JOURNALThe Medical BusinessThe Monthly Newsletter for the Informed Health Care Professional

Brought to you by the Medical Management Institute | July 2013 | Issue 6 Volume 4

mmiclasses.com

Inside this IssueCMS News Updates

Focus on Health Insurance Policy Fees

Transitioning to Meaningful Use Stage 2

Online Pharma Seize

Build Your EMR

Become ICD-10 Certified Online

The Hospital Transition My Be Inevitable

Modifier of the Month: 25

MMI Member Updates

MMI Crossword Puzzle

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M M I N e w s u p d a t e s

ICD-10-CM Certification ProgramCompletely Online with Instructor SupportEffective October 1, 2014, the ICD-9-CM code sets used by medical coders and billers to report health care diagnoses and procedures will be replaced with ICD-10 codes. ICD-10 will be a radical change, requiring extensive planning and training.

That is why the amazing instruction team at the Medical Management Institute has put together a fully customizable ICD-10-CM certification training program, completely online! There are 5 training paths available: Coder, Manager, Provider, Clinical Staff, and Biller. These programs include ‘Implementation Insurance,’ guaranteeing no additional charges for continuing education should ICD-10 not be implemented on October 1, 2014.

• The ICD-10 Coder Certification Path is $1,299 and includes the following online modules:

• ICD-10 Implementation Planning

• ICD-10 Documentation Requirements

• Advanced Anatomy & Physiology

• Basic Coding for ICD-10

• Specialty Coding for ICD-10

• Final Online Certification Exam

Visit mmi-classes.com/collections/icd-10 for more details, and contact us for discounted group rates!

HIPAA Training For Your OfficeAre You In Compliance? $29.99 CourseHIPAA Privacy Rules require the adoption of specific practice policies to address patient privacy issues. In addition, the Security Rules require you to conduct a risk assessment and have written policies on handling protected patient information. In addition, both rules require annual and ongoing training efforts for all physicians and staff.

This 30 minute video offers real world examples and provides flash cards to aid in preparing for the

final exam. Your employees can access it through any web browser.

Course features: • Video & webinar instruction in the basics of both

the Privacy & Security Rules• Real world examples of breaches & how to avoid

them• Copy of the HHS & Office of Civil Rights HIPAA

summary for easy access• Certificate of completion for each staff member• One year access to HIPAA trained instructors• HIPAA updates emailed to you for one year

Enroll online for the “HIPAA Privacy & Security” course today by clicking here. [Group discounts are available upon request]

What’s Different About Hospital Coding?Learn What’s Different for $29.99Are you thinking about adding hospital coding to your “coding tool kit”? This $29.99 online course will give you a general overview of what’s different about hospital coding, as well as what it will take to become certified as a Registered Hospital Coder. Course features: • Completely online and work at your own pace• Complete instructor support via phone & email• Interactive learning tools• Pre-recorded videos & online study material to

follow along with• Practice exams to test your knowledge

Enroll online for the “What’s Different About Hospital Coding” course today by clicking here. [Group discounts are available upon request]

Looking for a Job?Check out the MMI Job BoardThe Medical Management Institute is proud to host an MMI job board! Visit www.mmiclasses.com and click on the “Job Board” tab to check out all of the latest postings. You can search by keyword (medical coding, remote, contract, etc) and by location.

MMI news updates

mmiclasses.com | info@mmiclasses.com | 866-892-2765

facebook.com/MMIfan | twitter.com/MMIclasses

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Medicare Urges Seniors to Join Fight Against FraudJune 06, 2013In mailboxes across the country, people with Medicare will soon see a redesigned statement of their claims for services and benefits that will help them better spot potential fraud, waste and abuse. These newly redesigned Medicare Summary Notices are just one more way the Obama Administration is making the elimination of fraud, waste and abuse in health care a top priority. Because of actions like these and new tools under the Affordable Care Act, the number of suspect providers and suppliers thrown out of the Medicare program has more than doubled in 35 states.

“The new Medicare Summary Notice gives seniors and people with disabilities accurate information on the services they receive in a simpler, clearer way,” said CMS Administrator Marilyn Tavenner. “It’s an important tool for staying informed on benefits, and for spotting potential Medicare fraud by making the claims history easier to review.”

The redesigned notice will make it easier for people with Medicare to understand their benefits, file an appeal if a claim is denied, and spot claims for services they never received. The Centers for Medicare & Medicaid Services (CMS) will send the notices to Medicare beneficiaries on a quarterly basis.

CMS Issues Program Integrity Guidelines for MarketplaceJune 14, 2013Today, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule outlining program integrity guidelines for the Health Insurance Marketplace (Marketplace) and premium stabilization programs.  

Through the Affordable Care Act, consumers and small businesses will have access to new Marketplaces where they can access quality, affordable private health insurance.  Consumers in every state will be able to buy insurance from qualified health plans directly through these Marketplaces and may be eligible for tax credits to lower the cost of their health insurance.    

“In just a few months, consumers across the country will have access to a new Marketplace in their state where they can easily shop for health insurance that meets their needs and the needs of their families,” said CMS Administrator Marilyn Tavenner.  “The release of these guidelines signals that we’re ready to build on our ongoing efforts and ensure that the new systems are fiscally sound.”

Consumers Saved $3.9 Billion on Premiums in 2012June 20, 2013Today, the Department of Health and Human Services (HHS) announces that nationwide, 77.8 million consumers saved $3.4 billion up front on their premiums as insurance companies operated more efficiently.  Additionally, consumers nationwide will save $500 million in rebates, with 8.5 million enrollees due to receive an average rebate of around $100 per family.  

Today’s report includes the 2012 health insurer data required under the Affordable Care Act’s Medical Loss Ratio(MLR), or “80/20 rule.”  The report shows that, compared to 2011, more insurers are meeting this standard and spending more of their premium dollars directly toward patient care and quality, and not red tape and bonuses.   

HHS Launches Health Insurance Marketplace Educational ToolsJune 24, 2013The Obama administration today kicked off the Health Insurance Marketplace education effort with a new, consumer-focused HealthCare.gov website and the 24-hours-a-day consumer call center to help Americans prepare for open enrollment and ultimately sign up for private health insurance.  The new tools will help Americans understand their choices and select the coverage that best suits their needs when open enrollment in the new Health Insurance Marketplace begins October 1.

“The new website and toll-free number have a simple mission: to make sure every American who needs health coverage has the information they need to make choices that are right for themselves and their families—or their businesses,” said Health and Human Services Secretary Kathleen Sebelius.  

CMS News Updates reprinted from cms.gov

CMS news updates

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n June 28, 2012, the Supreme Court upheld the individual mandate of the Affordable Care Act (ACA). Justice John Roberts summarized the ruling as follows:

"The Affordable Care Act is constitutional in part and unconstitutional in part. The individual mandate cannot be upheld as an exercise of Congress’s power under the Commerce Clause. That Clause authorizes Congress to regulate interstate commerce, not to order individuals to engage in it. In this case, however, it is reasonable to construe what Congress has done as increasing taxes on those who have a certain amount of income, but choose to go without health insurance. Such legislation is within Congress’s power to tax."

As we move toward implementation of the ACA and the individual and employer mandates in 2014, certain aspects of the law are being reviewed and additional legislation is being proposed to amend portions of the law including reviewing fees on health insurance policy premiums.

The ACA calls for specific taxes including an additional 0.9% Medicare tax on earnings over $200,00; additional 3.8% tax on unearned income over $200,000; an excise tax on pharmaceutical manufacturers selling over $5 million annually; a

3.2% tax on medical devices and more. For a summary of all the taxes and fees, check out www.irs.gov and search for “Affordable Care Act Tax Provisions”. In addition to these taxes listed, the ACA imposes three specific fees or taxes on health insurance policy premiums.

What are these health insurance premium fees? The first is a temporary fee originally called Comparative Effectiveness Research Fee (CERF). Since the bill was passed, this fee has been renamed the Patient-Centered Outcomes Research Institute (PCORI) Fee. The money collected from

this fee will go into a fund to research the health outcomes and the clinical effectiveness, risks, and benefits of two or more medical treatments/services. This fee is charged to the insurer of fully insured polices or plan sponsor/employer for those who have self-insured group plans. The fee applies on the first day of the policy/plan year beginning on or after October 2, 2011 and continues to apply through policy/plan years ending before October 1, 2019. The fee starts at $1 per covered person – or insured “lives” – not per employee. The fee increases to $2 per person the second year and can be adjusted for inflation after that. The fee will be treated as an excise tax and returns will be filed on form 720. Although this tax will be paid by the insurance company for those who are fully insured, the cost will be rolled into the insurance premiums and will “pass through” to the insured. Employers who are self-insured are responsible for filing and paying this fee. This fee is tax deductible.

A second fee is the Reinsurance Assessment Fee. This fee may also be called the Transitional Reinsurance Program. This is also a temporary fee/tax intended to help move the uninsured with pre-existing conditions into the health insurance

O

Focus on Health Insurance Policy FeesThe Patient Protection & Affordable Care Act| Janet Salyer

Focus on Health Insurance Policy Fees

“The Affordable Care Act is constitutional in part and unconstitutional in part.”

-Justice John Roberts

- Justice John Roberts

5Focus on Health Insurance Policy Fees

market place. The fee starts at $63 per covered person (per member per year or PMPY)for 2014 and applies to the all those covered by major medical health insurance. A family of four, for example, will have an additional $252 included in their health insurance premiums in 2014. The fee does not apply to the dental and vision and indemnity plans. The reinsurance fee decreases

to about $40-$45 per covered person in 2015 and to about $25-$30 per covered person in 2016. The fee is scheduled to end after three years. The Reinsurance Assessment Fee applies to fully insured plans and self-insured employer groups. Again, the fee will be paid by the insurance company for fully insured with the cost considered “pass through” and rolling into the insurance premiums. Plan sponsors or employers will pay the fee for the self-insured groups. This fee is tax deductible. These funds will be administered by the state or by HHS if the state fails to set up a certified risk assessment plan.

The third fee is the Health Insurance Industry Fee. This is a permanent fee intended to cover some of the premium subsidies and cost sharing reductions for those who are eligible for assistance and purchase health insurance on the exchanges. The fee will apply to fully insured plans including Medicare and Medicaid and to dental insurance premiums, but does not apply to self-insured group plans. The fee will apply to all health insurers and will be divided among all the companies. Not-for-profit insurers, such as Kaiser, will pay half the amount that for-profit insurers pay. Although this is charged to the insurance companies, this fee is also considered “pass through” and the fee will be rolled into the premiums. This fee is expected to add 2-2.5% to the insurance premiums in 2014 and increase to 3-4% by 2018. So a 2014 monthly insurance premium of $500 would increase by $10 to $12.50 each month. The amount of the fee will increase according to market demands and unless is it revised by Congress is a permanent fee. This fee applies to grandfathered and non-grandfathered plan premiums. This is NOT a tax deductible fee.

What are “pass through” fees and why are insurers allowed to pass these fees on to consumers? The ACA also establishes a Medical Loss Ratio (MLR). Insurance companies are required to pay 80% of

premiums collected in the individual and small group market and 85% of premiums collected in the large group market on c la ims and improvement of care. The companies are to use the rest of the premium dollars for payroll and operating expenses. If the company does not spend the required percentage on claims in each market segment, then they are to rebate premiums. Since these new ACA fees don’t fall into either claims or operating expenses, then insurance companies are allowed to “pass through” the charges to the consumer. The monies collected will not be kept by the insurance company and will not be part of the MLR calculations.

The ACA calls for the Department of Health and Human Services (HHS) to administer the risk corridor for the individual and small group market. According to the HHS, “Risk corridors protect against uncertainty in rate-setting in the first several years of the Exchanges by creating a mechanism for sharing risk between the federal government and qualified health plan issuers.”  Estimated cost for this corridor will be $.08 per member per month. HHS will administer this program from 2014 to 2016.

HHS has proposed a monthly user fee of 3.5% for each policy issued in a federally facilitated marketplace. It’s expected that state facilitated marketplace fees will be similar. This proposed fee will be largely paid by the insurers offering qualified plans in the marketplace with the cost being rolled into the premiums and “passed through” to insureds. These are expected to become effective in 2014 and to be permanent fees.

The HHS says that these programs and fees are intended to establish risk adjustments and risk corridors that will lower insurance premiums in the individual and small group markets between 10%-15%. According to analysts, this will make insurers compete on quality and service, rather on attracting healthy members. Currently, all policy fees are being reviewed by Congress. Bipartisan legislation to repeal the policy fees is currently being debated in the House of Representatives. Will these fees be repealed before open enrollment is scheduled to begin October, 2013? Only time will tell. As always, it’s important that we a l l “ s t a y i n f o r m e d o n reform”.

Janet Salyer is a MMI Instructor & Senior Broker at Insurance Planning Solutions

“Risk corridors protect against uncertainty in rate-setting in the first several years of the Exchanges…”

-The Affordable Care Act

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S. and international regulators seized more than $41 million in illegal medicines worldwide and shut down 1,677 websites as part of their ongoing fight against

counterfeit drugs sold on-line.

The U.S. Food and Drug Administration (FDA) said on June 27th, it used federal court warrants to seize website domain names and post messages letting visitors know that people who traffic in counterfeit drugs may face severe penalties under federal law. The message also offers a link to a site - www.fda.gov/BeSafeRx - that explains the risks of fake online pharmacies.

Several sites had sleek interfaces and names that could easily be confused with legitimate pharmacy retailers. For example, the FDA shuttered Walgreens-Store.com; the well-known drugstore chain's website is actually Walgreens.com.

The FDA launched a campaign last fall to warn consumers that the vast majority of online pharmacies do not follow laws or pharmacy industry standards and their products could harm or even kill.

" I t i m p a c t s c o n s u m e r s e v e r y d a y , " F D A Commissioner Margaret Hamburg told CNN's Dr. Sanjay Gupta. "These products can have none of the active ingredients that people need for the treatment of their disease. They can have too much or too little (of the ingredient); they can have toxic ingredients, and they can prevent patients from getting the actual medications that they badly need to treat their disease."

The moves the agency announced Thursday took place as part of Operation Pangea VI, a weeklong crackdown organized by the international police

agency Interpol that ended on Sunday.

Investigators visited the websites and used undercover IDs to order the drugs. They received counterfeit drugs that were not approved by the FDA. Some arrived with no directions for use and in strengths and quantities not available in the United States. Some also had different ingredients than the real drugs, which can be very dangerous to the patients taking them.

"You essentially have no idea what it is that you would be buying and what you would be taking," said John Roth, director of the FDA's Office of Criminal Investigation.

The goal of Pangea VI was to identify the makers and distributors of illegal drug products and medical devices and remove those products from the supply chain. Some of the medicines that were sold illegally by the websites targeted during Operation Pangea VI included:

• Avandar y l : F D A - a p p r o v e d A v a n d a r y l (glimepiride and rosiglitazone) is used to treat type 2 diabetes and to minimize potential associated risks, including edema caused by fluid retention, worsening the condition of the heart, or heart failure. Avandaryl must be prescribed by a certified healthcare provider and dispensed by a certified pharmacy with a medication guide explaining the potential risks.

• “Generic Celebrex”: This generic drug sold online is not an FDA-approved product. FDA-approved Celebrex (celecoxib) is a non-steroidal anti-inflammatory product used to treat the signs and symptoms of osteoarthritis and rheumatoid arthritis and to manage acute pain in adults. To minimize the potential associated risks, including gastrointestinal bleeding, heart attack or stroke, in some people with long-term use, Celebrex must be dispensed with a medication guide explaining the potential risks.

• “Levitra Super Force” and “Viagra Super Force”: While Levitra (vardenafil) and Viagra (sildenafil) are FDA-approved medicines used to

Online Pharma SeizeGlobal Bust Shuts Down Over $40M in Illegal Meds | Jennifer Donovan

Online Pharma Seize

U.

"These products can have none of the active ingredient that

people need for the treatment of their disease.”

--FDA Commissioner Margaret Hamburg

7Online Pharma Seize

treat erectile dysfunction (ED), Levitra Super Force and Viagra Super Force are not FDA-approved products and claim to contain dapoxetine. The FDA has not determined the safety or efficacy of dapoxetine. People with certain heart conditions should not take ED medicines containing vardenafil or sildenafil. There are also potentially dangerous drug interactions or serious adverse effects with these drugs, such as loss of hearing or vision.

• Clozapine: FDA-approved Clozaril (clozapine) is used to treat severe schizophrenia and is associated with potentially fatal agranulocytosis, a severely low (and dangerous) white blood cell count that can predispose patients to serious, life-threatening infections. To minimize potential risks, consumers who are prescribed FDA-approved Clozaril must be enrolled in a registry that ensures regular monitoring of their blood counts.

Online sales of those erectile dysfunction treatments can be especially enticing to patients who may be too embarrassed to visit a drugstore to buy the drug in person.

Roth said consumers should watch for red flags that indicate an online pharmaceutical website may not

be legitimate. They include sites that offer steep discounts from a drug's regular price, those that don't require a prescription to fill your order or ones that contact you through a spam email.

"This is a constant struggle for us, but one of the most important things we can do is educate the consumers about what a legitimate website looks like," he said.

A January study by the National Association of Boards of Pharmacy, which accredits online pharmacies, found that only 257 of 10,275 online pharmacy sites it examined appeared legitimate.

Last year, Operation Pangea V resulted in the arrests of about 80 people and the seizure of $10.5 million in medicines. In addition more than 18,000 illegal pharmacy websites were shuttered.

Roth said there were no arrests in the latest operation, but the investigation is continuing.

Resources: CNN, Physician Business Technologies, Atlanta

Journal Constitution, OIG, DEA

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On February 17, 2009, President Barack Obama signed into law the American Recovery and Reinvestment Act of 2009 (ARRA). This was dubbed the “Stimulus bill”. ARRA provided $787 Billion to boost the economy. $147 Billion of this bill was set aside for healthcare-specific improvements. $19 Billion is earmarked for the "Health Information Technology for Economic and Clinical Health" (HITECH) Act.

There is money set aside specifically for Electronic Health Records (EHR) technology through the HITECH provisions of ARRA. HITECH is designed to encourage physicians and healthcare organizations to migrate to electronic health records (EHR) and to show “Meaningful Use” with the goal of providing a Personal Health Record (PHR) to every patient to enable them to better manage their own healthcare process. Providers who attested with 90-days data completed by 10/2/2012 could earn up to $44,000 over five years as part of this program. Each year after 2012, the total earning opportunity decreased. Those attesting with data captured after 10/2/2013 would be subject to Medicare penalties starting in 2015. In summary, if an EP attested for any meaningful use in 2013, they would not be penalized. Anyone attesting after 2013 are automatically subject to penalties starting in 2015.

The HITECH program extracts penalties if no MU by 2015. Penalties are based on prior years reporting with a 2 year lag. If the EP attested in 2011 or 2012, they must complete a full year of MU attestation in 2013 to avoid penalty. If they had any MU attestation in 2013, there is no penalty in 2015. Medicare MU registration and attestation must be done before 10/3/2014 to prevent adjustment in 2015. This means the 90-day reporting period must start no later than 7/1/2014. The EP must continue to meet MU requirements annually to avoid adjustments in subsequent years. Massachusetts has passed a law that threatens to revoke the physician’s license if they do not meet MU.

The penalties are cumulative with other CMS programs and there are some hardship exceptions (see figure 1.1 on the following page).

The rules for an Eligible Professional (EP) are very simple; Buy a "Certified" EHR + Attest for Meaningful Use = Get incentive payments.

The Meaningful use program is building the foundation to drastically alter, and hopefully improve, the way in which we provide care and referrals for patients. Stage 1 requires providers to move from paper to electronic data capture. Stage 2 requires providers share this data with patients and other providers. Stage 3 will most likely push the use of this shared data to lower costs, improve outcomes, increase patient safety, and enable many other improvements to the US healthcare system.

Buying a "certified" system today requires providers to purchase a system that is certified by an ONC-ACB company in accordance with the 2011 rules. Buying and using a system starting January 1, 2014 for Stage 2 attestation AND Stage 1 attestation must be done using a system certified under the 2014 rules.

Stage 1 certification required EPs to show meaningful use of 15 core objectives plus 5 of 10 menu objectives for a total of 20 objectives in order to attest and receive their checks. These objectives included usage of:

• CPOE• Drug-drug / drug-allergy interactions• Problem list of diagnoses• eRx (electronic prescribing)• Active Medications• Record Demographics• Record Vitals• Record Smoking Status• Report ambulatory CQMs• Implement one CDS rule• Provide electronic copy of health info• Provide clinical summaries for each visit• Exchange information electronically• Protect PHI

Stage 2 makes this quite harder by requiring EPs to show meaningful use of 17 core objectives plus 3 of 6 menu objectives for a total of 20 to continue receiving checks and avoid penalties. New items in Stage 2 include:

• Secure Messaging (Direct Project)• Family Health History• Imaging Results• Registry Reporting• Progress Notes

Transitioning to Meaningful Use Stage 2Mike Jenkins, PMP, MBA | CEO of BuildYourEMR

Transitioning to Meaningful Use Stage 2

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Items that moved from menu to core include:

• Lab Results• Patient Lists• Patient Education• Summary of Care Records• Medication Reconciliation• Immunizations• Patient Reminders• Online Patient Information

In addition to more information, Stage 2 requires far more adoption. This includes patient engagement. To attest for Stage 2, EPs must prove that more than 5% of their patients have sent secure message to the EP and more than 5% of their patients have accessed their health information online. They must produce a Summary of Care for more than 50% of their patients. This is up from 10% for Stage 1. They must electronically transmit more than 10% of information, and they must send at least one patient record to a recipient with a different EHR vendor or to CMS.

Stage 1 Clinical Quality Measures (CQMs) reporting required 6 out of 44 where 3 are core or alternate core and 3 are from the menu. Stage 2 (After January 1, 2014) will require 9 out of 64 CQMs that are pulled from at least 3 of the 6 National Quality Strategy (NQS) domains. These are:

• Patient and family engagement• Patient Safety• Care Coordination• Population and Public Health• Efficient Use of HC Resources• Clinical Processes/Effectiveness

As of 6/25/2013 there is a stark contrast in the number of solutions certified on the ONC website (http://oncchpl.force.com/ehrcert).

In conclusion, All EPs MUST use a 2014 certified EHR for 90 days to attest for 2014 starting January 1, 2014. They must report on data collected no later than October 3, 2014

to avoid penalties. This means they must have a fully operational 2014 certified system by July 1, 2014 in order to capture 90 days data in 2014. A 2014 certified system is required for both Stage 1 and Stage 2 attestations.

2014 (Stage 2) is an order of magnitude harder than 2011 (Stage 1) certification. There are warnings that Stage 1 has created a false sense of security among vendors and EPs because it was so easy. The 2014 certification has drastically raised the bar for EHR vendors and for every EP who attests. Many Vendors will struggle with 2014 certification. There will be some consolidation, but there will be vendors who choose to abandon their customers at the 11th hour. EPs need to solicit their vendors now to get their commitment to finish their certification. If they feel the vendor is not being candid, they should start thinking about plan B. Those who wait too long will be forced to rush for Stage 2 or get penalized. A decision made during the rush hour may not be the best one for your practice and cause more harm. (http://www.buildyouremr.com/build-your-emr-blog/2013/5/7/time-spent-in-selecting-the-right-emr-vendor-is-a-sound-investment)

I am pleased to say BuildYourEMR (Buildyouremr.com) has completed the Modular 2014 certification already and is on its way to get the complete 2014 Certificate in 2013. Our staff physicians designed an EHR solution that is infinitely customizable at the practice, specialty, provider and even the individual staff levels. It meets the criteria for 2011 and 2014 ONC-ACB certification, and data exchange with registries, HIEs, patients, and other providers. We are committed to making physicians Meaningful Use journey painless and put back joy into practicing medicine. You really have to see it to believe it. Please visit our website and sign up for a free one-hour webinar where we demonstrate the solution and answer your specific questions. (http://www.buildyouremr.com/request-workshop)

Mike Jenkins is the CEO of BuildYourEMR, a healthcare solutions company that believes in listening to its

customers and providing elegant, yet clear solutions to meet their needs. He is an experienced professional that

blends people, processes, and products to cook up delightful solutions for healthy P&Ls and project

turnarounds. He is using these skills to expand BuildYourEMR (www.buildyouremr.com) and help

providers minimize their pain and risk as they successfully transition to Stage 2 of Meaningful Use.

Transitioning to Meaningful Use Stage 2

[Figure 1.1]

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Who is BuildYourEMRBuildYourEMR started in 2009 as Health Postbox Express (HEPOEX) and is doing business as BuildYourEMR offering solutions for healthcare organizations of all sizes. The company is headquartered in Missouri and led by a senior team who is passionate about improving the EHR experience for providers and patients.

What does BuildYourEMR doBuildYourEMR  is committed to providing  solutions that help physicians and their staff focus on patients, document more accurately, and meet all the Meaningful Use data exchange requirements without decreasing their productivity. By flipping EMR design convention on its head, BuildYourEMR is able to achieve this while using the physician's existing forms and workflows.  With BuildYourEMR you get personal service, quick response time, and you don't have to wait 24 months for a product enhancement or a small change on your encounter form.  

Contact BuildYourEMR today!BuildYourEMR is looking for strategic Practice Management and Billing partners to jointly offer our solutions to the market. The BuildYourEMR product supports bi-directional HL7 interchange and can interface in batch and real-time with most PM offerings. Please contact us quickly so we can be prepared for the upcoming wave in 2014.

• Call: 1.888.815.2729

• Email: info@BuildYourEMR.com

• Web: www.buildYouremr.com

Build Your EMR

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It is well- known in the healthcare industry that more and more physicians are switching from a private practice environment to alignment with hospitals.  The reasons can be multiple, but some of the more common are the economic demands of maintaining independence, increasing payer audits, preparing for ICD-10, and implementation of electronic medical records. Hospitals generally project business plans 5-10 years in advance.  Administrators are well aware of the market trends, and are offering rather lucrative options to bring physicians on board in an employed status.  Common inclusions in such offers are regular work schedules, coverage of malpractice insurance, salaries and incentive plans.  Based on economies of scale, hospitals are usually able to negotiate stronger managed care contracts, and offer more robust benefit packages than physicians are able to manage independently. Hospitals are establishing key people to handle physician acquisition transactions and some are actively seeking to fill such positions.  A result of these trends will be fewer available positions for coders and billers in physician practices. If you are a coder or biller in a physician practice, you must remain alert to indications that your group may be approached about, and agree to a hospital offer of alignment.  More importantly, you must be aware that hospital operations are significantly different from physician operations, and that the billing and coding positions in a physician office are not necessarily a smooth fit for hospital positions. In fact, many hospital managers see it is a relatively poor fit to bring on board physician trained staff, and that the efforts to train outweigh the advantage.  Coding rules are different in a hospital, particularly inpatient coding, which one would need to be prepared to handle as a hospital coder.  Billing is also handled much differently, and these two functions are usually two very separate operations, with little interaction between those departments. It is not very likely that you can expect placement as a hospital coder or biller without some advance planning and undertaking a personal initiative to enhance your knowledge and training. To some degree, you will need to put aside what you know and have been doing as a physician coder/biller, and this is a very difficult step for someone who has only had exposure to physician practices.  The natural action is to rely on your knowledge and experience to handle a new role.  It is often more difficult to “unlearn”, than to start as a beginner.  However, hospital coders are held to tight productivity and accuracy standards, and when supervisory staff must spend time

“retraining”, and making changes necessary to meet hospital reporting requirements, they may question the advantage of using a physician coder. Hospital billers are also held to productivity and accuracy standards, such as management tracking of the percentage of rejected claims and necessary re-bills on each biller as well as number of unbilled claims based on the number assigned to the biller.  Claims that must be delayed due to situations such as erroneous or missing charges must be indicated by the biller to avoid being counted as a claim that should have been billed.  Although there may be some variations between hospitals, all typically have quality standards that coding and billing staff must meet as an expectation of satisfactory job performance. Let’s take a look at some steps that you may consider to prepare for transitioning to a hospital position.  Although it may be difficult to transition, it is not impossible to sell yourself to a hospital manager. Take advantage of opportunities to learn about billing, coding and revenue cycle management in a hospital environment. This includes handling inpatient coding, being familiar with the functions of the chargemaster, understanding the expectations of productivity and handling billing using the UB-04. One concern that has been mentioned by some hospital managers is that they do not want to train someone and then have the person leave shortly thereafter.  If you have invested time and effort in learning basic information and ground rules about the hospital environment, it may be smart to offer to sign an agreement to stay at least one to two years if allowed to come on board.  The managers are likely to be more open to providing an opportunity if they have assurance that it is not a short term position. It is often a difficult decision to incur costs for additional training, particularly if you have long time experience in the physician practice.  As with many other industries, market trends determine that new skills are needed to maintain strength in a very competitive business.  As you more closely examine the current integration of independent physicians into hospital employees, look upon additional training as a personal investment to ensure that you are able to remain a valuable resource in new endeavors. 

Dorothy Steed is a MMI Instructor & Independent Consultant in Atlanta, GA.

The Hospital Transition May Be InevitableIt’s Better to Be Safe Than Sorry | Dorothy Steed

The Hospital Transition May Be Inevitable

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1. What is the definition of significant and separately identifiable?

Significant means a great amount of additional work. Separately identi f iable means the documentation shows the separate portion of the E&M service.

2. What is a global period?

The global period simply means that all the usual pre and postoperative work for a particular procedure is included in the reimbursement for that procedure. The global period may be considered a major surgical period of 90 days or a minor surgical period for 0–10 days.

3. Can a nurse practitioner (NP) provide direct supervision for chemotherapy services subsequent to a physician's evaluation?

If this is done in a hospital environment, incident-to billing is not allowed.

4. Can modifier 25 be appended to 99211?

Yes, as long as all other guidelines are met.

5. Does billing the second charge on the claim form need a separate diagnosis?

No, a different diagnosis is not needed. But you still have to meet the definition of separate and identifiable service.

6. If we provide a current procedural

terminology (CPT) 99212 level of visit and an electrocardiogram (EKG) in the same encounter in the office can I add modifier 25 on the CPT 99212 to show that the EKG is a separate identifiable procedure or is it included in office visit level of care?

Medicare providers should always check correct coding initiative (CCI) edits. You should not need a modifier 25 with the EKG.

7. We have a problem with being flagged for audits due to the high use of modifier 25. This is a dermatology practice with many patients having multiple procedures. Our physician is kind and does not want to run these elderly patients back and forth. Do you think this is fair?

The key to using modifier 25 is not always how often you may use it, but that you are utilizing it c o r r e c t l y a n d m a k e s u r e y o u h a v e t h e documentation to support its use. In the OIG report and other audits, most of the problems were usually because of the lack of documentation.

8. If a patient is seen in the office in the morning (AM) for a sinus infection and then has a heart attack and needs to be admitted late that same day, can you bill both a 99213 and 99223 with a modifier 25 on one of the services?

Modifier of the Month22 Questions About Modifier 25 | Jennifer Donovan

Modifier of the Month: 25

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In this example (multiple procedures) are not applicable with modifier 25.

9. Do we use modifiers for venipuncture (CPT-36415) when used with CPT 99211?

No modifier is needed in this example.

10.Is modifier 25 only used with E&M codes?

Yes, this is correct. Modifier 25 is used to identify a separately identifiable E&M service on the same date as a minor surgery.

11.I was told that if Medicare list the global period as XXX (global concept does not apply). Then do you not need to use a modifier 25?

This is right. XXX = the global period does not apply as no global days are assigned.

12.Scenario: Patient came in for postoperative care 99204, and incidentally needed to get a flu vaccination 90471 administered. Is it appropr iate to b i l l for t he flu and administration, G0008 and 90658.

Yes, you can bill for the flu vaccine and administration since it is unrelated to the surgery.

13.Where do I find the National Correct Coding Initiative (NCCI) modifier indicator table?

Go to: http://www.cms.hhs.gov/NationalCorrectCodInitEd/.

14.Can procedure codes 99024 and 9047159 be billed to carrier?

To use modifier 59 you would need to check the NCCI modifier table.

15. Are payments normally lower when billed with a modifier 25?

No.

16. Do we have to use modifier 25 if we are doing a physical with urinalysis (UA) CPT 81002?

The modifier 25 is only applicable to procedures done on the same day as an E&M.

17. If I go to the Medicare physician fee schedule database (MPFSD) and the procedure has global days indicating 0–10 days, then can I use the modifier 25 if

separately identifiable service was rendered?

Yes. Step 1 should be to utilize the MPFSDB. If 0–10 is listed in the global surgery column, this means the procedure is considered a minor procedure and it may be possible for you to use modifier 25. But remember you also have to check the NCCI modifier table as well. Do not use the modifier 25 if a 90-day period is listed since that would indicate a major surgery.

18.If a new problem was evaluated with history, exam, and medical decision-making, and a procedure is performed on that day to treat the new problem, can you bill for both the E&M and the procedure because it was not previously planned?

Not unless the E&M is significant, separately identifiable. There is a relative value unit (RVU) component in every surgical procedure related to performing the E&M prior to a procedure.

19.Is there a specific amount of days after a minor surgery that should be included in the postoperative care; is dressing changes, suture removal, etc.?

The global period for minor surgery is 0–10 days and the global concept typically includes all pre and postoperative work.

20.If modifier 25 is not the correct modifier to use with two E&M CPT codes billed on the same day (e.g., 99213 and 99223) what modifier would I use for proper reimbursement?

If a patient is seen in the office and then admitted to the hospital on the same day, you cannot charge for both the outpatient visit and initial hospital admission.

21.Does modifier 25 apply after the 10 days has past and the patient needs additional care?

In this example, the modifier 25 would not be needed. Remember it is used to identify an exception to the global surgery rules when a significant and separately identifiable E&M is performed.

22.Can you use modifier 25 with post-operative period modifier 24?

Yes, if there is a distinct new problem that is not a part of the global package. Reference NCCI edits.

Modifier of the Month: 25

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The American Medical Association recently instructed, when coding for drug testing by any method other than chromatography for multiple drugs or drug classes, you should report 80104 Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure. If qualitative methods other than chromatography are used to test for a single drug only, you should report 80101 Drug screen, qualitative; single drug class method (eg, immunoassay, enzyme assay), each drug class.

Through recent years, there has been confusion on proper coding when using a “kit” containing multiple dipsticks (or cassettes, cups, etc.), each of which is used to detect a different analyte. AMA’s CPT Assistant, December 2010, explains, “Kits are commercially available for 12 or more analytes. These test kits are…. effectively running multiple tests at once, in a single procedure, due to the test kit design.”

Proper coding when using such a “multiplex” test kit is a single unit of 80104—not multiple units of 80101. Payers in California and elsewhere have begun post-payment audits of provider claims, and are demanding repayment when multiple units of 80101 were reported, but where 80104 was appropriate. Improper payments have been substantial, in many cases equaling thousands of dollars, per claim.

Confusion Clear-up

Prior to 2011, qualitative testing of multiple drug classes in a single kit commonly was reported using multiple units of 80101. CPT® 2011 changed this with the introduction of 80104, which was created specifically “to describe a non chromatographic method wherein multiple drug classes were screened in a single procedure… more accurately reflecting the resources used in a multiplex test kit as compared to multiple runs using a single class methodology,” according to CPT Assistant (Dec. 2010).

The AMA’s CPT 2011 Changes: An Insider’s View further clarifies, “Code 80104 has been established to report a specific drug screen, qualitative analysis by multiplexed method for 2-15 drugs or drug classes (eg, multidrug screening kit).”

Be especially cautious when reporting multiple units of 80101, to be certain each unit represents (and documentation substantiates) a unique test, rather than the individual components of a single multiplex testing kit.

Finally, Medicare does not accept 80101 or 80104, and instead requires G0431 Drug screen, qualitative; multiple drug classes by high complexity test method (eg, immunoassay, enzyme assay) per patient encounter  and G0434  Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter. Note that the Medicare codes specify “per patient encounter,” rather than per procedure or per analyte. 

For additional instructions, see MLN Matters® Number: SE1105 Revised.

Payers Targeting 80101 Abuse for Drug TestingJennifer Donovan

Payers Targeting 80101 Abuse for Drug Testing

“[Test Kits] are effectively running multiple tests at once, in a single

procedure, due to the test kit design.”-AMA’s CPT Assistant

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Manager

Coder

Biller

Clinical Staff

Provider

ICD-10 Implementation

Planning

ICD-10 Doc Requirements

Assessment of ICD-10 Pre-Requisites

ICD-10 for Office

Managers

Office Readiness for ICD-10

ICD-10 Implementation

Planning

ICD-10 Doc Requirements

Advanced Anatomy & Physiology

Basic Coding for ICD-10

Specialty Coding for

ICD-10

Certification Exam

(Pre-Requisite: Registered

Medical Biller)

Advanced Anatomy & Physiology

Billing for ICD-10

Certification Exam

ICD-10 Doc Requirements

ICD-10 for Office Staff

(Pre-Requisite: Need to be licensed)

ICD-10 Doc Requirements

ICD-10 for Qualified Health

Care Professionals

Specialty Coding for

ICD-10

ICD-10-CM CERTIFIED

Your Guide to Becoming ICD-10-CM Certified Effective October 1, 2014, the ICD-9-CM code sets will be replaced with ICD-10 codes. ICD-10 will be a radical change, requiring extensive planning and training. MMI will be launching a fully customizable ICD-10-CM certification training program in the next coming months, which you can learn more about here: mmi-classes/collections/icd-10.

Your guide to certification is detailed below:

Hospital Coding ConferenceJuly 15-19, 2013 in Atlanta, GA

• Monday-Wednesday: Facility Coding, Inpatient & Outpatient

• Thursday-Friday: Facility Billing

For schedule & hotel accommodations, click here. Or call 866-892-2765.

Facility Coding•Role of Chargemaster in Coding• Identifying the Correct Principal

Diagnosis• Identifying Complications and Co-

Morbidities•Determining Present on Admission

Indicator•Using ICD-9 Volume 3•Using Facility Modifiers•Observation and Inpatient

Challenges

Facility Billing•Learn how to use UB-04•Proper reporting of Condition,

Occurrence and Value Codes•Role of Revenue Codes• Identifying Charging Errors and

Omissions•Procedure/Device Edits•Cycle Billing and Overlap of

Service Dates

16

The United States Preventive Services Task Force (USPSTF) published a recommendation in the June 25 issue of Annals of Internal Medicine that recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection and one-time screening for all adults born between 1945 and 1965.

Up to 3.9 million people in the United States are infected with HCV, a virus that can cause inflammation, permanent liver damage and cancer, according to USPSTF. An estimated 15,000 Americans die each year from the consequences of HCV infection.

USPSTF designated the recommendation as Grade B, which means, according to the task force, "There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial." On that basis, USPSTF suggests that providers offer the HCV screening.

The most significant risk factor for HCV infection is past or current injection drug use. The task force states, receiving a blood transfusion before 1992 is also an established risk factor. Additional risk factors include:

chronic hemodialysis,

being born to an HCV-infected mother,

incarceration,

intranasal drug use,

getting an unregulated tattoo, and

other percutaneous exposures, such as being a healthcare worker or having surgery before the implementation of universal precautions

The publication stated that HCV infection is most prevalent among people born from 1945 through 1965 (approx.. 80 million individuals collectively referred to as “baby boomers”) and many of them are unaware that they are infected. The CDC estimates that one out of every 30 baby boomers is living with an HCV infection. This presents a problem because HCV progresses slowly, and the risk of serious complications increases as time passes, the article explained.

This is an update to a previous recommendation. In 2004, USPSTF recommended against routine screening for HCV infection in asymptomatic adults who are not at increased risk for infection. At the time, the task force also found insufficient evidence to recommend for or against routine HCV screening for adults at high risk for infection.

To inform an update, researchers studied published evidence focusing on research gaps identified in the

previous review. The researchers found adequate evidence that the antiviral regimens used as treatment for HCV result in improved clinical outcomes, and that targeted screening misses up to two-thirds of infected patients. In addition, screening tests appear to be accurate for identifying HCV-infected patients with minimal risk of harm.

The American Association for the Study of Liver Diseases issued a statement applauding USPSTF for

upgrading its recommendation from a C to B level. "This seemingly small change…signals an incredible change in the lives of patients who have HCV and are unaware of it," the statement said. "A 'B' rating allows for payment by Medicare and private insurers for testing with no co-payment by patients." (CPT code 86803: Quest 8472 LabCorp 140659)

Hepatitis C Screenings for Baby BoomersNow Covered thanks to USPSTF’s Change in Classification

Hepatitis C Screenings for Baby Boomers

‘Up to 3.9 million people in the United States are infected with HCV’

“This...signals an incredible change in the lives of patients who have HCV

and are unaware of it.”-The American Association

for the Study of Liver Diseases

“...infection is most prevalent among people born from 1945 through 1965 and many of them are unaware that

they are infected.”-USPSTF

17

Resources: American College of Physicians

http://uspreventiveservicestaskforce.orgAnn Intern Med. Published online 25 June 2013 doi:

10.7326/0003-4819-159-5-201309030-00672AAFP.org

Hepatitis C ICD-9 Codes

Hepatitis C Screenings for Baby Boomers

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July

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July 2013 MBJ Crossword Puzzle

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July 2013 MBJ Crossword PuzzleWe hope you enjoyed this July issue of the MBJ

...now put your knowledge to the test!

Across1. The Health Insurance Portability and Accountability Act

4. Responsible for protecting the public health by assuring the safety, efficacy and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation

5. Indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed

9. The money collected from this fee will go into a fund to research the health outcomes and the clinical effectiveness, risks, and benefits of two or more medical treatments/ services

12. The CDC estimates that one out of every 30 baby boomers is living with this infection

13. A federal system of health insurance for people over 65 years of age and for certain younger people with disabilities

14. A test that checks for problems with the electrical activity of your heart

15. Means that a l l the usual pre and postoperative work for a particular procedure is included in the reimbursement for that procedure

16. Tools that help us measure and track the quality of healthcare services provided by eligible professionals, eligible hospitals and critical access hospitals within our health care system

17. Used to treat type 2 diabetes and to minimize potential associated risks

18. This was dubbed the “Stimulus bill” and provided $787 Billion to boost the economy

19. Set of standards defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria

20. A longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting

21. A short-acting selective serotonin reuptake inhibitor marketed for the treatment of premature ejaculation in men

22. A non-steroidal anti-inflammatory product used to treat the signs and symptoms of osteoarthritis and rheumatoid arthritis and to manage acute pain in adults

Down2. This law makes preventive care—including family planning and related services—more accessible and affordable for many Americans

3. Current Chief Justice of the United States

6. Used to treat severe schizophrenia and is associated with potentially fatal agranulocytosis

7. CEO of BuildYourEMR

8. The percentage of insurance premium dollars spent on reimbursement for clinical services and activities to improve health care quality

10. A temporary fee/tax intended to help move the uninsured with pre-existing conditions into the health insurance market place

11. Designed to encourage physicians and healthcare organizations to migrate to electronic health records and to show “Meaningful Use” with the goal of providing a Personal Health Record to every patient to enable them to better manage their own healthcare process

July 2013 MBJ Crossword Puzzle

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The Medical Business Journal is brought to you by the Medical Management Institute

The Medical Business Journal is a monthly source of up-to-date information on all issues affecting the healthcare industry. Its content ranges from medical coding and billing to healthcare reform legislature and beyond. The MBJ is not affiliated in any way with the Department of Health and Human Services, Medicare, or the Centers for Medicare and Medicaid Services. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting or other professional services, and is not a substitute for individualized expert assistance. The CPT codes, descriptors, and modifiers are copyrighted by the American Medical Association. For more information, please call MMI at 866-892-2765.

Editor in ChiefCarleigh Benscoter

ContributorsKathy DysonJennifer DonovanJanet SalyerMike JenkinsDorothy Steed

Layout & DesignCarleigh Benscoter

MBJ

THE MONTHLY NEWSLETTER FOR THE INFORMED HEALTH CARE PROFESSIONAL

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