document the time spent in your note
–
Time does not need to be continuous
–
Time does not need to be spent with the patient
and includes:
•
•
•
•
•
Writing Rx
Doing discharge summary
Making follow up arrangements
Contacting other providers
Resident time does not count