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Preparing for the RACs
Top 10 RAC/OIG Targets
OIG Work Plan
Employee Benefit Plan Alert: Fiduciaries must focus on Plan Fees
The Potential Liability of Self-Funded Health Insurance Plans
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2008 Diagnosis Code Changes
2008 CPT Code Changes
2008 Modifier Changes
Consultations
MS-DRG and Present on Admission
OIG Work Plan
Increasing Revenue In Your Practice
2007 Medicare Update
2006 Medicare Update
2006 Medicare Bulletin: Nine-day hold on all Medicare payments
2005 Healthcare Update
2005 New Jersey Healthcare Bulletin
2005 Healthcare Events Update
Medicare and Medicaid (CMS) Alert
2005 Medicare Update ACAP Convention
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October 2005 Program
Presented by
Amper’s Healthcare Services Group
Overview of Topics
Ambulatory and Hospital Services
- Proposed 4.3% reduction in physician conversion factor
- Competitive Acquisition Program (CAP) update
- Reduced reimbursement for radiology multiple procedures same patient same day
- National Provider Identifier has 85,000 physician applications to-date
- Proposal to update the relative values of physicians’ practice expense in 2006 fee schedule –four year transition
- Initial appeal for redetermination in writing January 2006 –applies to denials
- Proposal for one version of the 855 enrollment form versus three versions currently
- Drug payment reductions scheduled for January 2006 –approximately 15%
- Healthcare organizations are spending approximately 25% more for EMR than planned –14.1% of practices have installed EMR
- Electronic attachments to claim forms
- Carriers can audit previous billing errors
- Pay-for-Performance quality indicators for January 2006 –G codes to be set up –no extra pay for physicians at present time –long-term CMS plan to eliminate annual economic increases and change to only pay-for-performance increases
- Starting October 1, CMS will no longer process hospital electronic Medicare claims for payment unless they comply with HIPAA
- Under the final inpatient PPS rule, hospitals that report quality indicators will receive payments at the full market basket update of 3.7 percent (up from 3.2 percent in the proposed rule); hospitals that don't submit quality data will receive an adjustment of market basket minus 0.4 percent
- Outpatient PPS proposal -changes would range from a 2.1 percent decrease for low-volume urban hospitals to a 6.4 percent increase for rural, sole community hospital
- A certificate of medical necessity (CMN) is no longer required for power wheelchairs and power-operated vehicles
- Aggressive post-acute care transfer policy, but stops at 182 DRGs, rather than the proposed 231 DRGs –per diem versus DRG payment
- The Medicare prescription drug benefit is for ALL people with Medicare
- No matter how they get their health care today or whether they have existing drug coverage
- Covers brand name as well as generic prescriptions
- Monthly premium would be approximately $37 in 2006 & the patient would pay a share of the cost of their prescriptions. Costs vary depending on the drug plan that is chosen.
- Annual deductible up to $250 in 2006
- People with Medicare will have a choice of plans to provide this coverage -there is additional help for those with limited income & resources
- If a patient receives a letter & 4 page application from Social Security, they should fill it out & mail it back
- Patients can call 1-800-MEDICARE for additional help
- NJ State Health Insurance Assistance Program— (800) 792-8820
- Will also be offered by most Medicare Advantage plans
Important Dates
- Summer 2005
- Patients with Medicare can apply for extra help through the Social Security Administration
- October 2005
- “Medicare & You” Handbooks are issued to compare plans available in their area
- November 15, 2005
- First day a patient can join a Prescription Medicare Coverage Plan
- Can join between 11/15/05 and 5/15/06
- If they join by 12/31/05, coverage will begin 1/1/06
- After 12/31/05, their coverage will become effective the first day of the month after the month they join
- January 1, 2006
- Medicare Prescription Drug Coverage Begins
Additional Assistance
- The amount they pay depends on their income & resources
CMS has identified 10 organizations that will offer nationwide prescription drug coverage
- Aetna Life Insurance Co.
- Connecticut General Life Insurance Co.
- Coventry Health & Life Insurance
- MEDCO Containment Life Insurance Co.
- Memberhealth, Inc.
- Pacificare Life & Health Insurance Co.
- SilverScript Insurance Co. (Caremark Rx Inc)
- Unicare United HealthCare Insurance Co.
- Wellcare Health Plans, Inc.
Medigap policy with Drug Coverage
- Patient will get detailed notice from their insurance company telling them whether or not their plan is on average, at least as good as standard Medicare prescription drug coverage.
Coverage from Employer or Union
- Will also receive notice
- If they drop their current plan, they may not be able to get it back
Hospital Supplemental Compliance Guidance
- Auditing standards for Fraud and Abuse areas
- Process improvement versus positive outcomes
- Internal Control review approach
- Risk Assessment –high, medium, low –statistical sampling approach
- Work process review
- Opportunities for improved controls
- Test controls implemented
- Monitoring and feedback
Gainsharing Arrangements
- Hospital incentive plans cannot encourage physicians to reduce or limit clinical services
- Potential implication of the anti-kickback statute
- Consider the personal services safe harbor
- Five Cardiology arrangement approved by the Office of Inspector General (OIG)
- Program Safeguards
- Limited duration of time and dollars
- Specific cost savings
- Patient care unaffected
- Baseline cost savings
- Product choice
- No steering of patients
Medicare Update
- Ambulatory and Hospital Services
- Part D Medicare Prescription Drug
- Compliance Developments
UpdatePresented by Healthcare Services GroupPresented Group
Overview of Topics
2006 Diagnosis Code Changes
New/Revised ICD-9 Codes Effective October 1, 2005
- Codes are effective 10/1/05 with no grace period
- 173 New Diagnosis Codes
- 42 Revised and Deleted Diagnosis Codes
- Endocrine, Nutritional & Metabolic Immunity –5 New Codes (240 –279.9)
- Androgen Insensitivity Syndrome
- Volume Depletion
- Dehydration
- Hypovolemia
- Overweight
- Blood & Blood Forming Organs –5 New Codes
- Mental Disorders –2 New Codes
- Alcohol Induced Sleep Disorders
- Drug Induced Sleep Disorders
- Nervous System & Sense Organs –52 New Codes(320-389.9)
- 47 Sleep Disorder Codes
- 5 Diabetic Retinopathy Codes
- Circulatory System –2 New Codes & 23 Revised Codes (390-459.9)
- Long QT Syndrome
- Erythromelalgia
- Respiratory System –No new codes
- Digestive System-23 New Codes(520-579.9)
- Diseases of Oral Cavity, Salivary Glands ∓ Jaws
- Diseases of Esophagus, Stomach ∓ Duodenum
- Genitourinary System –9 New Codes (580-629.9)
- Chronic Kidney Disease –7 Codes
- Urinary Obstruction –2 Codes
- Complications of Pregnancy & Childbirth –4 New Codes
- Multiple Gestation Following (Elective) Fetal Reduction
- Skin and Subcutaneous Tissue –No New Codes (680-709.9)
- Musculoskeletal –No New Codes
- Congenital Anomalies –No New Codes (740-759.9)
- Conditions in thePerinatalPeriod –15 New Codes (760 –779.89)
- Noxious influences affecting fetus or newborn via placenta or breast milk
- Anticonvulsants
- Antimetabolic agents
- Meconium passage during delivery
- Aspiration –11 Codes
- Meconium staining
- Symptoms, Signs and Ill-Defined Conditions –3 New Codes (780-799.9)
- Other Excessive Crying
- Asphyxia
- Hypoxemia
- Injury and Poisoning –9 New Codes
- Mechanical Complications of internal orthopedic device, implant or graft –4 Codes
- Dislocation of prosthetic joint
- Prosthetic joint implant failure
- Peri-prosthetic fracture around prosthetic joint
- Peri-prosthetic osteolysis
- Articular bearing surface wear of prosthetic joint
V Codes — 59 New Codes
- Personal History of:
- Infections of the Central Nervous System
- “Unspecified” “Other” Disease of the Respiratory System
- Pneumonia –Recurrent
- Urinary Tract Infection
- Nephrotic Syndrome
- History of Fall
- Family History of:
- Osteoporosis
- Other Musculoskeletal Diseases
- Genetic Disease Carrier
- Encounter for weaning from respirator
- Mechanical complication of respirator
- Bed confinement status
- Encounter for antineoplastic chemotherapy
- Encounter for antineoplastic immunotherapy
- Donors, Egg –6 Codes
- Suicidal Ideation
- Vaccination Not Carried Out Because Of:
- Unspecified Reason
- Acute Illness
- Chronic Illness or Condition
- Immune Compromised State
- Allergy to Vaccine or Component
- Caregiver Refusal
- Religious Reasons
- Patient Had Disease Being Vaccinated Against
- Other Reason
- Behavioral insomnia of childhood
- Pregnancy exam or test, positive result
- Encounter for blood typing
- Body Mass Index –20 Codes
2006 CPT Code Changes
458 CPT Changes
- 277 New Codes
- 71 Revised Codes and
- 110 Deleted Codes
Codes Effective 1/1/06 with no grace period
CPT Code Changes for 2006
- E/M –
- Deletions
- Inpatient Follow-Up Consult Codes (99261 –99263)
- Confirmatory Consult Codes (99271 –99275)
- Nursing Facility Codes (99301 –99313)
- Domiciliary/Rest Home Codes (99321 –99333)
- Additions
- 3 Codes for “Initial Nursing Facility Care, Per Day” (99304-99306)
- 4 Codes for “Subsequent Nursing Facility Care, Per Day” (99307-99310)
- 1 Code for “E/M of a patient involving an annual nursing facility assessment” (99318)
- 5 Codes for “Domiciliary or rest home visit for the Evaluation & Management (E/M) of a new patient” (99324-99328)
- 4 Codes for “Domiciliary or rest home visit for the E/M of an established patient” (99334-99337)
- 2 Monthly codes for “Individual physician supervision of a patient (patient not present) in home, domiciliary or rest home” (99339-99340)
- Anesthesia –2 New Codes; 1 Deleted Code
- Integumentary–36 New Skin Graft Codes; 8 Deleted Codes
- Musculoskeletal –6 New Codes; 2 Deleted Codes
- Incision & Drainage, Abscess, Spine
- PercutaneousVertebral Augmentation
- CPT Code 28890 Extracorporeal Shock Wave replaces deleted code 0020T
- Respiratory –2 New Codes; 5 Deleted Codes
- Resection of Apical Lung Tumor
- Cardiovascular –20 New Codes; 4 Deleted Codes
- Endovascular Repair
- Thrombectomy
- Digestive –23 New Codes; 7 Deleted Codes
- 19 New Laparoscopy Codes
- 8 New Gastric Restrictive Procedures
- Urinary –7 New Codes
- Female Genital System –2 New codes
- Nervous System –7 New Codes
- Balloon Angioplasty Codes
- Balloon Dilatation of Intracranial Vasospasm Codes
- Radiology –9 New Codes; 6 Deleted Codes
- Endovascular Repair of Thoracic Aorta
- 3D Radiology Services
- Stereoscopic X-ray guidance
- High Energy Neutron Radiation Treatment Delivery
- Pathology/Lab –29 New Codes; 7 Deleted
- Occult Blood Codes
- Other Sources
- Single Specimen (e.g. digital exam)
- Hemoglobin, by device cleared by FDA for home use
- Lipoprotein
- Molecular Diagnostics
- Medicine –56 New Codes; 38 Deleted
- Vaccinations
- Human Papilloma Virus (HPV)
- Zoster (Shingles)
- Infusions –6 New Codes
- Injections –5 New Codes
- CNS Assessments/Tests (Neuro-Cognitive, Mental Status, Speech Testing) –7 New Codes; 3 Deleted
- Chemotherapy Administration –11 New Codes; 8 Deleted
- Ophthalmology –0 New Codes; 8 Deleted
- Ocular Prosthetics, Artificial Eye (92330 –92335)
- Supply of Materials (92390 –92396)
- Spectacles (except prosthesis for aphakia)
- Contact Lens (except prosthesis foraphakia)
- Low Vision Aids
- Ocular Prosthesis
- Education & Training for Patient Self-Management –3 New Codes
- By a qualified non-physician health care professional
- Could include caregiver / family
- Special Services –3 New Codes; 2 Deleted
- Service(s) provided in the office during regularly scheduled evening, weekend or holiday office hours, in addition to basic service
- Service(s) provided between 10pm & 8am at 24-hour facility, in addition to basic service
- Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to the basic service
- Conscious Sedation
- Deletions
- Conscious Sedation Codes (99141 & 99142)
- Additions
- 99143 –First 30 minutes of “moderate” sedation services provided to a child under 5 by the same physician performing the diagnostic or therapeutic service that the sedation supports
- 99144 –For an individual 5 or older; add-on
- 99145 –For each additional 15 minutes of sedation
- Different provider performing moderate sedation
- 99147 –First hour of services for a child under 5
- 99148 –For individuals 5 and over
- 99149 –For subsequent 15 minutes
- Category III Codes –26 New Codes
- Medication therapy management by a pharmacist
- Computed tomography (CT) of heart
- Deleted Category III Codes –11
- The deleted Category III codes have now become Category I CPT codes
Smoking Cessation
- Smoking and Tobacco-Use Cessation Counseling became effective 3/22/05
- Patients must be competent and alert at the time the services are provided
- Minimal counseling is included in an E & M visit
- Beyond that, Medicare will cover 2 cessation attempts per year
- Each attempt may include a maximum of 4 intermediate (3 to 10 minutes) or intensive (more than 10 minutes) sessions
- Total annual benefit covering up to 8 sessions in a 12-month period
- Physician & patient have flexibility to choose between intermediate or intensive cessation strategies for each attempt
- Billing codes
- Prior to 7/4/05 an unlisted code, 99199, was utilized
- One unit per session to be entered in units field of claim
- After 7/4/05
- G0375 –Smoking & tobacco-use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
- G0376 –Smoking & tobacco-use cessation visit; intensive, greater than 10 minute
s
Ambulatory Surgery Centers
- Medicare Modernization Act (MMA) froze ASC pay through 2009
- Physicians continue to be paid under the fee schedule for services rendered in the ASC setting
- Group 1 -$333
|
Group 5 -$717 |
- Group 2 -$446
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Group 6 -$826 |
- Group 3 -$510
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Group 7 -$995 |
- Group 4 -$630
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Group 8 -$1339 |
APC Proposed Rule for 2006
- Separate payment for some packaged services
- New status indicator “Q” to identify separately payable packaged services
- E/M Facility Guidelines
- Still in developing and testing stage
- Drugs and Drug Administration
- New CPT codes in 2006 for drug administration
- Drug rates to switch from Average Wholesale Prices (AWP) to Average Sales Prices (ASP)
- Makes drug reimbursement more accurate
- Matches how drugs are paid for in physician offices
- Radiology Services
- CMS proposes to apply a 50% payment reduction to radiology procedures that fall within the same “family” when more than one radiology exam is given to the same patient, same session
- CMS proposes 11 “families” of radiology codes
- Observation
- Report number of hours via units not one unit for a “per day” stint in observation
- CMS proposes eliminating codes G0244, G0263, G0264 and 99217-36 and replacing them with two new G codes
- Modifiers
- Modifier –52 (reduced services) –a 50% payment reduction would apply for discontinued procedures that don’t require anesthesia
- Modifier –CA
- An emergent patient dies while undergoing an inpatient-only service but prior to being admitted
- Inpatient-only List
- CMS proposes moving 25 codes from the list
- 23 would be made separately payable under APC’s
- 2 would be packages
- Blood & Blood Products
- Payment for 15 of 33 blood codes will be decreased in 2006
- Transitional Pass-Throughs
- CMS proposes eliminating 3 pass-throughs and bundle their costs into the procedures that use the items
- C1814 –retinal lamp, silicone oil
- C1818 –integrated keratoprosthesis
- C1819 –tissue local excision
- Vaccines
- Hepatitis B vaccines to be paid
- Patients would still be responsible for co-pays and/or deductibles
- Co-payments
- Beneficiaries’ share of the APC bill to fall from 32% in 2005 to 30% in 2006
2006 OPPS Changes
Medical Nutrition Therapy (MNT)
- Updated information to the CMS Claims Processing Manual effective 8/12/05
- CMS provides MNT services for the following diagnoses:
- Renal Disease
- Chronic Renal Insufficiency
- Diabetes
- Lab results must be reviewed to determine if patients will be covered for MNT services
- Episode of Care –12-month period
- An initial visit for an assessment
- Follow-up visits for interventions
- Reassessments as necessary during the 12-month period beginning with the initial assessment to assure compliance with the dietary plan
- First year patient may receive three hours of service
- Subsequent years, patients with renal disease may only receive two hours of MNT
- MNT services may be billed in addition to Diabetes Self Management Training (DSMT) during the same time period but not on the same date
- MNT services will be paid if there is:
- Change in medical condition, diagnosis or treatment regimen related to diabetes or renal disease that requires a change in MNT
- MNT services are not covered for patients receiving maintenance dialysis when payment is made under End Stage Renal Disease payment guidelines
- CPT Codes 97802 –97804 (Status Indicator A) are to be billed for MNT services
- G codes G0270 and G0271 (Status Indicator A) are to be billed when there is a change in the patient’s condition requiring a second referral during the same episode of care and when additional hours of MNT are performed
- An Advanced Beneficiary Notice (ABN) should be obtained if it is possible that the charges will be denied
Correct Coding Initiative (CCI) Changes
- 2860 Changes for Version 11.3 effective 10/1/05
- 2542 New Bundling Edits
- 158 Deleted Bundling Edits
- 1 Mutually Exclusive Edit
- 159 Modifier Indicator Changes
- Majority of code pair additions are for Surgery: Nervous System (60000-69999) and Radiology (70000-79999) code ranges
- Major Reimbursement Changes
- Code 20690 (Application of a uniplane, unilateral, external) as a component code into many repair, revision/reconstruction codes in the 27000 series
- Can use an appropriate modifier to override the edit
- Various vascular injection procedures that are intravenous (36010-36015) or intra-arterial (36100-36247) have been bundled with injection codes G0351, G0353 and G0354
- Can be overridden with an appropriate modifier
- 64708 (Neuroplasty, major peripheral nerve, arm or leg; other than specified) is a comprehensive code into which numerous codes in the 64400 series have been bundled
- Can be overridden with an appropriate modifier
- Modifier Use No Longer Allowed:
- Brachytherapy–approximately 400 edits
- You can no longer use a modifier to bill clinicalbrachytherapy–77776 (Interstitial radiation source application;simple) with a variety of E/M codes (nursing facility care codes; rest home codes; home visit codes)
- Esophagoscopy Codes –43202 through 43232 are bundled into endoscopy code 43205
- Hernia Repair Add-On Code 49568 is bundled into hernia repair codes 49570 through 49611 and into laparoscopy codes 49650 and 49651.
Medicare Audits
- In 2004, Medicare paid $19.9 billion for improper claims.
- They are urging carriers and the Office of Inspector General (OIG) to conduct more audits, pre-payment reviews and fraud investigations
- CMS Medicare Improper Payment Rates Report
- Medically unnecessary services
- Improper coding
- Insufficient documentation
- Noted as biggest offense that leads to improper payments
- Providers who fail to submit medical records at the carriers’ request contributes to the error rate. This automatically makes the claim “improper”
- Medicare has extended the time providers have to send in their records from 55 days to 90 days
- CMS will also give every provider who fails to submit all the necessary documentation the first time a second chance to send in the missing information instead of automatically ordering recoupments
- Providers will have 15 days after they receive their second notice to submit the missing information
Contacts
Lew Bivona
Maureen Doherty
Michael McLafferty
Georgina Mendoza
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