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7/27/2012
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CODING TEXAS STYLE! AAPC Tyler Symposium Agenda
and Syllabus
Saturday, August 4th 2012
Registration and Check-In 7:00 – 7:45
7:45 Welcome and opening remarks: Dr. Spain
Morning Sessions:
8:00 – 9:00
Speaker: Reed Pew AAPC Chairman and CEO
“The AAPC and the Future of Healthcare”
9:00 – 10:00
Speaker: Annie Boynton CPC CPC-H CPC-P CPC-I RHIT CCS CCS-P CPhT
“ICD-10: Bracing for Change”
Break 10:00 – 10:15
10:15 – 11:15
Speaker: Hitesh Singh MD “Oncology – Understanding Lung Cancer”
11:15 – 12:15
Speaker: Debra L Patterson MD “Medicare Contracting,
Medical Review Audits, and Other Assorted Medicare ‘Stuff’ “
Lunch and Quiz 0.5 CEU!! 12:15 – 1:30
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Afternoon Sessions:
1:30 – 2:30
Speaker: William F Turner Jr, MD, Cardiothoracic Surgeon
“An Anatomical Look at Advances in Thoracic Surgery”
2:30 - 3:30
Speaker: Stephen C Spain MD FAAFP CPC “Quality Initiatives and ACO’s:
What Coders Need to Know”
Break 3:30 – 3:45
3:45– 4:45
Speaker: Loretta Swan CPC
“Take Charge of Coding: Establishing a Review Process
For Best Results”
3 4
President: Stephen C. Spain,
MD, CPC Email: [email protected]
Vice President: Patty Hobbs,
CPC, CPMA Email: [email protected]
Education Officer: Barbara
Sullenbarger, CPC Email: [email protected]
Treasurer: Judy Young, CPC
Email: [email protected]
New Member Development:
Vickie Lowder, CPC Email: [email protected]
Secretary: Zella Haynes, CPC Email: [email protected]
The Tyler “Rose” Chapter of the AAPC Officers:
7/27/2012
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Our members are our most valuable resource, and this
symposium would be impossible to produce without the hard work
and extra effort of our many volunteers. The officers would like to
give special thanks to these Tyler Rose Chapter Members:
Sharon Abercrombie, CPC, Food Chair
Gloria Sikora, CPC,Marketing Chair
Jessica Smith, IT
Kayla Williams, CPC-A, Marketing Presentation #1
Reed Pew
AAPC
Reed Pew
Chairman and CEO
AAPC
• Currently 117,000 members
• 26 credentials and counting, incl our new CPPM credential
• Have trained over 8,000 coders on ICD-10 implementation
• Now about more than coding with credentials in coding, audit,
compliance and practice management
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AAPC
• With local chapter’s help, will administer 25,000 exams this
year
• Will train 1,800 students in distance learning program
• Licenses over 250 PMCC instructors
• Handles > 500 inbound calls per day
• Assists > 540 local chapters
• Will ship 75,000 low cost code books
9
Do we have a headwind?
10
Coming Storm
• Healthcare reform; now approved by SCOTUS with mandate as a tax
• ICD-10-CM – wouldn’t we all like to know the final date?
• Costs must be contained; but thus far, nothing done
• Baby boomers (77 million vs. 40 million on Medicare today) retiring soon
• EMR’s required by CMS by 2015
• Continued reimbursement reductions
• All happening at once
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My stab at Healthcare Reform
• What has been passed now is more insurance reform
• Will not reduce costs – in fact will increase costs
• Supply/Demand – more patients, no more physicians
and probably less hospitals
• ACO’s are unproven
• Real solution?
– Remove payers from decisions; sometimes known as consumer
based healthcare
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AAPC – Moving Forward
• The credentialing entity for ALL non-clinical
physicians office personnel
– Coding (CPC + 21 others)
– Auditing (CPMA)
– Compliance (CPCO)
– Practice Management (CPPM)
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Why?
• Reimbursements will be reduced
• Physicians must figure out how to make the same or more
money
• Efficiency and leverage will be the key
• Efficiency is getting more for less
• Leverage comes from more mid-level practitioners
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More Efficient Practice
• Health world is changing, driven by costs
• Mundane tasks will become electronic
• Practices will only pay well for “intelligent” employees
• Practices want managers that can manage and do
• Yet, more emphasis on compliance, documentation, coding
and efficiency
• Aging population means more patients
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What do Physicians Need?
• To ensure charts are documented and coded correctly,
but more…
To learn how to document to get the most out of each encounter
• Practice meets all regulatory compliance requirements
cheaply and without their involvement
• An efficient, smooth, well-run office(s)
• Reduced A/R, write-off’s, internal problems
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Thus, Opportunity
• Coders that have skills beyond coding
will be of value!
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So…
• Can you audit?
• What do you know about regulatory compliance?
• Can you make an office run efficiently? Smoothly?
• Can you reduce A/R, write-offs? Can you resolve,
or better, eliminate internal problems?
18
But…
• Coding is the key to all of this
• It drives revenue
• If a coder knows coding and something
else – very valuable
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Back to Today
• AAPC will continue to: 1. Assist and provide pre-certification training for coders now, other
credentials in future
2. Administer, with huge help from chapters, high quality and
demanding certification exams
3. Prepare membership for ICD-10 in lowest cost manner possible
4. Sell the best and lowest cost code books
5. Give great member service
6. Deliver constantly improving Coding Edge and email news letters
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Check Out
• Our member savings benefits online
http://www.aapc.com/resources/member-benefits.aspx
• Use of this could save $100’s each year
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2013 Code Books
• Produced by Ingenix, high quality
• Lowest cost anywhere:
CPT®, ICD-9, HCPCS bundle only $169.95
ICD-9-CM only $54.95
CPT® only $94.95
HCPCS only $54.95
ICD-9, HCPCS, Procedural Coding Expert (has CPT® codes in it
plus more) only $129.95
• Check out all prices at AAPC online store
22
2013 National Conference
April 14th – 17th
Disney’s Coronado Springs Resort
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ICD-10
• Roadmap
• Track progress
• Reduce costs
• Be fully prepared
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ICD-10 Roadmap
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2014 ICD-10 Conferences
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• AAPC will host seven 2 ½ conferences in year of
implementation date
• They will be held in Southern California,
Northern California, Northwest, Southeast,
Texas, Midwest and East Coast.
• See our website under ICD-10 for more details
Reduced Costs
1. If you follow the entire roadmap you will pay no
more than $1,595
2. Most coders will only need code-set training in
2014, only $395 - $695
3. Some may need to brush up on Anatomy and
Physiology, only $149
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Fully Prepared
1. 5010 by January 1, 2012 – now July 1, 2012
Webpage on all you need to know on ICD-10 resources page
2. If you are charged with or a part of implementation, our two-
day boot camp will tell you all you need to do.
3. Readiness Assessments
Verify now if your physician’s documentation will work for ICD-10
If not, educate in advance
AAPC can help - $395/doctor includes education
4. Code-set knowledge
General and/or by specialty
Two days
Wait until 2014; don’t waste money now
Regional conferences in 2014 being announced
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Two Sister Companies
1. AAPC Physician Services
• Documentation and coding audits
• Compliance Tool-kit
• ICD-10 readiness assessments
• RCM consulting
• Separate management, separate addresses from AAPC
• www.aapcps.com
2. American Society of Health Informatics Managers (ASHIM)
• Training in Health Information Technology
From Health viewpoint
From IT viewpoint
• CHISP credential (only one of its kind)
• www.ashim.org
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Our Motto
• Better
• Faster
• Cheaper
• Plus one: Amazing Member Service
Let us know if we are not providing this!
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Question and Answer
What Would You Like to Know?
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Presentation #2
Annie Boynton
Implications of an ICD-10 Delay • It is important to continue moving forward with ICD-10
• Loss of momentum poses a significant risk to the entire healthcare industry
– 30 Day Public Commentary Period
• Overcome fear of change!
• ICD-10 is coming! – Proposal to delay ICD-10 until
October 1, 2014 was announced April 9, 2012.
• Treat the delay as a gift of time, additional time will help spread out costs, and allow the industry to become better prepared for ICD-10
– Better Manage the Change Process
• Strategic thinking is more critical than ever
– Planning
– Training
– Testing
ICD-10 Quick Reference Guide
Proposed Implementation deadline 10/1/2014
W58.11XA Bitten by
crocodile, initial encounter
W58.01XA Bitten by
alligator, initial encounter
Worldwide ICD-10
Adoption Timeline
United States and Italy are the last industrialized nations to implement ICD-10 for morbidity reimbursement.
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The ICD-10 Challenge
•ICD-10 requires a more complex business approach than HIPAA
5010. – HIPAA 5010 changes were specified by CMS by prescriptive EDI technical specifications.
CMS recommended health care payers’ use of new and modified HIPAA 5010 data
elements.
– ICD-10, on the other hand, requires health care payers to interpret the new ICD-10 code
set and determine how to modify business processes so that efficiencies can be gained
to drive organizational value and competitive differentiation.
– ICD-10 process changes will impact all physician practices and hospitals but there are
benefits too:
• Medical Management
– Medical Policy changes made to align with ICD-10 may impact business process
– Opportunity: richer code set allows for more focused Care Mgmt & Wellness Programs
• Contracting
– Updating contracts containing ICD-9 codes & references may impact business process
– Opportunity: additional detail allows for a more precise pricing structure
• Fraud & Abuse
– Richer data set available for Fraud & Abuse analytics may impact business processes
– Opportunity: greater specificity of code sets allows for more automation in reviews 38
Tran External
Reporting
Physicians
Clearinghouse EDI Transaction
Billing System
EHR
Coding Encounter
Documentation
Clearinghouse EDI Transaction
Payers
Claims
Payment Medical
Management
Fraud/Abuse
Preauthorization
Referrals
Med/Utilization Review
Case/Disease Management
Claims
Adjudication
Contract
Design
Benefit
Design
Compliance
Reporting
Quality
Analysis
Actuarial
Analysis
Network
Management
Translation
Pre-adjudication
Edits
Gateway
Call Center
Transactions
Data
Warehouse
In both Physician and Payer settings, ICD-10 represents a major impact to all business and
technology areas that utilize medical codes.
ICD-10 Impact Map
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ICD-10-CM Diagnosis Code Example
Diagnostic Code Set - Broad Impacts
ICD-10-CM provides 50 different codes for “complications of foreign body accidentally left in body following a procedure,” compared to only one code in ICD-9-CM.
– T81 category for complications due to foreign body show how specific these ICD-10-CM codes are compared to the one general ICD-9-CM.
– ICD-10-CM codes describe the actual complication, e.g. perforation, obstruction, adhesions, as well as the actual procedure that had been done that resulted in the foreign body being left behind.
• T81.530, Perforation due to foreign body accidentally left in body following surgical operation
• T81.524, Obstruction due to foreign body accidentally left in body following endoscopic examination
• T81.516, Adhesions due to foreign body accidentally left in body following aspiration, puncture or other catheterization
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ICD-10-PCS Procedure Code Example
Procedure Code Set - Heavily Impacts Inpatient Procedures
ICD-10-PCS provides dozens of combinations of codes for Coronary Artery Bypass Grafts compared to only 7 codes in ICD-9-CM.
− Specificity of an ICD-10-PCS code compared to the more general ICD-9-CM code
− ICD-9-CM codes 36.14 and 36.16 would be reported for this same procedure
− Each ICD-10-PCS character has a specific meaning, and there is no decimal point used in ICD-10-PCS procedure codes
– 02100Z8 Bypass, One Coronary Artery to Right Internal Mammary Artery,
Open • 0 stands for the medical-surgical section
• 2 is the heart and great vessels body system
• 1 is the root operation of bypass
• 0 is the body part – one coronary artery
• 0 is the approach, which is open for this case
• Z indicates no device was used
• 8 is a qualifier for right internal mammary artery
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Crosswalks are not the solution to ICD-10 deployment for the
industry, rather a tool to be used in creating the solution.
What Are Crosswalks?
• Crosswalks are a translation tool used to assign an ICD-9 code to the best possible match in ICD-10 (and potentially the reverse as well).
• Crosswalks will likely be created based on the CMS-created General Equivalency Mapping (GEM) files
– GEMs not crosswalks
– GEMs are more of 2 way translation dictionaries for diagnosis and procedure codes from which crosswalks will be developed.
– Interpretation of the GEMs will impact everything from medical necessity to reimbursement.
• The development of a crosswalk ideally should be a temporary measure used for specific purposes.
• Crosswalks should not alter the meaning of a code; rather represent the facts as accurately as possible.
• Creating a crosswalk from “scratch” will incur significant costs.
42
The Mapping Problem
•Development of a single “official”
mapping between ICD-9 and ICD-10 is a
major industry concern: – Not all of all the codes will map accurately 1:1
– All other codes will either lose information or assume information
that may not be true
– Imperfect mapping will affect processing and analytics in a way
that impacts revenue, costs, risks and relationships
– The level of impact is directly related to the quality of translation
– The anticipated quality of translation is currently an unknown
– GEMs do not provide a definitive match
– There may be multiple translation alternatives for a source system
code, all of which are equally plausible
– Some translation projects will require selection of a “best
alternative”
Why Do We Map?
43
Why Providers Map
Why Payers Map
Contracting with payers
Outdated documents and reports
containing ICD-9 codes
Lab orders need updates
New medical review edits
Quality Measurements
May need automated coding support
Contracting with providers and employers
Coverage determinations
Payment determinations
Plan structures
Statistical reporting
Actuarial projections
Fraud and abuse monitoring
Quality measurements
Source: Brian Levy, MD and Elaine King of Health Language 44
ICD-9 ICD-10
14,000 Diagnosis Codes
4,000 Procedure Codes
68,000 Diagnosis Codes
87,000 Procedure Codes
Angioplasty (procedure codes)
1 code
39.50
Angioplasty (procedure codes)
854 different codes
047K047 Specifying body part, approach and device
Pressure Ulcer Codes (diagnosis codes)
7 codes
707.00-707.99
Show location, but not depth
Pressure Ulcer Codes (diagnosis codes)
125 different codes
L89.131 Specific location, depth, severity, occurrence
No equivalent ICD 9 Code
-Indicated through notes and
other methods
Y71.3
Surgical instruments, materials and cardiovascular
devices associated with adverse incidents
Autopsy
89.8
No ICD 10 code
More than just a crosswalk
Example ICD-9 to ICD-10 changes
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• There may be multiple translation alternatives for a source system code, all of which are equally plausible
• Some translation projects require selection of a “best alternative”
Clinical Example:
A provider sees a patient in a [subsequent encounter] for a [non-union] of an [open] [fracture] of the [right] [distal] [radius] with [intra-articular extension] and a [minimal opening] with [minimal tissue damage].
ICD-9-CM code: 813.52 Other open fracture of distal end of radius (alone)
ICD-10-CM code: S52.571M Other intra-articular fracture of lower end of right radius, subsequent encounter for open fracture type I or II with nonunion
NOTE: For all codes related to fractures of the radius:
• ICD-9 codes = 32
• ICD-10-CM codes = 1731
ICD-10 Crosswalk Example
46
Example of Change Impact & Sensitivity – Diagnosis Related Groups (DRG)
Based
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Benefit How Achieved
• Strategic imperative
• ICD-10 transition should be viewed more broadly than “complying with a
government regulation”; it serves as an opportunity to create differentiation
and new and incremental value for the organization.
• Positive impact to Case Mix /
Quality Reporting
• More specific diagnosis reporting
• Case mix adjustments
• More specific quality monitoring / reporting; e.g., Stent Insertion (specific
codes for open vs. subcutaneous stent insertions)
• Reduced cycle time
• Increased throughput
• Reduced administrative
expense
• Fewer claim rejections and denials due to non-specific diagnoses
• Fewer requests for clinical information
• Expectations of fewer denials from payers could result in significant reduction
of rework / administrative expense for both physicians and payers
• Positively affect patient /
community health
• More specific disease management programs
• Enhanced reimbursement • Targeted reimbursement based on revised diagnoses and procedure coding
Transitioning to ICD-10 can result in significant value realization.
Benefits of ICD-10
Implementation
48
III. Physician, Hospital, Office staff and Vendor
Readiness
A Call to Action…
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• Physicians
• Clinical Administrative Staff
• Patient Accounting
• Coders
• IT Staff
ICD-10 Impact on Providers and
Payers
49
• Coding/ Billing Workflows
• Contracting Approaches
• Prior Authorization/Notification Changes
• Reporting Analytics
• Physician/ Coder Query Process
• Claims/ Billing Systems
• System Interfaces
• Electronic Data Interchanges (Clearinghouses)
• Practice Management Systems
• EHRs
People
Process
Technology
ICD-10 Impacts on Physicians
Different types of physician practices
will experience different impacts:
– Private practice physicians (solo, small group)
– Large physician groups
– Employed & academic physicians (all models)
– Government, Researchers and other types
Physician practices are highly cost
sensitive, and are already contending
with:
– HIPAA Changes
– American Recovery and Reinvestment Act (ARRA)/Health Information Technology for Economic and Clinical Health (HITECH) meaningful use incentive drivers and penalty avoidance
– e-Prescribing incentives/penalties
– ACOs
– Physician Quality Reporting Initiative (PQRI) Incentives & penalties
50
ICD-10 Impacts on Physicians
Bottom line: physicians will have to increase
level of medical record documentation
across all places of service
51 51
Concerns/Risks - Productivity impacts – Incremental effort required to support increased granularity of ICD-10 codes will likely
decrease productivity • More detailed medical records • More time to translate/interpret by coders
• Revision of coding “quotas”
• Increase provider queries by coders
• Increase queries for documentation by facilities • Same notes used in facility and office
• Increased delays in authorizations
• Increased claim rejections
• More time to research/resolve reimbursement issues
– Training requirements - People • Physicians
• Documentation Remediation – More time to document (and in more detail)
• Coders • Code Selection/Documentation Interpretation – More time to document
• Revenue Cycle Staff • Policy/Contract Changes
• Office Administrative Staff • Prior Auth Changes
Productivity losses should be expected during the initial 3-6 months due to steep learning curve
associated with use of ICD-10-CM/PCS
Concerns/Risks Discussed - Practice
52 52
Concern/Risk Mitigation
– Establish a solid practice performance baseline as early as possible.
– Knowing business in an ICD-9 world
- Collaborate with payers prior to implementation to understand baseline performance.
• New coding will likely change everyone’s
• Contracts
• Reimbursement Policies
• Coverage/Benefit Determinations
• Need to create atmosphere of awareness
• Changes and potential downstream impacts
– Perform coding/documentation audits
• Practice coding in ICD-10 prior to go live - time consuming
• Documentation remediation plans for physicians
• Time consuming – resource intensive
• Crucial to documentation and ultimately revenue
• Roughly 60% of the time ICD-9 Documentation works in the ICD-10 Code Set
Concerns/Risks Discussed - Practice
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Considerations - Business
Processes • Office billing/coding work flow
– Increased coding queries to physicians for further documentation
• Contracting code crosswalks reexamined – Medical management program requirements
• Prior Authorization/Notification changes
– Increased complexity/requirements
• Billing & Reimbursement Accounting
– Analysis and trending by payer, changes in coding and data trends
– Previous data analysis obsolete
– Extensive remapping required (i.e. comparing healthcare outcomes from ICD-9 to ICD-10)
Solutions:
• Analyze and remediate processes now to avoid potential productivity impacts
• Involve process stakeholders in implementation planning
• Centralize Planning
– Consider formal project planning
• Develop a plan to monitor revenue impacts and responses
54 54
Concerns/Risks - Job Transitions/Retirement
• Aging workforce
• Shortage of ICD-10 coding skills requiring years to master
• Timing will have impact • Increased stress/fear of change = increased likelihood of attrition issues
- Inexperienced workforce coming into a very difficult climate – morale issues
- Training is Costly - HIMSS Virtual Briefing October 2011
- 50 hours training per coder @ $100/per coder = $5k per coder for ICD-10 education
- Lack of tools/resources
- Competing priorities (5010, EMR, Meaningful Use, etc.)
Concerns/Risk Mitigation - Understand, value and invest in people - like never before
- Consider supplementing practice staff to support the initial transition - Help bridge initial decreased productivity - Better able to absorb attrition
- Reduce stress to avoid mistakes
- Too early for full staff/coder training on ICD-10 now, but not for brushing up on anatomy and
physiology, pathophysiology, pharmacology, etc (much more critical in ICD-10)
Concerns/Risks Discussed – Work Force
ICD-10 Impact Area:
Technology
55
ICD-10 Challenge: Significant Technological Impact
Understand the Need for Dual Processing
Both ICD-9 and ICD-10 Coding will be needed for some time (maybe 1 year+) post
ICD-10 transition
Practice Management & Financial Systems
Code field type/size increase to 3 - 7 alphanumeric characters in all applications
using ICD codes
Redesign System Interfaces
The way systems communicate may need to be remediated for ICD-10/ dual
processing
Software Changes
Code editing programs (Example: Encoder) will need to be analyzed, redesigned
and tested; Recalculation of DRG groupers and case mix indexes for inpatient
billing
Electronic Data Exchanges
Reporting to federal, state, and other regulatory agencies / authorities will need to
be analyzed, redesigned to accommodate new data and tested
ICD-10 Impact Area:
Technology
56
ICD-10 Challenge ICD-10 Remediation/ Action ICD-10 Mitigation Strategy
Plan ahead for possible systems remediation down time
Engage Vendors and Trading Partners Early:
• Is your organization still moving forward with ICD-10 despite the
announcement of October1,2014 proposed delay?
• Who are the ICD-10 contact people and their contact information?
• Will there be any additional fees charged as a result of the ICD-10
upgrade?
• When will system upgrades for ICD-10 go into effect?
• Will there be any additional training needed as a result of the ICD-10
upgrade?
• Is there a charge associated with any additional training that is
required?
• Besides system upgrades, what additional documentation and forms
changes will you provide? (Matrices, Clickable templates, etc)
• Will system upgrades for ICD-10 require additional hardware to
support the software modifications?
• What modifications to my EHR must be made in order to
accommodate ICD-10?
• How will your products and services accommodate both ICD-9 and
ICD-10 as we work with claims for services provided both before and
after the transition deadline for code sets.
• Does our license with you include ICD-10 regulatory updates on a
moving forward basis after the ICD-10 go live?
• What does testing mean to your organization and when will we be
able to test ICD-10 claims/transactions?
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Concerns/Risks Discussed -
Financial Concerns/Risks – Sustainability in the face of potential financial impacts
• Delayed payments due to utilization of new codes
• Increase in account receivables
• Cash flow/line of credit risks due to possible negative revenue cycle impacts
• Sustainability of the Superbill
• Impacts to People, Business Processes, and Technology will be significant
– Industry estimates indicate at minimum 3-6 months and potentially up to a 5+ year stabilization of
cash flow post ICD-10 cut over
Concerns/Risk Mitigation – Establish a solid financial baseline/revenue cycle up front
• What does the practice ICD-9 world look like today?
• What things will a practice need to think about from a modeling/trending standpoint going
forward?
• What do practices need to monitor on the back end?
– Cash flow management
• Establish transition plan with banks/payers as far in advance as possible
• Consider reserving at least six months of revenue prior to implementation mandate
• Have tools and processes to analyze practice cash flow in place early on
• Establish a contingency plan to mitigate revenue impacts
58
ICD-10 and the Physician Practice
• Practitioners may consider collaboration with Payers, State Medical Associations, Specialty Societies, etc for training and leadership in areas of:
– Code comprehension of specialty specific changes
– Documentation guidance to satisfy medical necessity requirements and increased granularity of the ICD-10 code set
– Specialty Specific Training/Education
– Communication of regulations, guidelines and updates
– Practice Management issues
External Resources: • www.aapc.com/ICD10
– Free Code Translator
– Free Resources
– Free Newsletters
• www.cms.gov/ICD10
– Free Implementation guides
• www.icd10watch.com
– Industry blog/watchdog
• www.ahima.org/ICD10
– Free ICD-10 Newsletters
• www.icd10monitor.com
– Talk Ten Tuesday Podcast
QUESTIONS??
• Speaker Contact:
• Annie Boynton
• BS, RHIT, CPC, CCS, CPC-H, CCS-P,
CPC-P, CPC-I, CPhT
• Director 5010/ICD-10 Communication,
Adoption & Training • [email protected]
• THANK YOU!!
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Presentation #3
Hitesh Singh, MD
Lung Cancer – a clinical
overview
Hitesh Singh MD
Department of Medical Oncology
University of Texas Health Sciences Center at Tyler, Texas
August 2012
79 year-old Male, smoker
Presenting with dyspnea
to the ER
CXR has 7 cm Right
Lower lobe mass
What could the mass be?
• Lung cancer (>1 cm) ~ 85%
• Metastasis – such as breast, colon 5-10%
• Other- 3% – Sarcomas
– Lymphomas
– Carcinoids
• Could be Infectious or Inflammatory
nodules
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Lung Cancer Incidence and
Mortality Incidence- 221,130 Mortality - 156,940
What would make us suspect
Lung cancer?
Risk Factors:
Smoking
90% of all cases
25% related to 2nd
hand smoking
Radon
Asbestos exposure
Family history
Presentation:
Productive cough (especially blood) - 75%
Chest pain- 40%
Weight loss 40%
Dyspnea- 20%
Recurrent infection 10-20%
We need a better look…
• CT scan of chest, abdomen and pelvis
(usually with Contrast)
• Size and distribution of masses
• Look inside airways for obstruction
• Look for blood clots in vessels
• PET scan
Next, we need to know if this is
cancer…
• We need a biopsy.
• Type of biopsy will depend on
– Location of the mass
– other masses
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Staging
Size of the primary mass (T)
+
Number (and location) of other masses
(N/M)
=
STAGE of the cancer
Making the Diagnosis…
• Need a Biopsy of the tissue mass
• Depends on suspicion of etiology, histology, accessibility, and stage of the cancer
• Methods
• Bronchoscopy, Mediastinoscopy, Thoracoscopy, Percutaneous
• How much tissue?
– FNA (EBUS- Transbrochial)
– Multiple cores
– Open Lung Biopsy
• Who?... Pulmonary Interventional Radiology, Thoracic Surgery
Staging
TNM
• T1: 0 – 3 cm
• T2: 3 – 7 cm
• T3: > 7 cm
• T4: other
• N1: bronchial
• N2: ipsilateral mediastinal
• N3: Contralateral
mediastinal
• M1: Mets
Stages T N0 N1 N2 N3
T1 IA IIA IIIA IIIB
T2:3-
5
IB IIA IIIA IIIB
T2:5-
7
IIA IIB IIIA IIIB
T3 IIB IIIA IIIA IIIB
T4 IIIA IIIA IIIB IIIB
Clinical presentation
Local effects:
• Tumor obstructing a bronchus
• Tumor obstructing a bronchus an accumulation of cellular debris ?
• Spread to pleura?
• Laryngeal nerve involvement?
• Phrenic nerve involvement?
• SVC compression?
• Sympathetic ganglion invasion
• Pericardial involvement
Systemic (
Paraneoplastic)
• ADH
• ACTH
• PTrH - SCC
• Neuro- antibodies to
calcium channels,
Peripheral neuropathy
• Leukmiod reaction
• Pulm hypertrophic
osteopathy- clubbing
7/27/2012
19
Staging tools for Lung Cancer
• CT scan
• Bronchoscopy/EBUS, Mediastinoscopy
• MRI Brain
• Pet Scan
Different lung cancers
• Epithelial – 95%
– Non-small cell (NSCLC)
• squamous cell,
• Adenocarcinoma
• Large cell
– Small cell Lung Cancer (SCLC)
Histology Non Small cell cancer:
Squamous cell -----------------------------------------------
Adenocarcinoma
Well diff poorly diff large cell poorly diff
Well diff
Small Cell Cancer:
CK -7 TTF-1
CK-7 p53
Chromogranin Synaptophysin
Biopsy Elements
Histology (microscopic elements)
• Stains to confirm
Molecular Markers if non-small cell, non-
sq
• EGFR- predictive
• ALK- predictive
7/27/2012
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Squamous cell lung cancer Squamous cell lung cancer
• Squamous cell cancer
• Risk factors- smoking
• 25-45% of lung ca
• M>F
• Genetics: P53
• Natural history:
• Precancerous lesions
Adenocarcinoma of the Lung
• Risk factors: smoking- less association than squamous an small cell
• 25-40%
• F>M
• More common in nonsmokers and women
• Genetics: EGFR mutation, Alk mutation
• Natural history:
• Types: – Bronchial derived:
– Bronchoalveolar derived: BAC mucinous
7/27/2012
21
Adenocarcinoma: Bronchoalvelor
Cancer: “lepidic growth” Large cell
• 5% • Anaplastic – possibly
dedifferentiated
forms of SCC or
adenocarcinoma
– Stains can often
help differentiated
Small Cell Lung Cancer
• 13%
• origin
• Strongest relation
to smoking (99%)
• Natural history:
The best chance for cure:
• Surgery - Fev1- 1.4L
• Stage I, II : cancer is contained in one
lung:
– Surgery can be done – offers chance for cure
Incurable:
Stage IV: metastatic disease
– No surgery – since not curable
– With exceptions
• What about Stage III? ( locally advanced
Disease)
7/27/2012
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Stage 1 NSCLC
• ~ 10%
• 2 subsets – 1A- < 3 cm
– 1B- 3-5 cm
• Treatment: – Primary treatment
• Surgery: wedge resection, segmentectomy, lobectomy
• Radiation: If poor performance status, medically inoperable, older patients > 75 yo, + margins after surgery
• RFA
– Adjuvant chemotherapy ?
• Median survival: – 1A- 115 mo
– 1B- 76 mo
Stage 2 NSCLC
• ~ 20 %
• Still confined to one lung lobe:
• IIA: T1, N1, M0
• IIB: T2, N1, M0
T3, N0, M0
• Primary treatment
– Surgery:
• Lobectomy
– Radiation : If poor performance status, medically inoperable, older patients > 75 yo, + margins after surgery
• Adjuvant chemotherapy?
• Median survival
– IIA - 47 mo
– IIB – 24 mo
Stage 3- IIIA
Non-small cell • ~15%
• IIIA:
– T1, N2, M0,
– T2, N2, M0,
– T3, N2, M0,
– T3, N1 M0
– T4, N1, M0
• Treatment: Controversial
• IIIA, N2 , Disease
• If >1 node with 3cm- no surgery- Definitive chemo radiation: 60gy
• If 1 node with < 3cm or T3, T4, N0-N1- Neoadjuvant therapy followed
by surgery if stable dz.
– Neoadjvant chemo or neoadjvant chemo radiation- 50/50
• Median survival: 17 mo
Stage IIIB
• ~15%
• Subsets
– T1-3, N3, M0
– T4, N2-3, M0
• Treatment:
– Definitive concurrent chemoradiation.
– Surgery? only palliative
• Median survival: 10 months
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Stage IV
• ~40%
• M1a- – Contralateral lung - Treat as 2
primary: Resect
– Malignant pleural / pericardial effusion
• M1b- distant mets: – Solitary Brain – Resect or RT-
--> Rx the lung
– Solitary Adrenal - Resect---> Rx the lung
– Other - Chemo
• Median Survival: – 8 mo
When is chemotherapy used ?
• Adjuvant- Stage II- III
• Metastatic disease
– Principle in metastatic disease
Chemotherapy History
NSCLC Period Treatment Survival RR (
%)
Late 1970 BSC 2-4 months
1978 Cisplatin 6 months
1989 Carboplatin 6 months
1994 Vinorelbine 8- 10 months 15-30
1998 Gem, Paclitaxol 8- 10 months 15-30
1999 Docetaxol 8- 10 months 15-30
2004 Premetrexed 8- 10 months 15-30
2004 Erlotinib 8 -10 months
~30
2006 Bevacizumab 12 + months ~35
2011 Crizotinib
Concepts we know from years of
studies 1. Chemotherapy with 1 or 2 drugs better than
BSC 2. Two drug regimens are more effective than
one. 3. Two drug platinum doublet improves
survival and QOL in patients with good performance status
4. 3 drug regimens no better than 2 5. Elderly patients can be treated safely -
ELVIS
7/27/2012
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Schiller et al 2002
First study showing certain histology is responds better to
certain chemotherapy
Scagliotti et al, 2008
Targeted therapy
Hanahan et al, 2000
Anti- VEGF - Bevacizumab
EGFR TKI - Erlotinib Alk – TKI - Crizotinib
Targeted therapy for
non-small cell, non-Sq lung
cancer Monoclonal ab
• Antibody against
Vascular Endothelial
Growth Factor
– Bevacizumab
• Extracellular
Small Molecule Inhibitor
• EGFR Tyrosine Kinase -
Inhibtor
– Erlotinib
• ALK Tyrosine Kinase
inhibtor
– Crizotinib
7/27/2012
25
Bevacizumab Stage
4,
adeno
BPC PC
Resp
Rate
35% 15%
PFS 6.4
mo
4.5 mo
OS 12.3
mo
10.3
mo
1993 - Inhibition of vascular endothelial growth factor induced angiogenesis suppresses tumour growth in vivo 1995- The effect of antibody to vascular endothelial growth factor and cisplatin on the growth of lung tumors in nude mice. 2004- Bevacizumab plus carboplatin and paclitaxel with carboplatin and paclitaxel alone in previously untreated locally advanced or metastatic non-small-cell lung- phase II
2005-Paclitaxel–Carboplatin Alone or with Bevacizumab for Non–Small-Cell Lung Cancer.
N Engl J Med 2006;355:2542-50
Indication: Stage 4- Non- small cell, Non-Sq Side effects: HTN , hemorrhage, bowel perforation
Erlotinib
• 1997_ EGFR over expression in Lung Ca
• 2004 – FDA approval for second line After failure of chemotherapy- erloyinib as single agent
• 2011: FDA approval for first line in patients with EGFR mutation , and nonsquamous only
• Exon 19- 45%, Exon 21- 40%, • Exon 20, T790 ( resistance)
• Non Smokers,Young Asian,
Women, Adenoca
• SE: skin rash, diarrhea
RR: 67% Janne et al, 2010
Crizotinib
• 2007- Identification of the transforming EML4-ALK fusion gene in non-small-cell lung cancer
• 2008 – ALK mutation may sensitize tumors to ALK inhibitors
• 2010: ALK Inhibition in Non–Small-Cell Lung Cancer: Phase 2
• August 2011- FDA Approved
• NonSquamous
• Nonsmokers
• Women
Kwak et al, 2010
RR-70%
Lung Cancer treatment:
Do we need to differentiate the types? NSCLC New Finding Squamous cell Adenocarcinoma Large cell carcinoma
Before
2006
Platinum/Taxol Platinum/Taxol Platinum/Taxol
2006 •Phase 3 study Anti- VGEF
(bevacizumab)
2007 •EGFR mutation
•K-Ras mutation
•Phase 3 study
with PKI vs
standard
Erlotinib
2009 Phase 3 study Cisplatin/Gemcitabin
e
Cisplatin/Pemetrexed
Cisplatin/Pemetrexed
2010 • ALK mutation
Crizotinib
Lung cancer
Small cell
• Cisplatin/Etoposide
Nonsmall cell Platinum/Taxol
Adenocarcoma Squamous cell •Cisplatin/gemcitabine
EGFR mutation- Erlotonib Alk mutation- Crizotinib Platinum/premetrexed
7/27/2012
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Small cell lung Cancer
1. Limited Stage – Confined to ipsilateral hemothorax ,within one radiation
port
Presentation : 30- 40%
Treatment - Chemo (cis/etoposide) + Radiation -----> PCI
Survival 18 month
15-25% - 5 yr survival
2. Extensive ( outside the radiation field)
Presentation: 60-70%
Treatment – chemotherapy
Survival – 1 year
2%- 5 yr survival
Thank You.
Questions?
Presentation #4
Debra L. Patterson, MD
Medicare Contracting,
Medical Review Audits, and Other
Assorted Medicare Stuff
Debra L. Patterson, M.D.
August 4, 2012
7/27/2012
27
Disclosures
“Medicare Contracting, Medical Review Audits,
and Other Assorted Medicare Stuff”
Debra L. Patterson, M.D.
I have no potential conflicts with this
presentation.
Medicare Functional Environment
Medicare
Administrative
Contractors (MACs)
ZPICs
Zone Program Integrity
Contractors
Qualified
Independent
Contractors (QICs)
Enterprise
Data
Centers (EDCs)
Medicare
Secondary Payer
Recovery Contractor
(MSPRC)
Beneficiary
Contact
Center (BCC)
Administrative
Qualified
Independent
Contractors
(Ad QICs)
Healthcare Integrated
General Ledger
Accounting System
(HIGLAS)
Recovery Audit
Contractors
Comprehensive Error Rate
Testing Contractors (CERT)
QIOs, MACs and Others
Entity QIO FI/MAC CERT RAC PSC/
ZPIC PERM
Primary
Audit
Purpose
Promote
Quality
of Care
Prevent/
reduce
improper
Medicare
FFS
payments
Measure
improper
Medicare
FFS
payments
Identify/
collect
past
improper
Medicare
FFS
payments
Identify
fraud and
abuse in
Medicare
FFS
Measure
improper
Medicaid
payments
Provider
Education
Purpose
Educate
about
quality of
care
Educate
about
submitting
claims for
correctly
coded,
medically
necessary
services
N/A N/A N/A N/A
MAC Tasks
• A/B Claim Processing – Computer systems and EDI
– Front-end claim review
• Integrity Program – Enrollment
– Data analysis
– Medical review
– Local coverage policy
• Provider education
• Customer services
• Appeals and Redeterminations
7/27/2012
28
2/3
F
CA
NV
AZ NM
TX
ID
OR
WA
MT
WY
UT
CO
OK
KS
NE
SD
ND
LA
AR
MO
IA
MN
WI
IL
MI
IN OH
KY
TN
MS
AL GA
FL
SC
NC
VA WV
PA
NY
ME
NH
VT
MA
CT
NJ
MD DE
DC
RI
HI
AK
1
2/3
F
1
4/7
H
5
15
12
13
11
10
9
6 8
14
New
Juris
Old
Juris
Percentage
of Workload
Est. Date of
Solicitation
E 1 8.8% Jan 2012
F 2,3 5.8% Oct 2010
G 5,6 12.7% Sept 2011
H 4,7 13.2% Nov 2010
I 8,15 11.8% July 2014
J 10 7.3% Jan 2013
K 13,14 12.3% Mar 2012
L 12 10.9% Mar 2012
M 11 8.9% May 2014
N 9 8.2% Sept 2012
J1 – Palmetto
J2 – Noridian
J3 – Noridian
J4 – TrailBlazer
J5 – WPS
J6 – NGS
J7 – TBD
J8 – WPS
J9 – First Coast
J10 – Cahaba
J11 – Palmetto
J12 – Highmark
J13 – NGS
J14 – NHIC
J15 – CIGNA
MAC Jurisdictions Who are we?
• Novitas Solutions, Inc. (Novitas), formerly Highmark Medicare Services
Inc., is a wholly-owned subsidiary of Diversified Service Options, Inc.
(DSO), a subsidiary of Blue Cross Blue Shield of Florida (BCBSF)
• DSO was established in 1998 for fee-for-service government business,
which today includes Novitas, First Coast Service Options (FCSO), and
50% ownership in Tri-Centurion.
• Novitas and its predecessor organizations have been a Medicare contractor
since the inception of the Medicare Program.
• Novitas currently serves as the MAC for J12 (PA, NJ, MD, DE, and DC)
and the administrator of the nationwide Section 1011 contract for Federal
Reimbursement of Emergency Services Provided to Undocumented Aliens
110
Where are we?
111
• Existing Locations
Camp Hill
Williamsport
Pittsburgh
Hunt Valley, MD
• New Offices
Jacksonville, FL
Milwaukee, WI
Dallas, TX
Medicare FFS Regions
112
JFNoridian
JE2013
JH Novitas
JG2016
JM2015
J9FCSO2013
J12Novitas
JK2012
Diversified
Service Options
7/27/2012
29
Our commitment
Novitas will operate in such a manner that
fully demonstrates our commitment and
dedication to: • Integrity and compliance
• Fiscal responsibility
• Operational excellence
• Continuous improvement
• Meeting our stakeholders’ goals and expectations
113
Fast Facts
Jurisdiction H
Jurisdiction 12/L
• Annual Claim Volume ~ 165 Million ~ 125
Million
• % of National Workload 13.2 10.9
• Annual Benefit Payments ~$ 49 Billion ~$ 39
Billion
• Beneficiaries 9.9 Million 8.6
Million
• Part B Providers 155,000
158,000
• Hospitals 1,285
543
• Other Facilities 5,601
2,155 114
Key Implementation Items
• Timeline
115
Communications
•Objective – Identify the processes and procedures that will
ensure all stakeholders are informed of the
implementation, its progress, and any impacts
• Primary Groups − Professional Associations/Organizations
− Government
− Beneficiaries/Advocacy Groups
− Other CMS Contractors
116
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Outreach & Education
Professional Groups/Billers
117
Medical Societies
Hospital Associations
Providers
Rural Provider Organizations
Mass Immunizer Billers
IHS/Tribal Billers
Veteran Affairs
Non- Physician Providers (e.g.
Ambulance, Labs)
AAHAM/MGMA/HFMA Chapters
EDI Billers
Key Communication Venues
• In-person meetings
• Transition Consulting Teams
• Listservs/Social Media
• Website
– Newsletters/Policy/EDI
– Alerts/Updates
– Frequently Asked Questions (and Answers)
– Inquiries
118
www.Novitas-Solutions.com
119
Local Coverage Determinations
General
Scientific Basis
Data Driven
CAC members play a key role
Contractor Advisory Committees
State Based
Existing Schedule initially
JH Local Coverage Determinations
Created from J4/J7 Policies
Submission to CMS : 5/11/2012
Posting of LCDs : 6/28/2012
LCD reconsideration process
120
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31
Novitas LCDs for JH
See handouts for lists of the following
All JH LCDs
Existing TrailBlazer LCDS carried forward
LCDS from Pinnacle and Cahaba
Payment Accuracy
Several federal laws and executive orders require
that the government measure and attempt to
reduce the payment error rates in federal
programs.
http://www.paymentaccuracy.gov/
Trust Fund Expenditures
•Trust Fund Expenditures = $340 Billion
Part A Inpatient
Part AOutpatient
Part B
DME
37% Short and Long Term PPS
Acute care hospitals
4%
27% Physicians
Other professionals Ambulance
Laboratory and Diagnostic
32% Non-PPS Hospitals
Outpatient Hospital SNF
Hospice ESRD
Source: Medicare Fee-For-Service 2010 Improper Payment Report
Inpatient Review
–Office of Inspector General (OIG) reviews.
• As far back as 1998.
–RACs.
• Have identified lack of medical necessity for short
stay hospital admissions (1-2 days).
–CERT program findings.
–Focus of Program for Evaluating Payment
Patterns Electronic Report (PEPPER).
7/27/2012
32
Inpatient Review: New Environment
• A/B MACs began reviewing inpatient hospital claims for improper payment prevention/reduction in the summer of 2008:
– FIs and MACs allowed to review claims submitted beginning January 1, 2008.
• CERT began reviewing acute care hospital claims for improper payment measurement in April 2008:
– This corresponds with the beginning of the November 2009 Medicare Fee-for-Service (FFS) Improper payment report period.
– CERT will review claims beginning April 1, 2008.
2010 CERT Paid Claims Error
Rate
Type of Contractor Paid Claims
Error Rate
Projected Dollars
Paid in Error
Overall 10.5% $34,268,664,880
Part B 12.9% $10,939,319,559
DME MAC 73.8% $ 7,251,392,747
Part A (all) 6.9% $16,077,952,575
Part A (excluding
inpatient)
4.2% $ 4,745,626,984
Part A (Inpatient PPS) 9.5% $11,332,325,591
2011 CERT Paid Claims Error
Rate
Type of Contractor Paid Claims
Error Rate
2011
Projected Dollars
Paid in Error
Overall 9.9%
(10.5%)
$33,458,559,722
Part B 10.5%
(12.9%)
$ 8,881,006,974
DME MAC 67.4%
(73.8%)
$ 6,553,181,121
Part A (excluding inpatient) 5.1% (4.2%) $ 5,984,473,459
Part A (Inpatient PPS) 9.6% (9.5%) $12,039,898,168
2012 CERT Paid Claims Error
Goal
Type of Contractor Paid Claims
Error Rate
2011
Dollars Paid
in Error
2012
Goal
Needed $
Reductio
n
Overall 9.9% $33.4 B 6.2% ~ $12.5 B
Part B 10.5% $ 8.9 B
DME MAC 67.4% $ 6.6 B
Part A (excluding
inpatient)
5.1% $ 6.0 B
Part A (Inpatient
PPS)
9.6% $12.0 B
7/27/2012
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TrailBlazer Inpatient Pilot Error Rates
Sample DRG Description
1 291–293 Heart Failure
Short Stay
2 981–983 OR Procedures
Unrelated to
Principal Dx
3 Misc Cost
Outlier DRGs
4 Misc Long
Term Care
Hospital DRGs
5 166, 167
and 264
Open/Closed
Biopsy DRGs
6 247 Drug Eluting
Stent
Placement
DRG
55.04%51.43%
69.71%
56.43%
36.13%
98.83%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percen
tag
e
Sample 1 Sample 2 Sample 3 Sample 4 Sample 5 Sample 6
Sam
ple
1
Sam
ple
2
Sam
ple
3
Sam
ple
4
Sam
ple
5
Sam
ple
6
Current Reviews
•2011 Part A/B Crossover Review Results
0%
10%
20%
30%
40%
50%
60%
70%
80%
DRG
243
DRG
246
DRG
247
DRG
460
DRG
470
Overall
Current Reviews Error Reasons
• TrailBlazer findings similar to those of the CERT
– Unwarranted inpatient stay
– “Medical necessity” for admission not demonstrated in the
record
• Medical necessity for primary procedure not documented.
• Primary procedure not consistent with existing coverage
policy.
• Primary procedure not consistent with existing specialty
practice guidelines/standards.
Inpatient vs. Outpatient
– Inpatient admissions must have a written order for admission.
– All orders must have a legible signature and meet signature
requirements.
– After an outpatient procedure, a patient goes to recovery and may
stay overnight.
– It would only be observation if there was an order for observation and
a medical reason for observation (e.g., expanding hematoma,
complication, etc.).
– If patient is likely to be in hospital more than 24 hours, it would be
inpatient admission; otherwise outpatient.
7/27/2012
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Medical Necessity
Hospital records related to admissions/DRGs
for elective surgical procedures too often do
not contain enough detail about the patient’s
condition to satisfy basic InterQual screening
criteria.
Total Joint Replacement DRGs
“DJD knee, failed outpatient therapy, admit
for right total knee replacement.”
Medical Necessity Total Joint
Replacement
Evolution of the patient’s condition
History of the patient’s illness from onset until the present.
Prior course(s) of treatment and the result of prior treatment(s).
Current symptoms, findings and functional limitations due to disease.
Joint examination with objective findings consistent with historical details.
Operative findings supporting end-stage joint disease
Documentation of patient’s functional limitations or need for adaptive behavior or use of assistive devices (e.g., canes, walkers, wheelchair).
Suggested Actions
• Physicians and others who provide inpatient services must produce clinically meaningful inpatient records or supply the hospital with relevant documents from their outpatient records.
• Hospitals could proactively obtain previous diagnostic and therapeutic records from other sources
History and physical, progress notes, relevant “consultations,” from the surgeon and other treating physicians.
Physical and occupational therapist evaluations and therapy notes.
Imaging reports.
Therapeutic procedure (such as joint injection) notes.
7/27/2012
35
• DRG 227 – Cardiac defibrillator implant without cardiac catheterization
without major complications or comorbidities.
• DRG 243 – Permanent cardiac pacemaker implant with complications or
comorbidities.
• DRG 244 – Permanent cardiac pacemaker implant without complications
or comorbidities/major complications or comorbidities.
• DRG 246 – Percutaneous cardiovascular procedure with drug-eluting
stent with major complications or comorbidities or 4+ vessels/stents.
• DRG 247 – Percutaneous cardiovascular procedure with drug-eluting
stent without major complications or comorbidities.
TrailBlazer A/B Crossover Audits
•DRG 251 – Percutaneous cardiovascular procedure without coronary
artery stent without major complications or comorbidities.
•DRG 253 – Other vascular procedures with complications or
comorbidities.
•DRG 254 – Other vascular procedures without complications or
comorbidities/major complications or comorbidities.
•DRG 291 – Heart failure and shock with major complications or
comorbidities.
•DRG 292 – Heart failure and shock with complications or comorbidities.
TrailBlazer A/B Crossover Audits
• DRG 293 – Heart failure and shock without complications or
comorbidities/major complications or comorbidities.
• DRG 392 – Esophagitis, gastroenteritis and miscellaneous digestive
disorders without major complications or comorbidities.
• DRG 460 – Spinal fusion except cervical without major complications or
comorbidities.
• DRG 470 – Major joint replacement or reattachment of lower extremity
without major complications or comorbidities.
• DRG 552 – Medical back problems without major complications or
comorbidities (two days or less).
• Inpatient High Dollar Edit.
TrailBlazer A/B Crossover Audits
Take Home Message
• The quality of the information within a
document is usually more important than
the record’s volume.
• (Beware the Curse/Blessing of the EHR)
7/27/2012
36
Questions Presentation #5
William F. Turner Jr, MD
Hybrid Coronary Revascularization A Surgeon’s Perspective
William F. Turner Jr., MD
Louis and Peaches Owen Heart Hospital
Trinity Mother Frances Hospitals and Clinics
Tyler, Texas
www.heartsurgery-tyler.com
Hybrid Revascularization
Total endoscopic coronary artery bypass grafting in combination
with percutaneous catheter intervention as a simultaneous or
staged approach for the management of patients with multivessel coronary disease.
7/27/2012
37
Why “Hybrid Coronary
Revascularization?”
Complex PCI is transformed into a simpler procedure and
complex CABG is transformed into a simpler operation
Hybrid
Revascularization
Objectives
Relieve symptoms and prolong life
Achieve a durable result
Avoid Complications
Decrease Morbidity
Patient Satisfaction
Patients Don’t Want This! Patients Will Demand This !!!!
7/27/2012
38
Hybrid
Revascularization
“The Best Of Both Worlds”
No Documented Survival Benefit of
SVG over Stents (SYNTAX,EAST,BARI)
Survival Benefit of Internal Mammary
Artery Grafting to LAD
LIMA to LAD
“There is now incontrovertible evidence that
for patients with severe diffuse coronary
atherosclerosis who are candidates for
myocardial revascularization, internal
thoracic artery grafting to the left anterior
descending coronary artery is the single
most important determinant of survival
and event free survival.”
Floyd D. Loop NEJM, 1996
7/27/2012
39
Hybrid
Revascularization
Requirements
Collaboration between cardiologist and
surgeon
Education of the patient and referring
MD
Elimination of turf battles
Patient centric and not procedure
centric
Skilled operators(surgeon and
cardiologist)
Choosing The Appropriate Patient
True ostial LAD-high risk for stenting
Chronic total occlusions with
demonstrable ischemia
Left main involvement
Vessels unsuitable for TECAB can be
stented(PDA,PLB,OM3)
Multiple co-morbidities
Hybrid Revascularization
Contraindications Very large hearts (Cor bovinum)
Hemodynamic instability
(MI < 24 hrs; dysrhythmias)
Decompensated heart failure
Inaccessible artery (calcified, diffuse
disease, intramyocardial)
Morbid Obesity (BMI>40kg/m2)
Simultaneous TECAB and
PCI
Advantages
Complete revascularization in one
operative setting (hybrid suite)
Immediate quality assessment of IMA
Any graft issues corrected immediately
Shorter hospital length of stay and
faster functional recovery
No platelet inhibition during surgery
7/27/2012
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Staged Hybrid Approach
“Who goes first?”
Surgery followed by PCI :in majority of
patients
PCI followed by surgery: acute
coronary syndrome requiring PCI
culprit vessel in multivessel disease
Staged Hybrid Approach
a
PCI interval managed according to
post op recovery from TECAB
Qualitative assessment of graft
patency
No antiplatelet agent concerns
Revascularized myocardium(LIMA-
LAD)
Hybrid Revascularization
Illustrative Case 80 yo male with occluded LAD and
viable anterior wall; 90% RCA; EF~
40%
Multiple high risk characteristics – DM,
PVD, CRI, COPD
Rx: TECAB (LIMA-LAD) followed by
PCI (DES to RCA) on same day
Uneventful hospital course; no
transfusions; discharged to home in 3
days
TECAB
Total endoscopic coronary artery
bypass grafting performed in a
closed chest on a beating heart
without the use of
cardiopulmonary bypass.
7/27/2012
41
A Sixteen Year Odyssey
OPCAB ROBOCAB TECAB
Sternotomy
• Heart Stabilizer
• Heart Positioner
• Retractor System
•2,824cases
Closed Chest
• Endo IMA
• Endoscopic
Positioner
• Endoscopic
Stabilizer
• 70 cases
Small Incision
• Endo IMA
• NS Positioner
• NS Stabilizer
•323cases
TECAB:LIMA-LAD
TECAB:LIMA-LAD Transit Time Flow
Measurement: Every Graft !!!
7/27/2012
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TECAB-PCI TECAB-PCI
TECAB “Incisions”
Hybrid Revascularization
Procedures
Patient Num Surgery Graft PCI Targets
1 TECAB LIMA-LAD DES x 2 RCA
2 SVST LIMA-LAD DES x 1 CX
3 TECAB LIMA-LAD DES x 1 D1
4 TECAB LIMA-LAD DES x 1 RCA
5 SVST LIMA-LAD DES x 1 RCA
6 SVST LIMA-LAD DES x 1 RCA
7 TECAB LIMA-LAD DES x 1 RCA
8 TECAB LIMA-LAD DES x 1 CX
9 TECAB LIMA-LAD DES x 1 RCA
10 TECAB LIMA-LAD DES x 1 RCA
7/27/2012
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Post Op Results
No postoperative mortality
All patients discharged within 48 - 72
hours of surgery
3 conversions to small thoracotomy (2
poor flow, 1 inadequate working space )
Conversion ~7cm incision
Clinical & Economic
Impact
Complete revascularization without
sternotomy
No heart-lung machine
Less trauma
Superior IMA bypass conduit
Less painful than
sternotomy/thoracotomy
Fast functional recovery
Conclusion
Hybrid revascularization is
safe,effective and a viable
alternative to conventional CABG
for selective patients with
multivessel CAD
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Presentation #6
Stephen Spain, MD, CPC
7/27/2012
45
Stephen C. Spain, MD, CPC
President 2012, Tyler Rose Chapter of the AAPC
AAPC NAB member
Family Physician
CEO, Doc-U-Chart Practice Consultants
PQRI, PQRS, and ACO’s
What are these things, and…
…Why do coders need to
care?
“Quality” is the common theme
Medicine in Modern Times
• Improving access to care
• More medical schools
• More medical specialty societies
• Advances in services and tools
• Advances in treatments
• Centers for advanced treatment
• Improved outcomes, healthier population
• Higher cost
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The effects of rising costs
• Employees generally fared well
• The unemployed, particularly the elderly
and disabled were at a disadvantage
• “The Great Society”
• Federal healthcare spending will soon
eclipse all private spending on healthcare
• Healthcare is a HUGE expense
• We must be frugal
So why the emphasis on
quality? • Most services are high quality
• There are always be some “rotten apples”
• The “bad eggs” generate concern about
wasted resources
• Concern leads to action to stop waste and
ensure quality services across the board
• The taxpayer does not want to be “ripped
off”
How do we define “Quality”?
• Enduring
• Exceeds expectations
• Satisfying
• Good value received for the dollars
spent
CMS defines “Quality” as value
• From a payers perspective, if services
result in lower overall spending, then they
are of “value”
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CMS tries an experiment
• Premier Hospital Quality Improvement
Project
• Incentive payments for reporting quality
measures
• “Pay for Performance”
• Measures were closely linked issues,
treatments, or observations that had
potential to either save or waste money
CMS tries an experiment
• The Premier Hospital Quality Improvement
Project was very successful
• For extra pay, providers would report data
• Not much was done with the reported data
• The PQRI initiative was born of the
success of the Premier Hospital Quality
Improvement Project
PQRI
• Physician’s Quality Reporting Initiative
• Relies on “Measures”
• CMS enlisted help in developing measures
• AMA and other groups participated
• Several hundred measures are now being
reported and tracked
• There are measures that are pertinent for
virtually any type of healthcare provider
How does Quality Reporting
work? • For example pneumonia vaccine
• Providers reports vaccine status
• If unvaccinated, vaccine is given and
reported with corresponding code
• More vaccinated patients means fewer
cases of disease and treatment
• Less instance of illness saves
healthcare dollars
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How does Quality Reporting
work? • Several years of experience now
shows providers will report quality
measures:
• For vaccines,
• Preventive screenings,
• Health counseling,
• Effective disease treatments
PQRI in Practice
• Quality measures pertinent for every type
of provider
• Provider chooses at least 3 applicable
measures to report
• Reporting can be claim based, 3rd party
registry, or integrated into EHR
PQRI in Practice
• Example: Endocrinology
• Selects at least 3 measures:
– Hgb A1C with poor control A1C>9%
– LDL controlled LDL-C < 100mg/dl
– High BP controlled BP< 140/90
• A minimum of 3 measures must be
reported for at least 80% of eligible
Medicare encounters for the one year
period
PQRI in Practice
• Incentive is earned for successfully
reporting at least three measures for the
year
• No way to track progress
• Check arrives, if earned, as much as 6
months after the end of the reporting year
• The bonus is 0.5% of all Medicare
revenues received for the year
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PQRI in Practice
• Incentive payments are phased out in
2014
• Penalties for not participating go into effect
in 2015
• Initially 1.5%, increasing to 2% in 2016
• For those not now participating, there will
be keen interest in learning how to comply
with PQRI as penalties are phased in!
PQRI: Moving Forward
• Not much being done with data now
• Desired effect of reporting more passive in
nature
• Number of quality measures are ever
expanding
• Look for CMS to mandate measures and
for many more than 3 to be required
Accountable Care Organization
• The AAFP’s Medical Home
• Seemed to dovetail well with the PQRI
program
• The idea of centralizing care and tracking
progress with quality measures developed
• HMO’s never had this type of access to
electronic data and information retrieval
and tracking
Accountable Care Organization
• Provides all necessary medical services
• A new type of insurance network
• The ACO receives a lump sum payment
for providing services to at least 5,000
beneficiaries
• The ACO has carte blanche to use just
about any means they can come up with
to save money while providing quality care
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Accountable Care Organization
• Avoid redundant services
• Improve communication between providers
• manage illnesses more efficiently
• Avoid complications
• Emphasize preventive care and healthy
lifestyle education
• Providers will get to share in any savings
Accountable Care Organization
• Like an HMO, but not exactly…
• Patients must be included on decision
making boards
• Members are free to seek healthcare
outside the ACO, using their regular
Medicare benefits
• This freedom of choice will be a strong
incentive for the ACO
Accountable Care Organization
• PPACA
• 32 “Pioneer” ACO’s
• Over 200 more applications granted or
in process
• Too early to estimate success
• Like the PQRS, rely on reporting of
quality measures
• Initially 65, but final rule changed that
to 33 quality measures required
Accountable Care Organzations
• Let’s look at required Quality Measures
• 4 categories or “Domains”
– Patient/Caregiver Experience
– Care Coordination/Patient Safety
– Preventive Health
– At Risk Populations • Diabetes
• Ischemic Heart Disease
• Heart Failure
• Coronary Artery Disease
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Patient/Caregiver Experience
• 1. Getting Timely Care, Appointments, and Information.
• 2. How Well Your Doctors Communicate.
• 3. Patients’ Rating of Doctor.
• 4. Access to Specialists.
• 5. Health Promotion and Education.
• 6. Shared Decision Making.
• 7. Health Status/ Functional Status.
Care Coordination/Patient Safety
• 8. Risk-Standardized, All Condition Readmission*.
• 9. Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary
• 10. Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure
• 11. Percent of PCPs who Successfully Qualify for an EHR Incentive Program Payment.
• 12. Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility.
• 13. Falls: Screening for Fall Risk.
Preventive Health
• 14. Influenza Immunization
• 15. Pneumococcal
• 16. Adult Weight Screening and Follow-up.
• 17. Tobacco Use Assessment and Tobacco Cessation Intervention.
• 18. Depression
• 19. Colorectal Cancer Screening.
• 20. Mammography
• 21. Proportion of Adults 18+ who had their Blood Pressure Measured within the preceding 2 years.
At Risk Population: Diabetes • 22. Hemoglobin A1c Control (< 8%).
• 23. Low Density Lipoprotein (< 100mg/dl).
• 24. Blood Pressure < 140/90.
• 25. Tobacco Non Use.
• 26. Aspirin Use.
• 27. Hemoglobin A1c Poor Control (> 9%).
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At Risk Populations: Hypertension
• 28. Hypertension (HTN): Blood
Pressure Control.
At Risk Populations: IVD
• 29. Ischemic Vascular Disease (IVD):
Complete Lipid Profile and LDL Control <
100 mg/dl.
• 30. Ischemic Vascular Disease. Ischemic
Vascular Disease (IVD): Use of Aspirin or
Another Antithrombotic.
At Risk Populations: Heart Failure
• 31. Heart Failure: Beta-Blocker
Therapy for Left Ventricular Systolic
Dysfunction (LVSD).
At Risk Populations: CAD
• 32. Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Drug Therapy for Lowering LDL-Cholesterol.
• 33. Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD).
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Annual Wellness Visit
• Many measures are the same as AWV
requirements
• Fall risk
• Depression screen
• Weight screen
• BP screen
Comaparison ACO vs PQRI
• ACO
• Newer
• May not be viable
• PPACA
• Only 33 measures
• Voluntary
• PQRI
• 5 year history
• CMS likes them
• Pre-PPACA
• 100’s of measures
• Bonus now, penalty
later for NOT
complying!
The Future…
• 0.5% is not a huge incentive
• 2.0% penalty will be a strong incentive!
• Expect PQRS interest and participation to
EXPLODE in the next three years!
• Private insurers are implementing PQRS
and ACO’s
• Private Insurance involvement will further
drive participation
The Future…
• Experience in quality reporting will
ease ACO participation
• PARS implementation could be a
smart strategy to prepare for
integration into an ACO
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The Future…
• How can coders take advantage?
1.Understand PQRS and ACO’s
2.Discuss these programs with your
colleagues and superiors
3.Learn the quality measures that apply to
your area of expertise
4.Know how to find documentation for your
quality measures
The Future…
• How can coders take advantage? (cont.)
5.Develop tools for easier documentation of
quality measures
6.Develop tools and processes to tabulate
quality measures reporting
Summary
• Healthcare is changing…what else is
new?
• The payers want VALUE…don’t we all?
• These new systems are designed to
enhance value and save money
• Providers are going to have to adapt to
provide services AND report quality
measures
• SCOTUS
PQRI, PQRS, and ACO’s
What are these things, and…
…Why do coders need to
care?
Stephen C. Spain, MD, CPC [email protected]
AAPC Code #:
7/27/2012
55
Presentation #7
Loretta Swan, CPC
Take Charge of Coding: Establishing a Review Process for
Best Results
Loretta Swan, CPC
Tyler AAPC Annual Symposium
August 4, 2012
Objectives
• Reason and benefits of reviews
• Steps to implementing a coding review
program
• Case study example
Why?? You’ll never find yourself until you face the truth.
• Identifies potential risks to the provider(s)
• Ensures compliance with organizational policies & procedures, payer regulations and coding guidelines
• Facilitates the maintenance of an accurate assessment of coding practices
• It’s the right thing to do…
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Benefits Well done is better than well said.
• Decreases risk of fines and refunds
• Captures lost revenue and reduces denials
• Increases accuracy of the provider’s documentation
• “Spots” warning signals before they turn into “danger zones”
Step 1: Team Assembly Let’s make a dent in the universe - together.
The right staff
– Qualified, trained
– Certified coders
Assigned to each physician and office
Communications and introductions
The right number
– Physicians to coder ratio
Consider outsourcing option
Step 2: Develop a Plan Failing to plan is planning to fail.
• Types of reviews to be conducted
• Determine where and why your practice deviates from standards
• Identify coding problems or risk areas
• Determine sample size
• Determine the acceptable threshold
• Determine reporting structure
Step 3: Program Design Good plans shape good decisions.
• Define initial assessment
• Frequency of chart reviews
• Coding education for staff and
physicians
• Produce monthly coding “tips”
• Document the efforts to improve the
coding process
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Sample New Patients Utilization
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
1 2 3 4 5
CurrentPractice
Profile
NationalDist. %
Sample Established Patients
Utilization
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
1 2 3 4 5
CurrentPractice
Profile
NationalDist. %
Step 4: Get Ready It wasn’t raining when Noah built the ark.
Establish timeframe of reviews Produce reports for E/M utilization
comparison
Select focus of audit
Levels of services
All or selected providers
Step 5: Conduct Reviews We learn by doing.
Initial internal risk assessment *
– 10 charts per provider
– Based on determined focus
Record findings
Communicate
Letters/findings to physicians *
Provide tools *
1:1 meetings with Phase II results
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Step 6: Monitoring &
Education You monitor what you measure.
• Include everyone who participates in coding tasks
• Evaluate success
– Report, report, report *
– Consistent chart reviews
– Monthly coding meetings & newsletter
– Monthly physician utilization reports
Step 7: Resolve Loose Ends
Under-billed claims may be eligible for
appeals or re-billing.
Over-billed claims may require repayment
– See legal advice before implementing
corrective action and repayments
Our Phase I
Conduct an internal risk assessment
– Set goals based on findings
– Physicians
– Staff
Offer education sessions
Provide feedback to physicians/staff
– Letter
– Audit Checklist
Our Phase II - Providers
• Conduct 1:1 educational sessions
• Repeat chart reviews within 2 weeks
– Return to Phase I if within standard range
– Provide additional training on errors
• Repeat chart reviews after 4 weeks
– Return to Phase I if within standard range
– Refer to Phase III if no improvement after 60 days
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Our Phase III - Providers
• Cost of team member allocated to physician’s individual expense
• Provide 1:1 training
• Review documentation on site prospectively for 1 week
– Daily discussion with physician of findings
• Repeat chart reviews after 2 weeks
– Return to Phase I if within standard range
– Refer to Medical Director if no improvement
Phase III Course of Action
Review with
physician
To charge entry for
posting
No errors
To charge entry for
posting
Correct CPT codes
Errors detected
Chart audited
Chart given to
coder for reveiw
Physician sees patient
Success at Last!
Actual Case Study
Prior to program implementation
– 40 prepay audits of 99214
– 87% error rate (Services were down-
coded and paid at lesser rate.)
1 year after program implementation
– 56 prepay audits of 99214
– 0% error rate
Other Monitoring Ideas Remember where you have been and know where you
are going.
• Monitor high-risk areas more frequently.
– OIG workplan
• Conduct employee pre- and post- training
tests to ascertain level of understanding.
• Review claim rejection reports monthly.
• Follow up on reported issues identified by
staff and other sources.
• Develop written policy and procedures.
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Words of Advice… Tomorrow is often the busiest day of the week.
Focus on the right areas without overdoing it.
Keep it educational not investigational.
Begin somewhere; you cannot build on what you intend to do.
Attachments
Various Medicare Payment Review Entities
Sample Review Letters
Review Template - Summary
Review Tools
