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WELCOME!
Welcome to the winter issue of the Leading Edge: this issue is overflowing with information about coding and billing changes coming in 2012. Among other items, we highlight the many coding changes and the OIG work plan. In addition, Accountable Care Organizations (ACO’s) get center stage with final Medicare rules now in place. You may recall that ACO’s are one of the many paths that CMS is trying to connect health outcomes with health payments—all driven by Healthcare Reform legislation.
Other important regulatory changes are the imminent cutover to 5010, as described in our last issue. We provide a brief update on 5010 and the current status of Congressional attempts to deal with the “SGR” cuts to Medicare physician reimbursement originally scheduled to take place on January 1.
Inside you will find a profile of our corporate headquarters office in Warren. Later, you will read about holiday charity activities at many of our offices, “spirit week” in Lombard, and much more. I do want to highlight the heart-warming story contributed by Lisa Ivanovitch from the Salem office. I can’t think of a better story to illustrate the “spirit of the season,” even though the events described took place earlier this year.
As always, we appreciate your feedback and suggestions. In particular, we welcome new topics where you would like to have more information.
As the year draws to a close, I want to offer the personal thanks of each AHS employee for your confidence in AHS this year and, on our collective behalf, we wish you and your family a healthy, happy new year!
Please call or email me with your suggestions for the next issue: [email protected] or 908-279-8120.
Bill Gilbert
THE LEADING EDGEVol. 6 | Winter 2012Billing Technology Results
WELCOME | page 1
AHS PROFILE: WARREN | page 1
CMS ISSuES ACO FINAL RuLE | page 2
2012 E-PRESCRIBE (ERx) INCENtIvE PROGRAM | page 4
FEAtuRED EMPLOYEES | page 6Speaking at Everest College | page 6tis the Season to Give to Others | page 6
CALENDAR | page 8
ABOut AHS | page 7Lombard Spirit Week | page 7A Family Loss in Salem | page 7
“SGR”: MEDICARE PHYSICIAN REIMBuRSEMENt | page 8
CMS PuSHES BACk ENFORCEMENt OF 5010 | page 8
COMPLIANCE: OIG 2012 WORk PLAN | page 9
WHAt’S NEW FOR 2012 CPt CODES | page 10
IS OFFICE-BASED ANEStHESIA FOR YOuR PRACtICE? | page 12
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Anesthesia and Pain Management
AHS PROFILE: WARREN
Warren, New Jersey is the AHS corporate headquarters with twenty people including IT, finance, compliance, marketing, and AHS executives including David Langsam, AHS President & CEO. The finance team handles accounts payable, invoicing, accounts receivable and client refund processing for the entire company. Of course, they also lead budgeting and forecasting efforts across the company, and support the monthly board of directors’ calls and meetings.
The IT team in Warren is headed by the AHS CTO (Chief Technology Officer) Manny DaSilva. The IT team is always busy, working both near-term and longer-term development initiatives. Their scope encompasses AHS email, networks, servers and security plus Virtual Manager, InfoEdge dashboard and reporting, ScanEdge technology (currently being expanded into a comprehensive ProductionEdge “assembly line”) and EDI connectivity to payers across the country. The IT team lives by its mantra of “Automation, Information, Acceleration, Stability and Scalability.” If a proposed initiative doesn’t meet one or more of these criteria, it isn’t considered.
Since the Warren IT team is small and concentrates on new Roadmap development (the Roadmap is the company’s plan for technology additions and enhancements), the primary communications with each operations office is through the designated “super users” at each location. The online system “AHS 24/7 Issue Tracker” captures everything from new user requests and password changes to new feature requests. The technology that supports AHS 24/7 was recently upgraded and now is available to a much wider group of users. One result is that it can now be used by operations to input and track local issues.
The IT team manages the company’s production infrastructure which includes a secure collocation facility and supporting network configuration that assures AHS users and clients of high performance and high availability. The collocation facility hosts the latest IBM Power 7 server for Virtual Manager and related applications and a virtualized Windows server environment for email, scanning and other applications.
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CMS ISSuES ACO FINAL RuLE
The Final Rule for Medicare Accountable Care Organizations (ACOs) was published on October 20, finalizing CMS’ defini-tion of Medicare’s ACO and Shared Savings Program (SSP). The Final Rule included several key changes resulting from the “mountain” of comments generated by the proposed rule in March, stating the draft proposal was too risky and too de-manding for providers and hospitals to buy into the program. High profile physician groups that tested an early model of ac-countable care declared the draft rules unworkable in a letter that said none would participate without significant changes. Following are 7 of the rules that were revised in the Final Rule based on stakeholder comments.
1. Change in Start Date and Longer Initial First Year Agreement PeriodsThe final rule allows more flexibility and time for providers to prepare for establishing ACOs by allowing multiple start dates in 2012, on April 1 and July 1, 2012. The proposed rule only al-lowed January 1, 2012 as the first year start-up date.
The end date for the ACO “performance years” will be December 31, 2013, allowing the first performance year to con-sist of 21 months for the April 1 start date and 18 months for the July 1 start date.
Although an ACO’s first “performance year” could be 18 or 21 months, quality data will be collected on a calendar year report-ing period basis. For ACO’s starting in 2012, data for analyzing quality measures will only be collected from January 1 – De-cember 31, 2013.
During all calendar years of the agreement period, includ-ing the partial year associated with the April 1 and July 1 start dates, the EPs participating in an ACO that meets the quality performance standards but does not generate shareable savings will qualify for a PQRS incentive payment.
2. ACO Participation Models ACOs may choose one of the two incentive options issued in the proposed rule, Track 1 (one-sided) or Track 2 (two-sided), but with the following changes:
• Track 1 – Originally a shared-savings model for the first 2 years that would become responsible for losses in the third year. The final rule allows for a shared-savings model for all 3 years of the first agreement period. There would be no penalties for any losses in the third year.
• Track 2 – The model remains the same, with ACOs facing penalties all 3 years if they perform over costs. This model offers higher shared savings benefits than Track 1.
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• All ACOs must participate in the two-sided model in agree- ment periods subsequent to the initial agreement period.
• Modified the terms for an ACO who experiences a net loss during their first agreement period to identify in their application the cause(s) for the net loss and to specify what safe guards are in place to enable the ACO to potentially achieve savings in its next agreement period.
3. Shared Savings In the proposed rule both the one-sided and two-sided models had to create a savings of at least 2 percent of their MSR (mini-mum savings rate) before receiving any shared savings. The final rule has eliminated the 2 percent net share allowing all ACOs that achieve savings in excess of their MSR to share sav-ings on a “first dollar” basis. 4. Withhold of Shared Savings For Offset of Future LossesThe final rule rescinded both the 25 percent withhold for the two-sided model to offset any losses and the provision to retain any portion of shared savings withheld if the ACO terminates its agreement. 5. Assignment of Beneficiaries to an ACOOriginally the assignment of beneficiaries to an ACO would oc-cur after the start-up of the ACO, based on primary care utili-zation during a performance year. The final rule changed the beneficiary assignment to the beginning of the performance year based on the most recent data available, primarily from claims submitted to Medicare prior to the ACO start-up date. Assignment will be updated quarterly based on the most recent 12 months of data. Final assignment will be determined after the end of each performance year based on data from that year.
• Beneficiaries will first be assigned to ACOs on the basis of utilization of primary care services by “primary care” physi cians (internal medicine, general practice, family practice, and geriatric medicine)
• Beneficiaries who are not seeing primary care physicians may be assigned to an ACO on the basis of primary care services provided by another physician.
• Beneficiaries will only be assigned to one ACO.
6. EHR Meaningful use RequirementThe final rule eliminated the EHR requirement which required 50 percent of primary care providers in ACOs to have earned EHR meaningful use by the second year of the initial agreement period. Instead CMS will retain one EHR reporting measure that rewards and encourages greater EHR use, based on the percent of primary care providers who successfully qualify for an EHR Incentive Program payment. This measure is weighted higher than other measures for quality-scoring purposes.
tHE MEDICARE AND MEDICAID INNOvAtION CENtER (tHE INNOvAtION CENtER)The Innovation Center at CMS was created to test innovative payment and service delivery models to reduce CMS program expenditures, while preserving or enhancing the quality and safety of care for its beneficia-ries. It has developed the Shared Savings (SSP)/ACO dem-onstration programs along with other federal programs designed to facilitate cooperation among providers, hos-pitals and other healthcare entities. Here are some of the programs developed in 2011; most will take place in 2012.
Information on all the following programs can be accessed on CMS’ website at: http://www.innovations.cms.gov/
ACCOuNtABLE CARE ORGANIZAtIONS (ACOS)PIONEER ACO MODELDeveloped for organizations that have already begun or currently operate an ACO-type model with a goal of 30 Pioneer ACOs that would begin operation in 2011. Applications for the program ended this past fall. Start-up date: 3rd & 4th Quarter 2011 with initial performance period to end 12/21/2011.
ADvANCED PAYMENt MODEL FOR ACOSAllows certain ACOs in the SSP program to access a portion of their savings up-front to help offset ACO start-up costs. Designed to test whether:• and how pre-paying part of future shared savings could increase participation in the SSP, • advance payments will increase the uptake and speed for ACOs to generate Medicare savings.
This model is restricted to: 1. ACOs with no inpatient facilities AND less than $50 million in annual revenue. 2. ACOs where the only inpatient facilities are critical access hospitals and/or Medicare low-volume rural hospitals AND less than $80 million in annual revenue.
OtHER FEDERAL PROGRAMS These programs have been designed to support reducing total health system costs while achieving better health and improved experience of care.
COMPREHENSIvE PRIMARY CARE INItIAtIvE (CPC)A multi-payer initiative to foster collaboration between public and private payers to strengthen primary care services. CMS will be soliciting other payers, includ-ing Medicaid, to provide enhanced support above and beyond visit based fee-for-service payments for primary care practices in their networks. Insurance carriers will be solicited first, followed by primary care practices.
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For now, CMS will use survey based measures, claims and administrative measures and the GPRO (PQRS Group Reporting Option) web interface as a means of ACO quality data reporting for certain measures. As providers adopt and gain more expe-rience with EHR technology, CMS will reconsider using certi-fied EHR technology as an additional reporting mechanism. 7. Quality Reporting MeasuresReportable quality measures were reduced from 65 measures to 33 measures, or 23 scored measures when accounting for the patient experience survey modules scored as 1 measure and the “all or nothing” diabetes and CAD measures scored as 1 measure each. The 5 domains have been reduced to 4 do-mains, with the elimination of the hospital safety domain.
• Patient experience • Care coordination and patient safety • Preventive Health • Caring for at-risk populations
This measure set will be the starting point for ACO measure-ment. CMS plans to modify measures in future reporting cycles to reflect changes in practice and quality of care improvement, and will continue to align ACO quality measures with other quality measure programs, such as the PQRS and EHR Incen-tive programs.
You may access this final rule through CMS’ website at this link: www.cms.gov/sharedsavingsprogram
2012 E-PRESCRIBE (ERx) INCENtIvE PROGRAMThe eRx incentive for 2012 is 1% of calendar year 2012 Medicare charges.
Who can report?A provider that has 10% or more of their Medicare Part B charges comprised of the eligible codes (see below for the full list) for the period January 1, 2012 – December 31, 2012.
How to receive an incentive payment for 2012?Individual Providers• an EP must submit 25 unique eligible visits.• eRx measure may be submitted via the claims-based method, registry or EHR (direct and/or through an EHR data submission vendor)
Group Reporting Method (GPRO)• GPRO groups of 25-99 EPs must report 625 eligible visits• GPRO groups of 100+ EPs must report 2,500 eligible visits• eRx measures may be submitted via claims-based, registry or EHR (direct and/or through an EHR data submission vendor)
The program will start as a four-year demonstration program in five to seven markets across the country and will include approximately 75 practices in each market.
The payment model includes a monthly care manage-ment fee, average of $20 per month per beneficiary, paid to the primary care practices. In years 2-4 of the initiative, there will be potential to share Medicare program savings.
PARtNERSHIP FOR PAtIENtSThis public-private partnership brings together leaders of major hospitals, employers, physicians, nurses and patient advocates along with state and federal govern-ments in a shared effort to make hospital care safer, more reliable, and less costly, Using $1 billion in new funding provided by the ACA and leveraging a number of ongoing programs, the two goals of the partnership are to: • Keep patients from getting injured or sicker – The goal by the end of 2013 is to decrease prevent- able hospital-acquired conditions by 40% compared to 2010. • Help patients heal without complication – By the end of 2013, the goal is to reduce hospital readmis sions by 20%.
BuNDLED PAYMENtS FOR CARE IMPROvEMENtS A voluntary program that bundles Medicare payments to hospitals, physician groups, non-physician practitioners, and others to promote patient-centered care within the hospital setting and post-discharge.
Participants:• will be given a choice of four models and would apply to CMS and bid on a target price for given medical services/episodes of care• would be paid under the traditional Medicare fee for service system, but after the episode was concluded, total payments would be compared to the target price and the groups could share in Medicare’s savings.
HOSPItAL PROGRAMSHospital Value-Based Purchasing Program Designed to promote better clinical outcomes for hospi-tal patients and improve their experience of care during hospital stays.
In FY 2013, an estimated $850 million will be allocated to the hospitals based on performance on quality measures shown to improve clinical care and patient satisfaction. The fund will gradually increase over time, resulting in a shift from payments based on volume, to payments based on performance.
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eRx Payment AdjustmentsMedicare will reduce an EP’s Medicare payment by 1.5% in 2013, if the EP does not appropriately submit the eRx measure in 2012.
The 2013 eRx payment adjustment would not apply to:• A provider who is not a physician, NP or PA as of June 30, 2012• Providers whose Medicare Part B charges for covered services to which the e-prescribing quality measure applies are less than 10% of the total 2012 Medicare Part B charges • A provider with less than 100 claims for the “eligible codes” for service dates of January 1 – June 30, 2012.
REQuIREMENtS tO AvOID tHE 2013 PAYMENt ADjuStMENt.Individual ProvidersTo avoid 2013 payment adjustments in the eRx program, providers must:• Report the electronic prescribing code (G8553) at least 25 times for eligible encounters (eligible codes) for January 1– December 31, 2012, or• Report the electronic prescribing measure’s numerator code at least 10 times for reporting period: January 1 – June 30, 2012 (via claims-based reporting only)
NEW - Providers may submit the eRx code even if there is no eligible code (visit code). This new provision is for providers who do not regularly subscribe during a billable visit (e.g. surgeons who subscribe during post-op visits that are not billable to Medicare). This will only be allowed during the January - June reporting period via the claims-based submission.
Group Providers: Group Reporting Method (GPRO)• GPRO groups of 25-99 providers must report an eligible code at least 625 times• GPRO groups of 100+ providers must report an eligible code at least 2,500 times• The reporting period for both of these categories is January 1 – June 30, 2012• The reporting method for GPRO is via claims-based reporting only.
SIGNIFICANt HARDSHIPSA provider or group practice can request consideration for a significant hardship exemption for the 2013 payment adjustment.
There are four eligible exemptions for practices that:• practice in a rural area with limited high speed internet access.• practice in an area with limited available pharmacies for electronic prescribing.• have an inability to electronically prescribe due to local, state, or Federal law or regulation.• prescribe fewer than 100 prescriptions during a 6 month reporting period. For 2013, the 6 month period is January 1 – June 30, 2012.
SELF REFERRAL AND ANTI-KICKBACK WAIVERS FOR ACOS
With the release of the ACO Final Rule, CMS, (OIG) and the Department of Health & Human Services (HHS), issued an “interim final rule with comment” defining waivers to the physician self-referral law, the federal anti-kickback statute, and civil monetary penalties law to encourage providers to participate in the Medicare Shared Savings Program (SSP) or Advance Payment Initiative.
There will be five waivers issued to cover ACO organizations:
• ACO pre-participation waiver for start-up account able care arrangements
• ACO participation waiver during the term of the ACO participation or thereafter
• Shared savings distributions waiver for payments earned under the program
• Compliance with physician self-referral law waiver
• Patient incentive waiver for medically related incentives to encourage preventive care and treatment compliance
An ACO need only fit with one waiver to be protected, even if the entity meets the criteria of more than one waiver. The waivers apply uniformly to each ACO, ACO participant, and ACO provider/supplier and are intend-ed to be self-implementing. Apart from meeting ap-plicable waiver conditions, no special action (such as a special application) is required by parties in order to be covered by the waiver.
CMS will oversee the physician self-referral law. The OIG will be responsible for enforcing the civil monetary penalties, while the OIG, with the Department of Jus-tice, will be responsible for the federal anti-Kickback statute. Comments on the interim rule are due on January 3, 2012. You may access this interim rule by clicking below and scrolling to Related Notices and Guidance under the date, October 20, 2011.
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Eligible Codes 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109
FEAtuRED EMPLOYEES
SPEAkING At EvERESt COLLEGE Chris Walters, Manager of Coding, and Barbara Lewis, Human Resources Manager, were recently asked to speak at the new Everest College Melrose Park campus for Corinthian Colleges. The presentation was in front of approximately 50 students in the Medical Billing and Coding curriculum, and included a dis-cussion of AHS history and structure, best practices, and helpful hints to get ahead in the industry.
The presentation highlighted AHS’ ongoing efforts to work with and support local medical billing and coding colleges. AHS also participates in CCI’s externship program, allowing students to get hands-on experience working in the industry.
‘tIS tHE SEASON – tO tHINk OF OtHERSMany AHS’ offices look forward to the upcoming holiday season, not only to enjoy celebrations with family and friends, but to help others in need. Here are reports from some of the offices:
BraintreeFor many years, the Braintree office has worked with “Quincy Action”: an organization that supports families who need help during the Christmas season. Each year the office is assigned a family and buys the items on their Christmas list. Clothes, food, household needs and toys for the kids are the major items re-quested by the families.
This year’s family is a family of four; mom, dad and two sons, one with special needs. In earlier years, everyone took an item from the list to buy for a family member but for the last few years, the office has come up with some creative ideas. An office store was set up with snacks. The price is a little over the retail price and this year the store contributed $300. There have also been raffles and an office yard sale. All ventures combined, the office raised $600 to contribute to buy gifts for their adopted family.
Once the gifts are bought, they are all wrapped in beautiful Christmas paper and given to the family near Christmas time.
ChambersburgOn December 20, 2011, the Chambersburg office will have their annual Christmas celebration. Usually the office starts their day with a Christmas breakfast, but this year they will have a fabu-lous Christmas lunch along with various games (including Wii), Christmas movies and a Secret Santa event. In addition, they will extend their Christmas spirit by donating food to a local Food Pantry. Anyone who brings in a bag of non-perishable food will be placed into a drawing for a $100.00 Gift Card.
LombardFor the fourth consecutive year, AHS Lombard will be holding a Food Pantry drive to support the York Township Food Pantry located in a nearby suburb. The facility is host to area residents struggling to make ends meet. Eligible residents can visit the pantry once a month and take advantage of the stocked shelves. The facility operates solely on private donations, so Food Drives such as ours are especially helpful as they prepare to meet the increased demand for the holiday season.
Hoping to beat the previous best turnout of 10-12 boxes of canned goods and other non-perishable food and household items, this year, a little friendly inter-department competition has been added. The departments are vying against each other for the “Most Charitable” award and trophy. With bragging rights at stake, the prediction is that Lombard will set new records and help stock the pantry shelves in time for Christmas.
PortlandThis holiday season, the Portland office is assisting one of its own. A former employee was recently diagnosed with a very seri-ous medical condition and could no longer continue employment with AHS. She is a single mother with two boys. A friend of hers coordinated an anonymous “giving tree” filled with ornaments of items to make their Christmas special. Each participant picks an ornament and buys the item listed on the ornament as their gift. This is a very special opportunity for the office to help one of their office-mates.
SalemThe Salem office has picked St. Ann’s Home, in Methuen, MA as their charitable entity. St. Ann’s Home is a non-profit organiza-tion providing services for children and adolescents with special behavioral and emotional needs. 120 children live at St. Ann’s and more than half of them will spend Christmas day there. Al-though there is no substitute for being with family, the gifts will likely make their holiday brighter. The office will join other par-ticipants in sending gifts from their wish list.
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A Family Loss in Salem, By Lisa Ivanovitch
I am a coder in the Salem office. In November, I celebrated my 15th year with the company.
Throughout my 15 years here I have made a lot of friends. There are quite a few of us “old timers” (not age, but length of service) here in Salem and we are more like family than co-workers. We are there for each other to provide support and friendship.
This past June, my sister’s home caught on fire. She owns an old Victorian duplex in Haverhill, MA that my family and I lived in for 8 years. She lived on one side with her 3 teenagers and she renovated the attic into a small apartment for our parents. She rented the other half of the home to her best friend and her two adult children.
The fire started in the tenants’ apartment and quickly went through the hollow space between the apartments to the at-tic and roof. My niece screamed to my father that the house was on fire and he got my mom, who is almost blind, out of the house safely. There was no one else home, but each family sadly lost a dog.
My mom called to tell me the house was on fire. My husband and I were about 30 minutes from Haverhill when she called. I was able to find out everyone was safe before we got discon-nected. While heading to my sister’s house, I got a call from Karen Hatem, a friend at AHS, who talked to me and tried to keep me informed of what was happening. When we got to the fire, I was communicating with my manager and friend, Nancy Mamis, who also helped keep me calm.
The house was a total loss and my family became homeless. My husband and I became the caretakers of everyone and we were running on fumes. The Coding/Batching team provided
me with much needed emotional support. I was emotionally and physically exhausted. Just to have friends that really cared to talk to helped keep me going.
Not only was emotional support provided by my friends here in Salem, but they also brought in clothes for my family who literally had only what was on their backs at the time of the fire. Costume jewelry, nail polish and clothes were given to my nieces by Cindy Ard. I received a laundry basket with the “little” things most people would not think of, such as handheld video games, cards, toothbrushes, paper plates and napkins, to name a few of the items. Thank you again Laurie Mullen from the A/R team. Sara Sweatt, from depositing, brought in bags of clothes for everyone. Jean Peters gave my mom some clothes.
When my sister finally found a house to rent, Samantha Anaya in Customer Care gave her bunk beds for the girls. They are 15 years old and they were so excited to have them. Karen Ha-tem from the A/R team talked to a friend who gave my sister a dining room table and a truck full of various household items. There are so many people here who helped that it is impossible to name them all.
We recently held a fundraiser for my parents who are now stay-ing with my husband and me. Again, the support was incredi-ble. Many AHS employees bought tickets even if they knew they couldn’t attend; they just wanted to help out. The fundraiser was a success and my parents can now start replacing some of what they lost in the fire.
Dealing with everything for my sister has taught me a lot about homeowners insurance, loss and starting over. The most im-portant thing it reminded me of was how important a good sup-port system is. I feel very lucky to have that here at AHS.
Everyone here has been amazing. I am truly thankful for that.
What do team jerseys, crazy hats, fuzzy slippers, baby pictures, and hamburgers have in common? AHS Lombard Spirit Week!
All were part of a week-long series of activities to encourage creativity and a sense of fun. The week-long events were topped off with the location’s annual barbeque, where managers grill and serve hot dogs and hamburgers for staff members.
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“SGR”: Medicare Physician Reimbursement
At this point, virtually everyone connected to physician reim-bursement and billing knows about the “SGR” (sustainable growth rate). Originally established in 1997 as a means to limit Medicare cost increases, it was routinely over-ridden by Con-gress, until 2010. That year, the 21.2% cut was averted 5 times, several times with a decision made after the deadline. For-tunately, before those deadlines, CMS announced they would not process claims for the first 10 business days, allowing Con-gress time to vote. In the end claims were processed under the correct SGR rate.
We are now seeing a replay of those earlier scenarios. Medi-care rates (officially the “conversion factor”) are scheduled to decrease by 27.4% on January 1. While both political parties agree this is unacceptable, until December 22, they could not agree on legislation to fix it. The SGR fix is part of legislation ex-tending the Social Security tax cut for another year and main-taining extended unemployment benefits.
As of this writing (December 23), the Senate has passed bi-partisan legislation postponing the cut for two months (keeping Medicare rates the same as 2011). Earlier this week, the House passed a motion to disagree with the two month extension. However, political pressure from both parties caused House leadership to change course yesterday. A “unanimous consent” vote is expected in the House today; if that fails, the House will re-convene next week. Most observers are confident that the two month extension will pass in a floor vote.
Of course, the two month extension means that we are likely to see a repeat of the last-minute political process leading up to, and potentially beyond, March 1. If Congress does not act until close to the deadline, CMS is expected to announce that it will hold claims for the first 10 business days of March, as it announced earlier this month for January (with the two month extension, CMS is not expected to hold January claims, though that has not been officially announced).
CMS did just announce that it is extending the 2012 Annual Partic-ipation Enrollment Period through February 14, 2012. However, the effective date for any participation change remains January 1.
CMS Pushes Back Enforcement of 5010On November 17, CMS announced that it is giving health-care providers, private insurers, and go-between companies until March 31, 2012 to switch to the new 5010 standards for electronic claims. Implementation of 5010 presents substan-tial changes to the content on electronic claims as well as the data available to providers in response to electronic inquiries for eligibility or claims status (see the last issue of The Leading Edge for more details).
Missed in much of the publicity about the CMS announcement is that January 1, 2012 remains the official deadline for the 5010 cutover. The Office of E-Health Standards and Services (OESS) press release said that, based on industry feedback, testing between some covered entities (providers, billing companies) and their trading partners (payors, clearinghouses) had not yet reached a threshold where a majority would be in compliance by January. OESS received reports that many covered entities were still awaiting software upgrades.
HIPAA regulations require providers to submit claims in the 5010 format by January 1 or OESS may investigate why the practice is in violation of HIPAA. The practice or clearinghouse must then show it is making a good-faith effort to comply with the new HIPAA standards during a 90-day grace period. Although there will be no penalties for those not in compliance between January and March, 2012, it still appears that OESS can investigate non-compliance.
Effective April 1, electronic claims submitted to health plans in 4010 format will be denied by the carrier resulting in no payment. Payment would not be made until the services were resubmitted via the 5010 standards.
AHS is ready to submit 5010 electronic claims and is already doing so with many payors with most expected to be converted by January 1, 2012. Exceptions will be health plans that are not ready to accept the 5010 transmissions.
CALENDAR WINtER 2012
Dec 31 - Submit 25 e-prescribe claims to avoid 2013 eRx penalty
Jan 3 - Advanced Imaging Accreditation Medicare ACOs - Final Waivers
Jan 27-29 - ASA Conference on Practice Management
Jan 29 - Last Day for EPs to attest for EHR Incentive Program for 2011 payment
Spring 2012 EHR Incentive Program - Proposed Rule Stage II
June 2012 EHR Incentive Program - Final Rule Stage II
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COMPLIANCE OIG 2012 Work Plan
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently published its Work Plan for 2012. The Work Plan provides brief descriptions of new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the next 12 months and beyond.
In 2012 OIG has targeted a number of new initiatives for Physicians and Non-Physician Providers under the sec-tion Other Providers and Suppliers (Pages I-16 to 24).
THESE INCLuDE:
High Cumulative Part B Payments. OIG will determine whether payment system controls are in place to identify such payments and assess the effectiveness of those controls. A high cumula-tive payment is an unusually high payment made over a speci-fied period to an individual physician or supplier, or on behalf of an individual beneficiary. High cumulative payments may draw greater OIG scrutiny to determine if they are reasonable and necessary, adequately documented, and provided consistent with Federal Regulations.
Incident-To Services. OIG will review physician billing for “inci-dent-to services” to determine whether those services have a higher error rate than for “non-incident-to services”. OIG found that 21% of services that physicians did not perform personally were performed by unqualified non-physicians. Currently there is a program flaw in that claim accuracy can only be identified by reviewing the medical record, which may expose Medicare beneficiaries to overutilization of services that do not meet pro-fessional standards of quality.
Impact of Opting Out of Medicare. OIG will review the situa-tion of physicians who have opted out of Medicare to determine whether they are submitting claims to Medicare, and what, if any, the potential impact is to beneficiaries in specific areas of the country that may have experienced a higher number of physicians opting out.
Evaluation and Management Services: Use of Modifiers Dur-ing the Global Surgery Period. OIG will review the appropriate-ness of using certain claims modifier codes during the global surgery period to determine whether Medicare payments for claims with modifiers used during the global surgery period were in accordance with Medicare requirements.
Ambulatory Surgical Centers (ASC’s) and Hospital Outpatient Departments (HOPD’s): Safety and Quality of Surgery and Pro-cedures. OIG will review safety and quality of care for Medicare
beneficiaries having surgeries and procedures in ASC’s and HOPD’s since these services have risen substantially over the past decade. OIG will assess care in preparation for, and pro-vided during, surgeries and procedures in both settings. CMS and stakeholders have expressed interest in the comparative safety and quality of care provided by ASC’s and HOPD’s.
Chiropractors: Part B Payments for Services. OIG will determine whether chiropractic services were performed in accordance with Medicare payment requirements. Chiroprac-tors’ services include only treatment by means of manual manipulation of the spine.
Physician-Owned Distributors of Spinal Implants. OIG will determine the extent to which physician-owned distributors (POD) provide spinal implants purchased by hospitals. Analysis will include Medicare claims data to determine whether POD’s are associated with high use of spinal implants which primar-ily involve orthopedic implants. However, it is noted that there has been rapid growth in the area of cardiac implants. PODS are business arrangements involving physician ownership of medical device companies and distributors.
Continuing OIG initiatives include:• Compliance with assignment rules.• Place of service errors.• Excessive payments for diagnostic radiology.• Medicare payments for Part B imaging services.• E&M potentially inappropriate payments.• E&M provided during global surgery periods.• E&M services trends in coding claims.• Medicare payments for Part B claims with G modifiers.• Payments for services ordered or referred by excluded providers.• Medicare claims review of Part A & B claims submitted by error-prone providers identified by CERT program.• Medicare payment for sleep testing and Polysommography by Sleep Disorder Clinics.• Outpatient physical therapy services by independent therapists.• Comprehensive Outpatient Rehabilitation Facilities – use of these facilities.• Laboratories: Part B payments for glycated hemoglobin A1C tests.• Laboratories: Trends in laboratory utilization.• Laboratories: Payments for laboratory test comparing Medicare, State Medicaid and Federal Employee Health
Further information regarding the HHS OIG Work Plan for Fis-cal Year 2012, is at this link http://oig.hhs.gov/reports-and-publications/archives/workplan/2012/Work-Plan-2012.pdf.
WHAt’S NEW FOR 2012 CPt CODES
For 2012 there are more than 500 changes to Category I CPT codes including over 200 new codes, more than 180 deleted codes and more than 130 revisions. Only Anesthesia (00100-01999), Surgery: Urinary System (50010-53899), Surgery: Male Genital System (54000-55980), Surgery: Maternity Care and Delivery (59000 – 59899), and Surgery/Endocrine System (60000 – 60699) are unchanged for 2012.
EvALuAtION AND MANAGEMENtFor 2012 the decision tree for New vs. Established Patients was re-established in the 2012 CPT book. The decision tree will help clarify the “three-year rule” for new versus established patients.
A new addition to observation care was added that allows physicians to report initial observation care codes using time as the key component when counseling or coordination of care dominates the encounter. For 99218 “physicians typically spend 30 minutes at the bedside and on the patient’s hospital floor or unit.” For 99219, “physicians typically spend 50 minutes at bedside…”
SuRGERY/INtEGuMENtARY SYStEMThere has been a change in the Skin Replacement and Skin Substitute Graft subsection with deletion of codes 15300 - 15431. These have been replaced by Skin Substitute Grafts codes 15271 – 15278. Reportedly there are fewer codes and more simplified for coding purposes.
There are many new add-on codes including 15277 Implanta-tion of biologic implant (e.g. acellular dermal matrix) for soft tissue reinforcement (e.g. breast, trunk) which is reported separately because the new replacement codes (15271-15278) do not include supply of the graft.
SuRGERY/MuSCuLOSkELEtAL SYStEMTwo new codes have been added: 22633 and 22634. Most other changes to this section involve descriptor revisions.
CPT 27096 now includes image guidance.
SuRGERY/RESPIRAtORY SYStEMRevised codes 32440-32491 for lung removal.
Three new thoracotomy codes that include biopsy(ies):• 32096 Thoracotomy, with diagnostic biopsy(ies) of lung infiltrate(s) (e.g. wedge, incisional, unilateral)• 32097 Thoracotomy, with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (e.g. wedge, incisional, unilateral)• 32098 Thoracotomy, with biopsy(ies) of pleura
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Three new thoracotomy codes that include wedge resection• 32505 Thoractomy; with therapeutic wedge resection (e.g. mass, nodule), initial• 32506 Thoractomy; with therapeutic wedge resection (e.g. mass or nodule), each additional resection, ipsilateral (List separately in addition to code for primary procedure)• 32507 Thoractomy; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for primary procedure)
A new category of services has been added for video-assisted thoracic surgery (VATS) and includes CPT codes 32601-32674.
SuRGERY/CARDIOvASCuLAR SYStEMPacemaker or Pacing Cardioverter-Defibrillator has 14 code revisions and nine new codes.
Combination codes were added to report renal catheteriza-tion and angiography (36251-36254), which include radiological supervision and interpretation.
Under subsection Cardiac Assist three codes 33981, 33982 and 33983 now include instructions that replacement of a ventricular assist device pump includes the removal of the pump and insertion of a new pump, connection, de-airing and initiation of the new pump.
SuRGERY/DIGEStIvE SYStEMSeveral parenthetical notes were added to this section to clarify code selection.
For Laparoscopy procedures (43644- 43659) the following was added: For laparoscopic implantation, revision, or removal of gastric neurostimulator electrodes, lesser curvature [morbid obesity], use 43659.
For Gastric Bypass for Morbid Obesity procedures (43846 – 43999) the following was added: For open implanta-tion, revision, or removal of gastric neurostimulator electrodes, lesser curvature [morbid obesity], use 43999.
Deleted codes 49080 and 49081 were replaced with three new codes (49082 – 49084) which describe abdominal paracentesis.
Liver biopsy (47000) now includes moderate sedation when provided.
SuRGERY/FEMALE GENItAL SYStEMA parenthetical note was added to the Introduction section which states, To report insertion of non-biodegradable drug delivery implant for contraception, use 11981. To report removal of implantable contraceptive capsules with subse-quent insertion of non-biodegradable drug delivery implant, use 11976 and 11981.
SuRGERY/NERvOuS SYStEMThis section has had significant updates including deleted codes, replacement codes, greater specificity to code description, and use of parenthetical notes and instructions throughout.
Codes 64622 – 64627 have been deleted and replaced by 64633 – 64636 for destruction by neurolytic agent, paravertebral facet joint nerve(s) with imaging guidance (fluoroscopy or CT). The new codes specify location cervical or thoracic and lumbar or sacral, and the number of joints injected.
The subsection on Neurostimulators (Peripheral Nerve) includes expanded descriptors that better explain the application of the code. Codes 64553 – 64595 apply to both simple and complex neurostimulators. For initial or subse-quent electronic analysis and programming of neurostimulator pulse generators, see codes 95970 – 95975. An electrode array is a catheter or other device with more than one contact. The function of each contact may be capable of being adjusted during programming services.
SuRGERY/EYE AND OCuLAR ADENExAMinor changes to this section. New parenthetical guidance is offered for Repair of Laceration subsection (65270 – 65290) stating 65280 and 65285 are not used for repair of a surgical wound, and Cornea subsection (65760 – 65771) for fitting of contact lens for treatment of disease, see 92071, 92072.
SuRGERY/AuDItORY SYStEMCode 69802 Labyrinthotomy, with perfusion of vestibuloactive drug(s); transcanal with mastoidectomy has been deleted.
RADIOLOGY/DIAGNOStIC RADIOLOGY (DIAGNOStIC IMAGING) Code 74174 was added as a new code to this section for 2012 with parenthetical instructions for its use.
There are minor changes made to this section in the area of revised code descriptions for Codes 70355, 72114, 72120, 75962 and 75964.
Several codes were deleted including 71090, 73542, 75722, 75724, and 75940 with instructions on how to report these services in 2012.
Transluminal atherectomy codes 75992 – 75996 have been deleted and replaced with other codes. In the case of 75994; it has been replaced with Category III temporary code 0234T. Codes 75995 and 75996 have been replaced with 0235T.
Several parenthetical notes were added to this section to clarify code selection. In subsection for Spine and Pelvis for Codes 72010 – 72275 parenthetical instructions state that for
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combined computed tomography (CT) or computed tomograph-ic angiography abdomen and pelvis study, see 74174, 74176-74178. There are further instructions in this subsection that state, Do not report 72191 in conjunction with 73706 or 75635. For CTA aorto-iliofemoral runoff, use 75635. Do not report 72191 in conjunction with 74175. For a combined computed to-mographic angiography abdomen and pelvis study, use 74174.
In the Abdomen subsection, there are parenthetical instruc-tions that state (Do not report 74175 in conjunction with 73706 or 75635. For CTA aorto-iliofemoral runoff, use 75635.) (Do not report 74175 in conjunction with 72191. For a combined computed tomographic angiography abdomen and pelvis study, use 74174.)
In the Vascular Procedures subsection, there are parenthetical instructions to ([do] not report 75635 in conjunction with 72191, 73706, 74175 or 74174.)
Transcatheter Procedures include parenthetical notes for (im-plantation of endovascular grafts and special notes for radio-logic supervision and interpretation of endovascular repair of abdominal aortic aneurysm involving visceral vessels).
RADIOLOGY/DIAGNOStIC uLtRASOuNDNumerous notations and parenthetical instructions in this sec-tion in reference to noninvasive vascular diagnostic studies (93880 – 93990). There are notes for ultrasound and duplex Doppler of transplanted kidney, and ultrasonic guidance pro-cedures.
RADIOLOGY/RADIOLOGIC GuIDANCEUnder subsection Fluoroscopic Guidance Code 77003 has been revised and includes parenthetical notes for its use.Code 77012 includes revised parenthetical notes: Do not report 77012 in conjunction with 27096, 64479 – 64484, 64490–64495, 64633-64636, 0232T.
RADIOLOGY/RADIAtION ONCOLOGYMany changes for 2012 in radiation oncology with new codes to report intra-operative radiation treatment delivery (77424, 77425) and intra-operative radiation treatment management (77469).New requirements specify that radiation treatment management is reported in units of five fractions or treatment sessions regardless of the actual time period in which the ser-vices are furnished.
RADIOLOGY/NuCLEAR MEDICINENew codes 78226, 78227, 78579, 78582, 78597, 78598 were added for 2012. Codes 78220 and 78223 were deleted.There are additional parenthetical notes regarding the use of several CPT codes in this section. Be sure to review to obtain the latest information on coding services in this section.
PAtHOLOGY AND LABORAtORYTier 1 and Tier 2 Molecular Pathology Procedures is a new sec-tion including detailed instructions. Code selection is based on the specific gene analyzed.
Parenthetical notes are included for 86703 HIV-1 and HIV-2, single result.
MEDICINECodes 90460, +90461 have descriptor revisions to clarify immunization code.
Codes 91010 and 91013 are replacement codes for 91011 and 91012 that have been deleted.
Code 92070 has been deleted and replaced with 92071, 92072 for contact lens fitting to treat ocular surface disease or to manage keratoconus.
The Sleep Medicine Testing subsection has a full page of instructions for testing and new codes have been added to report needle electromyography, per extremity, limited and complete or non extremity.
In 2012 significant instructions for hydration infusion codes 96360 and +96361 include expanded explanations for initial, sequential and concurrent infusion services.
CPt CAtEGORY III CODESCategory III CPT codes are a temporary set of codes for emerging technologies, services and procedures. In 2012 there are 31 new codes (0260T – 0290T) including those for systemic hypothermia in neonate, implantation of catheter-delivered prosthetic pulmonary valve, implantation or replacement and revision or removal of carotid sinus baroreflex activation device, intramuscular autologous bone marrow cell therapy, percutaneous laminotomy/laminectomy, and corneal incision to name a few.
Codes 0080T, 0240T and 0241T are revised for 2012.
If a Category III code best describes a service performed then this code is used instead of Category I “unlisted procedure” code.
MODIFIER CHANGES FOR 2012Modifier 21 has been deleted. To report prolonged physician services, see 99354-99357.
Modifier 32 Preventive Services was effective in January 2011, but not listed in the CPT book for 2011. Modifier 32 is used when the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive
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Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identi-fied as preventive, the modifier should be used.
Append Modifier 92 Alternative Laboratory Platform Testing when laboratory testing is being performed using a kit or trans-portable instrument that wholly or in part consists of a single use, disposable, analytical chamber; the test does not require permanent dedicated space, the test is designed to be hand car-ried or transported to the vicinity of the patient for immediate testing at that site. For Medicare payors, modifier 92 indicates point-of-service HIV testing (86701-86703 and 87389) only.
The CPT Web site provides a biannual electronic release of the Category III CPT codes. This section of CPT codes contains a temporary set of codes for emerging technologies, services, and procedures.
ANEStHESIA REvENuE tIPS
IS OFFICE-BASED ANESTHESIA FOR YOuR PRACTICE?Office-based anesthesia has grown significantly over the past 10 years. In 2005, the total number of procedures performed in an office setting was over 10 million (double the volume of just 10 years earlier) and this number continues to grow at an excit-ing pace. More and more office-based providers understand the value of providing select procedures in an office setting. To that end, anesthesia groups see this emerging trend as an op-portunity to maintain market share, and in many cases, expand their reach.
Office-based procedures are not appropriate for all procedures or patients, but they are expanding based on advancements in surgical techniques and increasingly safe delivery methods for anesthesia. Office-based procedures and the need for high quality office-based anesthesia care are projected to continue their rapid growth and provide excellent new anesthetizing lo-cation opportunities for anesthesia practices. However, office-based anesthesia is not for every practice and those who want to explore these new revenue-generating opportunities must understand the difference between office-based anesthesia vs. hospital-based anesthesia. Carefully examining a few specific areas of office-based anesthesia will provide you enough data to quickly identify if a new location is a viable new business ven-ture and if your group is ready to tackle the commitments and challenges of this expanding area of anesthesia.
Just as volume has shifted from the hospital setting to ambulatory surgery centers over the past several years, cases will also shift from the ASC and hospital settings to the office-based setting.
In evaluating office-based opportunities, anesthesia groups need consider:
•Personnelcommitment•Profitabilityofbusinessventure•Facility•Recordsanddocumentationretention•Liabilityinsurance(doesyourcurrentplancover office- based anesthesia-limitations?)•Equipmentsafetyaswellasgasanddrugprocurement, inventory and storage (who buys and maintains)•Understandingofanti-kickbackstatutesandStarkrulesso as to not run afoul of local, state of federal regulations•Marketingandcommunityoutreach•PracticeManagement
For this article, we will review practice and facility manage-ment, billing and fee structure. Future articles will review some of the other considerations.
PRACTICE MANAGEMENTAn enhanced level of practice management and strategic development is required and essential for anesthesia providers looking to expand through office-based anesthesia. These capabilities are not typically required for hospital-based anesthesia (except in a surgeon request model of anesthesia). Marketing, community outreach, market analysis and ROI (return on investment) development are all areas of focus for a venture into office-based anesthesia. It is important for the anesthesia provider to develop a comprehensive marketing plan to highlight its quality of care, patient safety, and efficient case management. Anesthesia practices should work with their practice management company throughout the process and this is a primary area for the practice management company to be engaged.
A thorough analysis of the benefits and risks of each location is necessary to assure the specific business venture is profitable and worth the time investment, as well as potential risks. (Could you lose another location due to picking up a new location, e.g. rival ortho groups?). Case volume, scheduling, room turn-over, hours, case mix and payer mix are a few of the areas where an anesthesia provider needs to dig deep and develop a detailed ROI.
FACILITY MANAGEMENTMoving into the office-based anesthesia realm requires groups to review and analyze portions of their business which did not require active participation in the past. Items such as emergency procedures, facility accreditation, equipment pur-chase and maintenance, drug and medical gas procurement,
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inventory management and secure storage are all items which now fall on the anesthesia provider’s shoulders and not the hospital’s or ASC’s, as is usually the case. In this process, the anesthesia provider is both a provider and also an entrepreneur.
FEE STRuCTuREDevelopment of a fee schedule for office-based anesthesia must take into account the specific market, competition and payer contracts. If an anesthesiology practice is working primarily at a hospital and is covering an office-based physician practice, the practice may choose to negotiate a lower fee. However, if outpatient anesthesia is the group’s primary business, there is less room for negotiation due to higher overhead and over-all costs. Fees may be charged at an hourly rate or on a per-case basis.
The first and foremost requirement in development of your fee schedule is your actual costs. Understanding your costs down to the hour based on the commitment for a particular location is essential. Drive time, set-up, drugs, machines, turn-over time, etc., are all items one must consider in the initial stages of an office-based anesthesia strategy. Failure to adequately address this building block will only create headaches downstream and will hamper your ability and confidence in the market. Working with your financial manager is key to this exercise; do not go at it alone.
BILLINGBilling for office-based anesthesia is not dis-similar to billing for anesthesia in the hospital or ASC setting. But providers must review their payer contracts to determine if office-based anesthesia is carved out or if the surgeon has global case rates for procedures. If they do, it is typical that the anesthesia por-tion is lower and the anesthesia provider must then negoti-ate with the facility for fair compensation. Make sure that you are not accepting below market rates for your services for you can run afoul of anti-kickback statutes and other pay-for-play schemes that are a target of the OIG.
It is also important that the anesthesia provider’s billing staff, whether in-house or out-sourced, understand the nuances of office-based anesthesia billing and the unique differences in patient relations.
IS OFFICE-BASED ANESTHESIA FOR YOu?AHS’ extensive expertise in anesthesia has proven extremely valuable as clients have turned to us for many of the services and tasks detailed above. If you are interested in learning more about how AHS can help you grow your anesthesia business, please contact Brice Voithofer, Vice President of Anesthesia and ASC Services at [email protected].
