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LOW-COST educational resources for Medical Office Professionals
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Making Sense of a Sudden Carrier Contract Break
Big Data: Is the Juice Worth the Squeeze?
Internal Audits for the Physician Practice
The Face of Your Practice Great Customer Service Success: Don’t Try Chasing Someone–Else’s Dreams
ETHICS:
Oct/Nov 2014 | Issue 9.6
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WE’RE PROUD TO INTRODUCE OUR EDITORIAL BOARD FOR THIS ISSUE Maxine Collins MBA, CPA, CMC, CMIS, CMOM, has more than thirty years of experience in medical practice management, adult education, and general business.
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Matt Dallman has spent the last 12 years in private healthcare management, consulting, and medical billing. He is Vice President of the boutique medical billing firm, VGA Billing Services, Inc., based in New York City.
editor Amber Joffrion, B.A. editorial@billing-coding.com
Shannon Deconda, CPC, CPC-I, CEMC, CMSCS, CPMA, is the Founder and President of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the President of Coding & Billing Services and a Partner at DoctorsManagement, LLC.
ceo - publisher Storm Kulhan storm@billing-coding.com
Chris Drevalas is the Vice President of Marketing & Finance at Alpha Review Corporation & has helped companies of all types with their workers compensation issues for the past ten years.
coo Nichole Anderson, CPC nichole@billing-coding.com subscriptions manager Ashley Rosenthal ashley@billing-coding.com continuing education Anne Marie Garth, Ed.D. advertising sales@billing-coding.com 877 700 3002
Rose T. Dunn, MBA, RHIA, CPA, CGMA, FACHE, is the “nuts & bolts” member of First Class Solutions, Inc. With 30 years experience, she has spoken publicly on numerous occasions, authored and edited several texts, and has experience in many areas of the healthcare administration industry. Dr. James Dunnick is a physician, board certified in internal medicine and cardiology. He has twenty-five years of clinical practice experience. He is also a certified professional medical coder and boarded by the national quality assurance and utilization group. Dave Jakielo, CHBME, is an International Speaker, Consultant, Executive Coach, and Author, and is President of Seminars & Consulting. Mathew J. Levy, Esq. is a Principal of Kern Augustine Conroy & Schoppmann, PC. Mr. Levy is nationally recognized as having extensive experience representing healthcare clients in transactional and regulatory matters.
CONTACT US
William J. McDonald, Esq. is Counsel to Campolo, Middleton & McCormick. He heads up the firm’s Healthcare and White Collar Criminal Defense practice groups.
Billing-Coding, Inc. P.O. Box 80669 Simpsonville, SC 29680
Marge McQuade, CMSCS, CMM has over 35 years experience in the medical field as an office manager, coder, and educator. Marge is the Director of Education for PAHCS (Professional Association of Healthcare Coding Specialists).
Phone: 877 700 3002 Fax: 888 573 7210 info@billing-coding.com www.billing-coding.com
Regina Mixon Bates, IRO, CPC, CPC-I, Approved ICD-10 AHIMA Trainer, CMOM, CMC, CMIS, is the CEO of The Physicians Practice S.O.S Group® based in Atlanta, GA.
approving CEU associations www.billing-coding.com/ceu
Alice Scott and Michele Redmond are coauthors of 15 books on medical billing and co-owners of Solutions Medical Billing Inc. in Rome, NY. Ranadene Tapio, MBA, CMRS, CMC, is a medical billing and revenue cycle expert at Business Office Consultants and has more than 20 years of experience in the healthcare industry. LuAnn Weis, MPA, CPC, CPC-H, has over 25 years of healthcare experience. She is currently employed at Langone NYU Medical Center as the Associate Director of Professional Billing Compliance.
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3
CONTENTS OCT/NOV 2014 - 9.6
42 22. Internal Audits for the Physician Practice
FEATURES 10. Making Sense of a Sudden Carrier Contract Break
14. Understanding Billing and Documentation Compliance with CMS’ Incident To and Shared/Split Visits 16. A Look at the Most Common Medical Bill Coding Errors 18. Don’t Let ICD-10’s Preparation Work Be for Naught 21. Big Data: Is the Juice Worth the Squeeze?
4
21
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BC Advantage Magazine
REGULARS 8. NEWS
12. Is Your Doctor Breaking the Law? The Truth About Waiving Co-Pays Revealed
10
12
24
26. Ethics: The Physician in the Middle
17. FREE Webinar and CEU
30. Office Based Surgical Procedure Audits: How to Handle Them
46. Making Everyday Negotiations a Win-Win
34. Successful Insurance Reimbursement
48. 5 Minutes With…David T. Womack
38. Marketing Your Practice in Today’s Healthcare Arena
50. Review:
Optum Learning: Understanding Modifiers
42. Due Process Upheld for Physicians Targeted for Termination from Medicare Advantage Plans
Outpatient Billing Expert
44. Success: Don’t Try Chasing Someone Else’s Dreams
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LETTER FROM OUR CEO I love Fall. I mean, I really love it.
It’s still warm during the days, cooler at night, leaves
aptly titled “Don’t Let ICD-10’s Preparation Work Be
are falling, corn fields turn into mazes and (for
for Naught” where she discusses some points that
my wife) Pumpkin Spice Lattes are back! Fingers
you can start implementing now (if you haven’t
crossed this wacky weather that is striking the coun-
already) without spending a major chunk of your
try will settle before the predictions of the Farmer’s
budget.
Almanac come into fruition. Here in South Carolina,
Another two articles that I found extremely inter-
we’re expecting another wet and cold winter which
esting are covering the topic of physicians being
just reinforces my desire to enjoy Fall the way it’s
dropped by carriers. Maxine Inman Collins, MBA, CPA,
supposed to be enjoyed.
CMC, CMIS, CMOM, and William McDonald, Esq. have both covered this topic from different perspectives
So, here is my usual wrap up of the issue. I know
so I hope you learn something from them.
you’re all waiting with such anticipation at what the issue holds and I’m sorry that I’m rambling. Our
It’s a jam packed issue that we bring to you (I know
cover story is about Ethics: The Physician in the
this because I bemoan the fact that we do not have
Middle. Ethics is a big issue and is something that is
some more advertisements for our own products in
core to ourselves and our businesses. Dr. Dunnick’s
here but I always lose out as the only male in the
article discusses the issue of patient treatment (and
office as the ladies here want to bring you as much
perhaps appeasement) versus the insurance com-
as possible!) that includes a myriad of topics for you.
pany responsibilities. We all face decisions every
We’ve got articles on marketing your practice, audit-
day for a myriad of issues in both our personal and
ing, insurance reimbursement, collecting copays,
professional capacities and Dr. Dunnick presents a
incident-to billing, medical billing errors, negoti-
perspective that I’m sure you will find interesting
ations, and success. Wow, say that in one breath!
and enlightening.
There is something for everyone in this issue, that’s for sure!
Now, I know that I’ve discussed ICD-10 implementation and how section 212 of H.R. 4302 affects our
So, grab a PSL (my wife made me write that!), sit
industry in 2015 in a big way. We’ve previously pub-
back, and enjoy this issue. As always I am here to
lished an article on the potential of skipping ICD-10
hear your thoughts and comments so drop me a line.
and moving forward to ICD-11 but the most import-
Until next time,
ant thing to emphasize now is to not let yourself
Storm Kulhan
become complacent and leave any form of moving forward with your plans by the wayside. We welcome Rose T. Dunn, MBA, RHIA, CPA, FACHE and her article
Storm Kulhan
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CMS Introduces Four New Modifiers to Reduce Improper Use of Modifier -59 (Transmittal 1422, Change Request 8863) The four new modifiers are effective January 1, 2015 with an implementation date of January 5, 2015. Recently the Centers for Medicare and Medicaid (CMS) advised that they are establishing four new HCPCS modifiers to define subsets of modifier -59. Providers use modifier -59 to indicate a “distinct procedural service” and is often used (and abused) with projected error rate of over $320 million just in MPFS payments. Collectively referred to as –X{ESPU} modifiers they are: • XE: Separate encounter (A service that is distinct because it occurred during a separate encounter) • XS: Separate structure (A service that is distinct because it was performed on a separate organ/structure) • XP: Separate practitioner (A service that is distinct because it was performed by a different practitioner) • XU: Unusual non-overlapping service (The use of a service that is distinct because it does not overlap usual components of the main service) The modifiers will be effective January 1, 2015 but it is important to note that CMS will not stop recognizing modifier -59 but as per CPT® instructions state, it should not be used when a more descriptive modifier is available. CMS may also selectively require a more specific -X{EPSU} modifier
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Get in touch with your MAC for more instructions on these modifiers.
PAHCOM 2014 Medical Manager of the Year nominees Congratulations to the PAHCOM 2014 Medical Manager of the Year nominees. There are six finalists that have been recognized as great leaders demonstrating excellence in medical office management and a strong commitment to improving their communities. The winner will be announced at the PAHCOM national conference October 21-23, 2014 at the Hilton Clearwater Beach, Florida. The finalists are: • Debbie Carlson, CMM, from Colorado Springs, OB/Gyn in Colorado Springs, CO • Lisa Garrison, CMM, from Premier HealthNet in Dayton, OH • Joan Newell-Walker, CMM, CPM, from Archer Family Health Care, University of Florida College of Nursing in Archer, FL. • Michelle Oglesby, CMM, SPHR, from Knoxville Comprehensive Breast Center in Knoxville, TN. • Elizabeth (Lisa) Sanchez, CMM, CMOM, CMIS, CPM, COM, from Covell Clinic in Maitland, FL. • Margie Warnock, CMM, HITCOM-PP, from Medical Center, LLP. in Dublin, GA. Learn more at: www.pahcom.com
Houston Tenet to Bring PMI Continuing Education to Employees Practice Management Institute® (PMI) has
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partnered with Tenet Physician Resources (TPR) in Houston to bring the Certified Medical Coding (CMC)® curriculum to their Houston area medical office coding staff. PMI carries a reputation of success and flexibility in the market and we have been fortunate to work with the trainers on a well-structured ICD 9/10 training session. Coding education is imperative for the success of any medical office and the resources available from PMI provide assurance that our providers/coders are performing at a high level,” says Patel. PMI Houston Learning Center Coordinator Donna Alwais emphasizes the importance of continuing education for the medical office staff as well as acknowledging TPR and PMI’s relationship as an outlet to provide resources for the medical office staff. Visit www.pmimd.com for more information
Dr. Evil Pleads Guilty to Medicare Fraud and Giving Unnecessary Chemo Treatments Dr. Fata, 49, of Oakland Township, pleaded guilty in U.S. District Court to several counts of health care fraud, money laundering and conspiracy, according to a press release from the U.S. Attorney’s Office. Authorities said that Fata submitted approximately $225 million in claims to Medicare between August 2007 and July 2013. In the end, Medicare paid out more than $91 million to Fata, of which over $48 million was for chemotherapy and other cancer treatments.
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9
MAKING SENSE OF A
SUDDEN CARRIER CONTRACT BREAK Narrow Networks, a term that has come about in the last few years describes carriers that have been trimming down their in-network providers in an attempt to curb costs. from fee-for-service payment models to payment based on quality and outcomes. The provider does not have a lot of say in the process. They are being ranked by the carriers and the market, present contract agreement, and based on the type of relationship they have with the provider. Physicians who don’t make the cut are out. Carriers need physicians to become active participants in the plans, and those who don’t want to cooperate will not be retained.
A
s contracts near expiration, thousands of physicians all over the country are receiving letters stating they are being dropped from networks. UnitedHealth recently dropped thousands of providers from its networks, mid-contract, and without apparent cause. Practice Management Specialist, Maxine Inman Collins, MBA, CPA, CMC, CMIS, CMOM, explains what is happening and shares ways you can protect your organization’s rights and interests. Narrow Networks is not a new concept, but one that is growing since the passage
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of the Affordable Care Act. Basically, the carriers are moving toward Accountable Care Organization (ACO) models where physicians join together to collaborate care and share with the medical home for the Primary Care Physician. That PCP directs the care of the patient. They could not go to the Specialist unless the PCP referred them. It is an effort to cut costs and improve care outcomes, also known as performance-based care. Carriers dropping providers is a trend that we will see more and more of across the country as carriers look at quality measures more closely. We are quickly moving
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In 2003, the Centers for Medicare and Medicaid Services (CMS) began contracting with private carriers to process Medicare claims for certain populations via Part D: Medicare Advantage programs (MA). Privatized fee-for-service programs offered Medicare beneficiaries a more balanced benefits plan, particularly during the Medicare donuthole, or period of non-coverage. The MA contracted carriers were paid based on Medicare standards, and they were also paid a stipend by CMS to handle and process the claims of their MA members. In 2006, Medicare spurred the program offering carriers more incentives to take on Medicare beneficiaries, and the program grew. Based on the data analyzed from the Providers’ claims, the Medicare Advantage Plan could receive a “bonus” or additional compensation from Medicare for accurate coding
reflecting the measurement of medical necessity as indicated on the claim form. Kaiser Family Foundation’s research revealed steady growth in the program with approximately 25 percent of all Medicare beneficiaries enrolled in Medicare Advantage plans as of March 2010. With these plans, some things have to be pre-certified. Providers have to follow their guidelines. Medicare Advantage carriers audit physician practices beginning in February. They are auditing for appropriate diagnosis coding as linked to the CPT® code. The carriers are not looking for fraud and abuse. They want to ensure that coding is done correctly in accordance with HEDIS (hierarchy of conditions) and Medicare Advantage standards. Incorrect coding can affect the total reimbursement that CMS pays the carrier for processing Medicare Advantage Plan products. This is why they want to ensure that the provider offices are coding and documenting properly. I work with a large practice near Dallas where the insurance carrier has sent in an employee to work in their office. Her role is to pre-audit every Medicare Advantage Plan claim to ensure that the diagnosis is correct, because like in the value-based modifier, the analysis of medical necessity is based on information being reported on the billing documents. Physicians and other health care providers, such as hospitals, are being judged and analyzed by the information listed on the claim—and that’s also how they are ranking the MA plan for reimbursement purposes. This means that offices not recording the appropriate medical necessity for a particular procedure are going to score a lower ranking and will be paid less. Carrier audits are performed to ensure that the diagnosis is properly documented, and the code matches the diagnosis. Medicare patients often don’t realize when they sign up for Medicare Part D for prescription drug coverage they are changing from traditional Medicare to a Medicare Advantage Plan which has different rules and regulations. For regular Medicare, we’ve never had to pre-authorize or pre-certify anything. If they have their card and they have the insurance, we have always filed services that we’ve provided and were paid for them if we do it correctly. What does all this have to do with Narrow Networks? As the MA program has grown and CMS has gained more experience, the goal is to make sure it is operating efficiently and cost-effectively. They have stated that they “periodically revise regulations to clarify various program participation requirements, strengthen
beneficiary protections, and strengthen their ability to select stronger applicants for participation in the program and remove consistently poor performers.” Fast forward to the ACA era and you have a similar scenario. Carriers want to be eligible for quality outcome incentives and preserve costs. So they are closely analyzing their networks and will continue to weed out providers scoring low on outcomes or not cooperating with the quality measure reporting. When they can demonstrate their network has better outcomes, they get paid based on the higher scores. Providers should keep diversified contracts so that actions taken by third-party payers will have less of an impact on the bottom line. In order for the physician provider or group of providers to efficiently survive in the industry, each will have to participate in the Medicare Quality Incentive Programs as well as in the Private Carrier’s initiatives. Pay-for-Performance is not the same as pay-for-reporting. Outcomes of care and the provision of higher quality of care at lower cost is the prevailing methodology for future reimbursement. Again, these measurements will be analyzed by looking at the information provided by the code(s) on the providers’ claim forms, and may also lead to a more in-depth review of the substantiating documentation. The Value-Based Modifier has already been implemented in the Hospital environment as well as for other providers of care. Physician practices must learn how to participate in any available performance/incentive program that the carriers have available in order to secure maximum reimbursement in the future. Pay-for-performance is here to stay. Providers and health care professionals can improve patient care and participate in available incentives as the program builds steam.
Maxine Inman Collins, MBA, CPA, CMC, CMIS, CMOM, has more than thirty years of experience in teaching and medical practice management. She is a veteran faculty member with Practice Management Institute® where she teaches administrative and clinical personnel how to ensure their providers receive proper payment for services rendered. Coding, reimbursement, compliance, and office management are a few of her areas of specialty. Her students learn best practices for personnel management, accounting, and budgeting. She is a knowledgeable and much sought-after resource for provider and staff development.
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11
IS YOUR DOCTOR BREAKING THE LAW?
THE TRUTH ABOUT WAIVING CO-PAYS REVEALED
Most people in the medical billing industry are aware that there are compliance issues with professional courtesies or the waiving of patient responsibilities, but there still seems to be a lot of confusion surrounding the issue.
W
hat they may not be aware of, is that the practice of waiving the patient responsibility may actually be breaking the law.
Many providers do not understand why they cannot decide to extend a break for services rendered to a family member or friend. They feel that they have a right to choose if they want to collect the money that the insurance carrier deems to be the patient’s share.
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The insurance carriers feel differently about the situation. They feel that by waiving the patient responsibility, the provider is intentionally charging a different price for the same service. For example: a provider charges $100 for a level 3 established patient office visit. The patient’s insurance carrier pays $80 and the patient has a $20 copay. If the provider waives the $20 copay, the insurance carrier feels that the provider is willing to accept $80 for the level 3 established patient office visit. Based on that theory, the insurance company assumes that they have overpaid the provider $20. They should
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reimburse the provider $60 and the patient should be responsible for the $20 copay. Why does the insurance carrier feel this way? Basically, all of these concepts— deductible, co-pay, and co-insurance— are cost share obligations. The rules of managed care state that the patient CANNOT see the doctor until they make their co-payment. Managed care is governed by federal law and is not open to interpretation. To “write-off” a co-pay, or to allow a patient to see the doctor without collecting the co-pay-
ment, is against federal law. Federal law never allows waivers of patient responsibility to be offered as part of any advertisement or solicitation. A provider cannot use the enticement of waiving the patient’s responsibility to get a patient in the door. A provider may think that they can advertise a special where they will waive the patient’s co-pay for a new patient consultation to try to get more patients into their practice, but this is illegal. Most managed care contracts that providers sign when enrolling to be participating with an insurance carrier forbid waiving patient responsibility. They consider such waivers to constitute insurance fraud, misrepresentation, and unfair competition. If an insurance carrier discovers that a provider is waiving co-payments, the insurance carrier has the right to stop payments on a claim and/or recover amounts already paid on claims. Professional courtesies must be distinguished from waiving patient responsibilities. A professional courtesy is when the provider waives the entire fee for a physician, or the dependent of a physician. A professional courtesy may also be a discount such as 50% for such an individual or the provider may choose to waive only the patient’s out-of-pocket expenses as well. This is known as accepting “insurance only” as payment in full. The issue is that this professional courtesy is often extended to many others such as staff, family of staff, friends, etc. Generally, if the professional courtesy is the waiving of the entire fee or a percentage of the entire fee, it is considered legal. However, if the professional courtesy is waiving the co-pay or the patient responsibility, it is usually considered illegal, especially if the patient has a federal insurance plan such as Medicare. This is true even if the patient is another medical professional. It would also be considered illegal if the professional courtesy were extended to a patient who is in a position to refer business to the provider. This could be considered fraud and abuse, especially in the case of Medicare, Medicaid, and TRICARE patients. Waiving patient responsibility for Medicare patients violates a federal statute that states that the provider knows that waiving the patient responsibility is likely to influence the patient to seek care from that provider.
Some individual states agree with the insurance carrier’s perception and have declared that the insurance-only courtesy is insurance fraud. If the provider accepts insurance only, then the state feels that they are misrepresenting their fees by charging insurance carriers a fee that is higher than the fee that they actually intend to collect. There are many situations where waiving the patient’s responsibility either in the form of a deductible, co-pay, or coinsurance is deemed illegal. Federal plans and managed care plans are covered under federal law and most commercial plans, depending on the state, are covered under state laws. If not illegal, it is most likely a violation of the provider’s contract with the insurance carrier. Violating the contract may result in the provider being removed from the insurance carrier panel. Providers are not supposed to “forgive” patient responsibilities without proof of financial hardship. Such financial hardship cases must be consistent and not provided routinely. The hardship should be documented in the patient’s chart. Therefore, the best course is to avoid waiving the patient responsibility unless a financial hardship has been established. Office policies should be reviewed regarding any courtesy discounts to make sure that they are compliant.
Alice Scott and Michele Redmond are coauthors of 15 books on medical billing and co-owners of Solutions Medical Billing Inc. in Rome, NY. www.solutions-medical-billing.com
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13
UNDERSTANDING BILLING AND DOCUMENTATION COMPLIANCE
WITH CMS’ INCIDENT TO AND SHARED/SPLIT VISITS
This article addresses the billing and documentation relationship between physicians and what is commonly referred to as Non-Physician Providers (NPPs).
have to be established patients without any new issues. Physicians must see the patient initially, clearly document a plan of care, and make the initial diagnosis before any follow up visits can be performed as incident to by the NPP. Afterwards, the physician needs to be an ongoing and active participant in the patient’s care. When the NPP is seeing the patient, the supervising physician must be physically present within the office suite and immediately available to provide direct supervision if necessary. (The supervising physician can be any physician within the group.) Keep in mind that the documentation must identify who rendered the service. Lastly, to bill incident to, the NPP and the physician must be employed by the same employer. Shared/Split Visit
N
PPs are individuals who are licensed by states under different programs to assist or act in place of a physician. In this article, we will focus only on Nurse Practitioners (NP) and Physician Assistants (PA).
bursed at 85% of the Medicare Physician Fee Schedule (PFS). The other way is to bill using the physician’s NPI by following CMS’ rules for incident to or shared/split visits at the 100% reimbursement of the PFS. Incident To Visit
There are two ways to bill for services that are provided by NPPs. The first way is to bill with the NPP’s National Provider Identifier number (NPI) which is reim-
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An Incident to visit is applicable only in a physician’s office which is place of service code 11. To bill incident to, patients
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A Shared/split visit means that face-toface evaluation and management (E&M) services are rendered and documented by both the physician and the NPP. The physician and NPP must be employed by the same employer. The level of service is based on the combined documentation of both providers, and the documentation must clearly identify what was personally performed by each provider. Shared/split is only applicable to evaluation and management (E&M) services, not procedures.
Critical care services and other time-based CPT codes cannot be billed as shared/split. Shared/split generally occurs in outpatient, inpatient, and the emergency room setting. The visit may occur at the same or separate times of the day. In the place of service office, incident to is applicable. This means if the NPP and the physician see a new patient in the office, and documentation supports a shared/split visit, the visit has to be billed using the NPP’s NPI number, not the physician’s NPI number. For the service to be billed using the physician’s NPI number, the physician’s documentation alone must support the level of service being billed. The only part of the documentation that the physician may use from the NPP’s documentation in this scenario (new patient in the office), is the review of systems and/or past, family, and social history.
1. Medicare Claims Processing Manual 100-04; Chapter 12; Physicians/NonPhysicians Providers, Section 30.6.1, 30.6.4, 120, 130 2. National Government Services: Medicare University presentation: Incident To/Shared Visits – Taking Credit for Someone Else’s Follow-Up
LuAnn Weis, MPA, CPC, CPC-H, has over 25 years of healthcare experience. She is currently employed at Langone NYU Medical Center as the Associate Director of Professional Billing Compliance. She oversees the medical auditing of the faculty practice which consists of over 1200 providers, among many other functions. She has an MPA in Health Administration and is certified as a professional coder and an outpatient hospital coder through the American Academy of Professional Coders (AAPC).
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15
A LOOK AT THE MOST COMMON
MEDICAL BILL CODING ERRORS Paying medical bills is a huge hassle and expense for companies. With the cost of providing workers compensation coverage for employees rising, it’s more important than ever that employers have a cost control process in place to minimize expenses and maximize savings. One important aspect of any cost control plan is medical bill reviewing.
some of the most common medical bill coding mistakes: • Modifier -50 Modifier -50 is supposed to be used whenever a bilateral procedure is performed during the same operative session. With Modifier -50, the payer is supposed to be responsible for only 150% of the allowable charge (100% of the allowable charge for the first side, 50% for the second side). However, this modifier shouldn’t be used on procedures that are inherently defined as bilateral. In such instances, use of Modifier -50 would lead to excessive charges. • Modifier -51
T
he medical billing process is confusing. Every service that a hospital or doctor renders has a specific billing code assigned to it.
Then, depending on the circumstances under which the service was rendered, billing modifiers may need to be used to adjust the final charges billed to the
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payer. Unfortunately, billing departments often misuse modifiers — usually accidentally but in some cases in an effort to get more money unfairly out of payers — and this leads to overcharging the payer. It’s important that employers are able to catch these billing mistakes, challenge them, and get them corrected. With that in mind, let’s take a look at
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When multiple medical procedures commonly performed together are provided during the same session or on the same day, Modifier -51 is used to let the payer know that two or more procedures are being reported during the same day. This provides the payer with a discounted rate on the additional services. However, this modifier is often not used when it should be, or it gets confused with Modifier -59, lead-
FREE CODING WEBINAR 1 CEU ing to unfair, excessive charges. • Modifier -59 Like Modifier-51, Modifier -59 involves multiple procedures. However, what makes Modifier -59 different is that it’s used when multiple, distinct (or independent) services are performed. Distinct is the key word to pay attention to in this case. • Modifier -62 When two surgeons work together to perform distinct parts of the same overall procedure, Modifier -62 is supposed to be applied, meaning each surgeon should be billing at 62.5% of his/her fee schedule. This should not be used if the co-surgeon is acting as an assistant during additional procedures, and it should not be used with Modifier -80 on the same CPT code for a co-surgery. • Modifiers -80/-81/-82/-AS This group of modifiers falls under the category of “assistant at surgery.â€? Understanding which modifier should be used in which situation is essential to accurate billing. Modifier -80 is to be used when the individual providing the assistance at surgery service is an MD. Modifier -81 is to be used when the individual providing the assistance at surgery service is a RN/CSA/. Modifier -82 should be applied when the person providing the assistance at surgery service is an MD and there wasn’t a qualified
resident surgeon available. Finally, Modifier –AS is used when the assistant at surgery is a PA, NP, or clinical nurse specialist. • Anesthesia Modifiers Whenever anesthesia is administered, it’s billed using specific modifiers. Proper use of these modifiers is important to accurate billing. Modifier –AA is used when an MD provides the anesthesia service independently. Modifier –QZ should be used when a CRNA performs the anesthesia service independently. –QK should be applied when an MD oversees two to four concurrent anesthesia procedures. And Modifier –QX is used when a CRNA performs the anesthesia service with an MD supervising. With so many intricacies in medical bill coding, your best bet is to partner with a medical bill auditing company. Medical bill auditors will carefully review every charge on every bill you receive to verify accuracy. When mistakes are spotted, they are challenged and corrected accordingly to save you money. It’s the best way to avoid excessive billing for employers, and it’s an integral part of any cost control plan.
Chris Drevalas is the Vice President of Marketing & Finance at Alpha Review Corporation. He has helped companies of all types with their workers compensation issues for the past ten years. www.alphareview.com
Mecenas sed elit erat. DIABETES Nunc dapibus tellus erat. Aliquam eget urna vitae CODING AND mauris ets sodales ornare. Praesent ac ligula egesDOCUMENTATION tas odio iaculis pulvinar. COMPLIANCE Phasellus aliquam pulvinar lobortis. Integer Presented by: eget quam et lobortisert. Darlene Boschert, RHIA, CPC, CPC-H, Mauris metus urna, conts CPC-I sequat non vehicula nec, fermentum sit amet This one-hour audio will: libero. Vivamus posuere Help participants to understand the iaculiset lacus, Donec
correct use of diabetes codes, manifesWDWLRQ FRGHV DQG WR JDLQ PRUH FRQˉdence by coding diabetes correctly and get claims paid correctly every time. - Coverage of coding manifestation codes along with coding for diabetes - Correct usage coding guidelines - NCCI edits discussed - Examples of secondary diabetes and coding guidelines for them. +RZ PRGLˉHUV FDQ WULJJHU DQG DXGLW
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DON’T LET ICD-10’S
PREPARATION WORK BE FOR NAUGHT Many providers did a great deal of work to prepare for ICD-10, only to be frustrated by its delay…again. However, that work should not be for naught. The goal for a new classification system was for greater specificity in the data captured through the coding and billing process. That specificity can be as important for current external auditor investigations as it will be for future uses of the data for outcomes measures and meaningful use.
G
ather baseline documentation on each provider in your group. Look at a sample of each provider’s records to determine if their current records have the details necessary to assign a diagnosis code without using an “unspecified” code. If you find a few providers whose documentation lacks the specificity needed, focus your remediation efforts in their direction.
there are documentation templates for the physician’s commonly treated conditions (e.g. fractures), then update these to capture the ICD-10 elements (laterality, specific type of fracture, Gustilo classification, etc.)
• Map their common ICD-9 diagnoses to ICD-10 diagnoses: Show the elements that are needed for more specific diagnoses (laterality, chronicity, degree, etc.).
• Selectively update problem lists for patients seen during a pilot period: In collaboration with the nurses, re-review the problem lists to make sure they reflect the specificity needed. For example, if the problem list shows Anemia, unspecified, but the physician’s note indicates Iron Deficiency Anemia, update the problem list accordingly.
• Modify drop downs to reflect these elements, if possible: Ask vendor if the unspecified codes can be dropped to the bottom of the list rather than appearing as the first choice.
Of course all of these activities should be done with the provider’s knowledge and active involvement. Inclusion in the process reinforces the documentation requirements.
• Modify forms or templates to include check boxes for the common elements: If
You may ask why to even bother to do this now when we’re uncertain if ICD-10
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will ever happen. There are benefits: (1) The data provided to payers is more precise and may help to avoid claim rejections and/or reviews. (2) Within each EHR is SNOMED-CT coding for the problem lists. Some of the clinical quality measures are triggered by the problem list. The data being submitted to the federal government for meaningful use purposes will be more complete based on SNOMED’s coding of the condition, and (3) when ICD-10 is launched, your providers will be ahead of the game.
Rose T. Dunn, MBA, RHIA, CPA, FACHE is Chief Operating Officer of First Class Solutions, Inc., a national consulting firm based in St. Louis, MO. Rose is a past president of AHIMA, is an AHIMA Approved ICD-10CM/PCS Trainer, and is a nationally sought-after speaker on a variety of topics. You can contact her at Rose.Dunn@FirstClassSolutions.com.
For the treatment of toxic plasma methotrexate concentrations (>1 micromole per liter) in patients with delayed methotrexate clearance due to impaired renal function
Voraxaze® New Technology Add-on Payment (NTAP) Extended Receive up to an additional 50% payment on your MS-DRG submission.* When you report a claim for Voraxaze® you can be reimbursed up to half the cost of Voraxaze® in addition to the current MS-DRG payment
USE VORAXAZE® ICD-9-CM CODE 00.95† TO BE ELIGIBLE FOR NTAP †
Payers may require the national drug code (NDC) to be submitted on the claim Product
NDC Number
Voraxaze®
50633021011 (11 digit)
Injection or infusion of glucarpidase
Call 1-866-369-9290 or email Voraxaze@thepinnaclehealthgroup.com with questions Indication and Limitations of Use d Voraxaze® is indicated for the treatment of toxic plasma methotrexate concentrations (>1 micromole per liter) in patients with delayed methotrexate clearance due to impaired renal function1
d Voraxaze® is not indicated for use in patients who exhibit the expected clearance of methotrexate (plasma methotrexate concentrations within 2 standard deviations of the mean methotrexate excretion curve specific for the dose of methotrexate administered) or those with normal or mildly impaired renal function because of the potential risk of subtherapeutic exposure to methotrexate1
Selected Safety Information d Serious allergic reactions, including anaphylactic reactions, may occur d The most common adverse reactions (incidence *1%) with Voraxaze® are paresthesias, flushing, nausea and/or vomiting, hypotension, and headache
Please see brief summary of prescribing information on adjacent page. Please see full prescribing information, including important safety information, at www.voraxaze.com. References: 1. Voraxaze® [prescribing information]. Brentwood, TN: BTG International Inc. March 2013. 2. New Medical Services and New Technologies. February 2014. http://cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/newtech.html.
DISCLAIMER *Procedure coding should be based upon medical necessity and procedures and supplies provided to the patient. Coding and reimbursement information is provided for educational purposes and does not assure coverage of the specific item or service in a given case. This information makes no guarantee of coverage or reimbursement of fees. Contact a local Medicare Fiscal Intermediary, Carrier, or CMS for specific information regarding coverage, coding, and payment. To the extent that cost information is submitted to Medicare, Medicaid, or any other reimbursement program to support claims for services or items, there is an obligation to accurately report the actual price paid for such items, including any subsequent adjustments. ICD-9-CM=International Classification of Diseases, Ninth Revision, Clinical Modification. NTAP=New Technology Add-on Payment policy provides additional payments for cases with high costs involving eligible new technologies while preserving some of the incentives under the averagebased payment system. The payment mechanism is based on the cost to hospitals for the new technology and is determined on a case-by-case basis. Under 42 CFR §412.88 Medicare pays the lesser of 50 percent of the cost in excess of the full DRG payment or 50 percent of the cost of the technology. If the actual costs of a NTAP case exceed the DRG payment by more than the estimated costs of the new technology, Medicare payment is limited to the DRG payment plus 50 percent of the estimated costs of the new technology. 2
©BTG International Inc. All rights reserved US-VX-2014-1091 August 2014 BTG and the BTG roundel logo are registered trademarks of BTG International Ltd. Voraxaze® is a registered trademark of Protherics Medicines Development Ltd., a BTG International group company.
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VORAXAZE® (glucarpidase) For Injection, for intravenous use Initial U.S. Approval: 2012 Brief Summary of Prescribing Information. For complete Prescribing Information, consult official package insert. INDICATIONS AND USAGE Indication VORAXAZE (glucarpidase) is indicated for the treatment of toxic plasma methotrexate concentrations (>1 micromole per liter) in patients with delayed methotrexate clearance due to impaired renal function. Limitation of Use VORAXAZE is not indicated for use in patients who exhibit the expected clearance of methotrexate (plasma methotrexate concentrations within 2 standard deviations of the mean methotrexate excretion curve specific for the dose of methotrexate administered) or those with normal or mildly impaired renal function because of the potential risk of subtherapeutic exposure to methotrexate. CONTRAINDICATIONS None WARNINGS AND PRECAUTIONS Serious Allergic Reactions Serious allergic reactions occurred in less than 1% of patients [see Adverse Reactions]. Monitoring Methotrexate Concentration/ Interference with Assay Methotrexate concentrations within 48 hours following administration of VORAXAZE can only be reliably measured by a chromatographic method. DAMPA (4deoxy-4-amino-N10-methylpteroic acid) is an inactive metabolite of methotrexate resulting from treatment with VORAXAZE. DAMPA interferes with the measurement of methotrexate concentration using immunoassays resulting in an erroneous measurement which overestimates the methotrexate concentration. Due to the long half-life of DAMPA (t1/2 of approximately 9 hours), measurement of methotrexate using immunoassays is unreliable for samples collected within 48 hours following VORAXAZE administration. Continuation and Timing of Leucovorin Rescue Continue to administer leucovorin after VORAXAZE. Do not administer leucovorin within 2 hours before or after a dose of VORAXAZE because leucovorin is a substrate for VORAXAZE [see Drug Interactions]. For the first 48 hours after VORAXAZE, administer the same leucovorin dose as given prior to VORAXAZE [see Warnings and Precautions]. Beyond 48 hours after VORAXAZE, administer leucovorin based on the measured methotrexate concentration. Do not discontinue therapy with leucovorin based on the determination of a single methotrexate concentration below the leucovorin treatment threshold. Therapy with leucovorin should be continued until the methotrexate concentration has been maintained below the leucovorin treatment threshold for a minimum of 3 days. Continue hydration and alkalinization of the urine as indicated. ADVERSE REACTIONS Serious allergic reactions, including anaphylactic reactions, may occur. The most common adverse reactions (incidence >1%) with VORAXAZE are paraesthesias, flushing, nausea and/or vomiting, hypotension, and headache. Clinical Trials Experience Because clinical trials are conducted under controlled but widely varying conditions, adverse reaction rates observed in clinical trials of VORAXAZE cannot be directly compared to 20
rates in the clinical trials of other drugs and may not reflect the rates observed in practice. The evaluation of adverse reactions in patients treated with VORAXAZE is confounded by the population in which it was studied, patients with toxic plasma methotrexate levels due to impaired renal function. Adverse reactions related to toxic methotrexate levels due to prolonged methotrexate clearance include myelosuppression, mucositis, acute hepatitis, and renal dysfunction and failure. The safety of VORAXAZE is based on data from 290 patients who were treated in 2 single-arm, open-label, multicenter trials enrolling patients who had markedly delayed methotrexate clearance secondary to renal dysfunction. Patients with osteosarcoma were eligible for these studies if the plasma methotrexate concentration was greater than 50 μmol/L at 24 hours, greater than 5 μmol/L at 48 hours, or greater than 2 standard deviations above the mean methotrexate elimination curve at least 12 hours after methotrexate administration and there was a 2-fold or greater increase in serum creatinine above baseline. All other patients were eligible for these studies if the plasma methotrexate level was greater than 10 μmol/L more than 42 hours after the start of the methotrexate or the plasma level was greater than 2 standard deviations above the mean methotrexate excretion curve at least 12 hours following methotrexate and the serum creatinine was greater than 1.5 times the upper limit of normal or the creatinine clearance was less than 60 mL/min at least 12 hours following methotrexate administration. Study 1, conducted by the National Cancer Institute (NCI), enrolled 184 patients; safety information is available for 149 patients. VORAXAZE was given at a dose of 50 Units/ kg as an intravenous injection over 5 minutes. Patients with pre-VORAXAZE methotrexate concentrations >100 μmol/L were to receive a second dose of VORAXAZE 48 hours after the first dose. The protocol specified that patients continue receiving intravenous hydration, urinary alkalinization and leucovorin, and that leucovorin administration be adjusted to ensure that it was not administered within two hours before or after VORAXAZE. In Study 1, VORAXAZE-related adverse reactions were collected on a flow sheet with a daily log of adverse reactions characterized as “glucarpidase toxicity.” Additional safety information was collected from clinical records submitted by treating physicians. This information was abstracted and categorized using the National Cancer Institute (NCI) “Common Terminology Criteria for Adverse Events” (CTCAE) version 3 scale. The Study 1 population enrolled patients with a median age of 18 years (1 month to 85 years); 63% were male, and the underlying malignancies were osteosarcoma/sarcomas in 32%, and leukemia or lymphoma in 63% of patients. One (n=106) or 2 (n=30) doses of VORAXAZE were administered intravenously; the number of doses was not specified in 13 patients. Doses ranged from 18 to 98 Units/ kg, with a median dose of 49 Units/kg. Study 2 is an ongoing expanded access program. At the time of data cut-off, 243 patients were enrolled and safety data was available for 141 patients. VORAXAZE was given at a dose of 50 Units/kg as an intravenous injection over 5 minutes. The criterion for allowing patients to receive a second glucarpidase dose was not specified in the protocol. The protocol specified that patients continue receiving intravenous hydration, urinary alkalinization and leucovorin, and that leucovorin administration be adjusted to ensure that it was not administered within two hours before or after VORAXAZE. Study 2 enrolled patients with a median age of 17 years (6 months to 85 years); 64% were male, and the underlying malignancies were osteogenic sarcoma in 32%, and leukemia or lymphoma in 62% of patients. One (n=122) or 2 (n=18) doses of VORAXAZE were administered intravenously; the number of doses was not
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specified for 1 patient. Doses ranged from 6 to 189 Units/kg, with a median dose of 50 Units/kg. In Study 2 only VORAXAZE-related adverse reactions were collected and severity was graded according to NCI CTCAE version 3. Among the 290 patients included in the safety evaluation of VORAXAZE, there were 8 deaths within 30 days of VORAXAZE exposure that were not related to progressive disease. Twenty-one of 290 patients (7%) experienced adverse reactions that were assessed as related to VORAXAZE. Most were Grade 1 or 2 events. One patient experienced related Grade 3 flushing. The most common related adverse reactions that were not hematologic, hepatic or renal events were paresthesia, flushing, and nausea and/or vomiting, which each occurred in 2% of patients (Table 1). Table 1: Per Patient Incidence of Grade 1 and 2 Adverse Reactions Assessed as Possibly, Probably, or Definitely Related to VORAXAZE Excluding Hematologic, Hepatic, or Renal Adverse Reactions Adverse Reaction
N= 290 n (%)
Paresthesias
7 (2%)
Flushing
1,2
5 (2%)
Nausea/Vomiting
5 (2%)
Headache
2 (1%)
Hypotension
2 (1%)
Blurred Vision
1 (<1%)
Diarrhea
1 (<1%)
Hypersensitivity
1 (<1%)
Hypertension
1 (<1%)
Rash
1 (<1%)
Throat irritation/ Throat tightness
1 (<1%)
Tremor
1 (<1%)
1
This incidence includes the following terms: flushing, feeling hot, burning sensation.
2
One of these reactions was classified as Grade 3 in severity.
Immunogenicity As with all therapeutic proteins, there is potential for immunogenicity. In clinical trials, 121 patients who received one (n=99), two (n=21), or three (n=1) doses of VORAXAZE were evaluated for anti-glucarpidase antibodies. Twenty-five of these 121 patients (21%) had detectable anti-glucarpidase antibodies following VORAXAZE administration, of which 19 received a single dose of VORAXAZE and 6 received two doses of VORAXAZE. Antibody titers were determined using a bridging enzyme-linked immunosorbent assay (ELISA) for anti-glucarpidase antibodies. Neutralizing antibodies were detected in 11 of the 25 patients who tested positive for anti-glucarpidase binding antibodies. Eight of these 11 patients had received a single dose of VORAXAZE. However, the development of neutralizing antibodies may be underreported due to lack of assay sensitivity. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors, including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of incidence of antibodies to VORAXAZE with the incidence of antibodies to other products may be misleading.
DRUG INTERACTIONS Use of VORAXAZE with Leucovorin Leucovorin is a substrate for VORAXAZE. Do not administer leucovorin within 2 hours before or after a dose of VORAXAZE. No dose adjustment is recommended for the continuing leucovorin regimen because the leucovorin dose is based on the patient’s pre-VORAXAZE methotrexate concentration [see Warnings and Precautions]. Other Substrate Interference Other potential exogenous substrates of VORAXAZE may include reduced folates and folate antimetabolites. USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy category C. There are no adequate and well controlled studies with VORAXAZE in pregnant women and animal reproduction studies have not been conducted with VORAXAZE. Therefore, it is not known whether VORAXAZE can cause fetal harm when administered to a pregnant woman. VORAXAZE should be given to a pregnant woman only if clearly needed. Nursing Mothers It is not known if VORAXAZE is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when VORAXAZE is administered to a nursing woman. Pediatric Use The effectiveness of VORAXAZE in pediatric patients was established in Study 1. Of the 22 patients in the efficacy dataset in Study 1, 12 were pediatric patients with ages ranging from 5 to 16 years. Three of the six pediatric patients with a pre-VORAXAZE methotrexate concentration of 1-50 μmol/L achieved a rapid and sustained clinically important reduction (RSCIR) in plasma methotrexate concentration, while none of the six pediatric patients with a pre-VORAXAZE methotrexate concentration >50 μmol/L achieved a RSCIR. The pooled clinical safety database for VORAXAZE included data for 147 patients from 1 month up to 17 years of age. No overall differences in safety were observed between these patients and adult patients. Geriatric Use Of the total number of 290 patients in clinical studies of VORAXAZE, 15% were 65 and over, while 4% were 75 and over. No overall differences in safety or effectiveness were observed between these patients and younger patients. Renal Impairment No dose adjustment of VORAXAZE is recommended for patients with renal impairment. Hepatic Impairment No specific studies of VORAXAZE in patients with hepatic impairment have been conducted. OVERDOSAGE There are no known cases of overdose with VORAXAZE.
Manufactured by: BTG International Inc. Brentwood, TN 37027 U.S. License No. 1861 Distributed by: BTG International Inc. West Conshohocken, PA 19428 VORAXAZE® is a registered trademark of Protherics Medicines Development Ltd. BTG and the BTG roundel logo are registered trademarks of BTG International Ltd.
BIG DATA:
IS THE JUICE WORTH THE SQUEEZE? Recently, while many have been banking on the ACA’s projected ability to lower the cost of healthcare, another cost-saving industry shift has been playing out behind the scenes: Big Data.
T
he Big Data phenomenon has promised the healthcare industry more efficient administration, superior clinical results, and $450 billion in savings, according to a study by McKinsey & Company. From Meaningful Use and the HITECH Act, to the implementation of ICD-10, to PQRS, to venture capitalists pushing the latest EHR product, the digitization of healthcare systems and medical documentation will inevitably become the standard in healthcare. So far, most of this data has improved healthcare administration--in the form of leaner budgets, less employee idle time, improved revenue cycle management and better fraud abuse prevention. Data is also poised to increase cost transparency--with side by side cost comparisons or services and devices and their success rates—and may even replace more traditional methods of clinical research in the future. For example, with their own data, Kaiser Permanente’s Southern California hospital reported a 26% lower mortality rate compared to other hospitals in the region. While we are counting on data to improve patient outcomes in the years to come,
patients today may be paying the price. Over the last two years, studies funded by the Agency for Healthcare Research and Quality (AHRQ) and the American Journal of Emergency Medicine showed an average of 30-40% of a physician’s time is spent in front of a computer screen. The same studies report that no one looks at 15% to 30% of this data. Another study conducted by the College of Health Information Management Executives reports that most hospital CIOs recognize the value of Big Data collection throughout their institutions, but lack the knowledge and resources to effectively analyze it and subsequently develop and implement clinical and cost saving solutions. Extracting and analyzing all of this information requires a skill set that health care providers do not have, so expensive third party companies are paid to analyze the data. The National Institute of Health alone has committed $96 million to fund centers that will analyze and interpret collected information, and the industry is expected to grow. This begs the question: Are we merely shifting the cost of healthcare to the cost of data analytics?
2. Like the ACA, physicians may be slow to participate. Treatment developed from statistics derived from Big Data may conflict with an individual provider’s current practice, philosophy, or judgment, rendering the process of Big Data Analytics a very expensive exercise in futility.
In addition to cost, there are some other caveats:
Matt Dallmann has spent the last 12 years in private healthcare management, consulting, and medical billing. He is Vice President of the boutique medical billing firm, VGA Billing Services, Inc., based in New York City. Matt’s investigative style of billing and collections has allowed him to resolve some of the toughest insurance issues that would otherwise require legal action. www.CreativePracticeSolutions. com
1. This new information, once extrapolated by a third party, can be used in any way the healthcare provider chooses. For example, favorable stats on a given diagnostic procedure can be touted to the public to increase business, raising the cost of healthcare where it might otherwise be unnecessary.
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3. The Physician Quality Reporting System, or PQRS, is reported primarily by a series of G codes via claim submission, bringing into question the reliability of the data. Will this information be accurate, or just haphazardly entered onto claims in order to avoid the penalty? In light of these, and other obstacles, we hope that the effort being put forth now be commensurate with the solutions that Big Data promises in the future. Otherwise, we will have inadvertently created a generation of healthcare providers who are also glorified data entry clerks.
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INTERNAL AUDITS FOR THE
PHYSICIAN PRACTICE Audit- a big buzz word in healthcare these days, but many practices that fall in the small to mid-size range fail to see the importance and relevance of proactive internal reviews.
L
arge practices and the mega groups, many owned by hospital physician enterprises, identify themselves as more of a potential target for audits and therefore they are more proactive with performing ongoing utilization reviews and coding/documentation audits. It is imperative that small to mid-size groups take notice of the value in readiness and that the size of the practice is not typically the triggering event for a carrier or governmental audit, but rather outliers in billing, coding, and documentation trends. Therefore, it is imperative that these practices be educated on at least the minimal monitoring activities that should be performed based on auditing and compliance.
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Certainly, a full audit program—for any practice—that is more comprehensive in nature is better, however, any review and monitoring will be beneficial for the practice as opposed to having none at all. All practices regardless of their size should have a constructed plan that identifies at least the minimal reviews of an audit program and most importantly it should be active and not merely a paper exercise. The program and plan should also not be to extensive that the practice is unable to adequately meet the demands of the program. When using the term audit program for such reviews, the term audit in and of itself may be a turn off to providers and sound overwhelming for the associated staff who may not feel that they are qualified to perform an actual “audit.” A “review program” can accomplish these same goals, in the same capacity, all the while capturing the provider buy-in as well. A full review program should include such components as: • Utilization reviews - Provider specific - Practice summary • Billing review • Coding review • Documentation review • Educational training • Proficiency observations This comprehensive review program is scalable to the size and volume of a practice, but certain elements are paramount and should be part of every practice’s review program. Utilization reviews are reports that are typically produced from a practice management program, i.e., the billing system of the practice. Utilization reports will vary from one system to the next as to the specific breakdown of the data. Typically, any system should be able to run a report from a specified time span
and show the frequency of codes billed, and most can be specific enough to create such a report based on either CPT or ICD-9 code usage. For purposes of such a review program, we would want to focus our attention to the CPT code utilization. The utilization patterns should be ran as to show the provider’s own specific utilization trends and then additionally to review the practice overall. By performing both reviews this will enable the practice to evaluate the provider’s specific trending to identify specific outliers. Additionally, performing the same trending analysis on the practice as a centralized unit will identify if the practice overall could be viewed as an outlier as well. So, what should you compare on the utilization review? Many systems are not sophisticated enough to provide a full risk analysis of the data and rather they merely spit out the numbers based on either ascending or descending CPT code range or the report can often be produced to show CPT codes in order of the most commonly billed usage patterns. Much focus is put on the trending of E&M service codes (99201-99245) as these services represent the ones with the most potential risk of audit based on a claims volume review—meaning this code set represents smaller claim amounts but certainly a much higher volume of claims. At minimum, the E&M trending for every provider within a practice should be monitored and evaluated to review for patterns that demonstrate outliers with their coding patterns. When reviewing the utilization, it should not be assumed that just because a provider has a bulk of their E&M services in one category that they will be an outlier. Utilization patterns that audit
organizations such as the RAC use are reviewed to specifically analyze the provider based on their specialty as well as on their geographic location all of which may cause a huge shift in the expected levels of service reported by the provider. If providers are identified as outliers through such trending analysis, it certainly does not mean that they should modify their coding and billing in order to be a conformist to a specific trending pattern. Rather, this should identify the provider and the specific services that may need
to be reviewed to ensure that accurate coding selections have been made based on the documentation created for the encounter. This analysis supports the next process in an effective review program and that is a billing/coding/documentation review program. The billing/coding/documentation review
component may be extensive in nature reviewing multiple dates, code sets, as well as a specific sample size of medical encounters for the documentation element, but extensive is not necessarily the key to a good review program. Using the information from the utilization review, the practice should be able to make a better decision on not only which providers actually need to have these areas reviewed, but also as to the extent of the review. For example, if we are looking a trending report such as:
We can see that the provider is consistent with the expected utilization trends, and while for compliance purposes, ALL providers should have their documentation reviewed annually—this provider’s coding aberrancy does not appear to be so significant as to cause alarm for audit risk. However, if the provider’s 99213 and 99214 numbers were reversed, the utiliza-
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tion would be significantly shifted causing reason for additional and immediate review of those services. The utilization patters could resemble the following trending:
to find that some of the billed 99214 encounters more appropriately satisfy the documentation and medical necessity of a 99213 encounter and billing these more appropriately would shift the pattern.
mal or comprehensive approach. A full comprehensive review program would include variations of this small scale approach and also incorporate a scheduled frequency at which this trending utilization and the reviews of the billing/coding/documentation would be performed. For example, a practice that has a full review program may require: • Monthly utilization reviews of each provider with a quarterly trending on these utilizations to identify those outliers for further review • Monthly audits of coding/documentation that are purposed toward the providers whose billing represents potential outlier risk for audit. These audits would be focused to those specific services noted as over/under utilized
As noted above, it is easy to spot how significant this change manipulated the utilization of the provider. When noting such a significant variance on the utilization, it should be noted that this provider would be in need of review for the billing/ coding/documentation. When constructing a review for this provider, it would be most important to perform a concentrated review on the services that are outside of the norm. Based on the pattern, focus might be turned to the 99214 service, but the practice should additionally review the provider’s 99213 services as these are well below the expected averages. Therefore, on review we might expect
However, it is also possible that after review of the documentation and billing that it is noted that the provider did bill appropriately based on the documentation and medical necessity of the encounter. In this instance then, we would not need to make any changes to the provider merely to create a pattern that is more in line with expectations.
• Quarterly coding/documentation audits for all providers regardless of utilization patterns. These would be compliance audits that are “all -purpose” type audits to ensure that all billing/coding/documentation are within compliance as they equate to CMS Policy and Documentation Guidelines. Performing these reviews on a quarterly basis as opposed to an annual review will not only ensure that the task is manageable but will also provide a regular review so that noted deficiencies are not found merely once a year.
Remember, this is a guide and it is used as a measuring stick. It is not a trending pattern that MUST be met. Reviewing the trending analysis of the utilization patterns of providers is the cornerstone of any review program regardless of a mini-
• The volume of each review is completely at the judgment of the practice. The OIG currently recommends auditing for compliance, but there are no specific requirements or rules associated as of yet— although it is forthcoming. The OIG does
6 th ANNUAL
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recognize a baseline audit to be as small as 10-20 records per provider annually. Taking this volume and applying a quarterly review program will create a manageable task even for smaller practices that do not have full compliance teams. • A random sampling of the records to review is always a key fundamental of a good review program. The records that are reviewed should include some of all of the services that are performed by the provider—especially E&M services. Although there are very complex methods for forming a more valid sampling approaching, such as Rat Stats, there are also simple approaches. When providing a review of a solo orthopaedic provider, consider a review that would include 4 new patients, 4 established patients, 4 in-office procedures, and 4 surgeries. The numbers could vary based on the size of the review, but incorporating each of these categories will create a review that is encompassing of a good variety of each of the provider’s service categories. Regardless of the size of the practice or the review program that is constructed, education should be a direct result from the review. There will be providers that need extensive education as their precision error rate may be found to be high, while other providers may only require very minimal suggestions for modifications of documentation and coding. In either case, all providers should be given feedback of the findings of any formal review conducted for compliance verification. Think of it this way, when we ourselves go to the doctor and they run a test, we want to know what our test results are—be it good or bad. Our providers should receive their “results”—good or bad; they should be informed as to the results of the review. The last component of a complex review program is proficiency reviews. This specifically relates to the billing/coding/auditing/compliance professionals who are involved in day-to-day operations for the provider. There are so many practices that have been the result of targeted carrier reviews not based on the provider’s deficiencies in these areas, but due to staff who (although their intentions were well) billed or coded the encounter incorrectly. The billing and coding of a provider’s service is the gateway to the income of the practice, so why wouldn’t it be included in a proficiency review? Regardless of the size of the practice, proficiency evaluation is a great way to ensure the optimization of compliance and reimbursement as it is the lifeline of any practice. All practices, regardless of size and volume, should construct a review program that minimally reviews the utilization patterns and performs focused reviews based on the analysis of the findings. All practices, regardless of their size, should immediately
begin the task of creating a review that is of a complexity scale to best meet the size and volume of their practice. The compliance and reimbursement benefits of creating and implementing such a program makes this endeavor a task that is certainly worth its value in Medicare dollars.
Shannon Deconda, CPC, CPC-I, CEMC, CMSCS, CPMA, is the Founder and President of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the President of Coding & Billing Services and a Partner at DoctorsManagement, LLC.
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Ethics. This one word evokes immediate emotions from physicians. Who would do something unethical? Surely no one in my group. I don’t really think anyone on my hospital’s medical staff would be guilty of real unethical behavior.
T
wo problems to this initial set of feelings are present.
First, we have seen media coverage of court case results of fines and even prison sentencing to pharmaceutical houses, hospitals, and providers with the latter group including physicians, midlevels, nurses, and clerical workers. Clearly it has been determined that a breach and even criminal breach of ethical standards has happened. We are all hopeful that these examples represent a very small percent of the total and I do feel that is the case. But a second problem exists. Does it not depend on your definition of what is unethical?
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For example, a physician turns in a bill for a colonoscopy on Mrs. Smith, and no colonoscopy was performed. Assuming it was not a clerical error I think there would be widespread agreement that this would be fraud. What about a pulmonologist who sees an eleven-year-old for complaints of shortness of breath and persistent coughing? The physician’s suspicion is asthma but to avoid giving the child a negative insurance label, the diagnosis is listed as shortness of breath and persistent cough. Is that unethical? Is it fraud? The purpose of our ethical discussion here is not electronic health record (EHR) error, poor documentation of medical necessity, error of education, nor planned advertent effort. We want to discuss the ethics of the physician on a daily basis in just trying to care for patients.
“The insurance company doesn’t want to pay for anything” is a phrase commonly shared between physician and provider. I think better stated, it is that the third party payers want to pay only for needed services. The difference comes in that the definition of a “needed service” is a function of your starting point of view. The insurance company wants to buy value, a quality product. The hospital and the physician are spending the insurer’s money and the payer wants the money used wisely, efficiently, appropriately. The insurer wants the services provided to be needed and necessary. The patients feel that they have faithfully paid their premiums for years. Now that a need is present, the insurer should not resist covering services. If it is ordered, I need it—testing or treating. So let’s look at a “needed service” example. A 67-year-old male dies suddenly of a myocardial infarction. His 68-year-old sister presents to the family physician the following week. Her point of view is my younger brother just died of an illness that runs in families. He had no warning. I need to be screened. That seems perfectly reasonable, even wise to be responsible and pro-active. The physician wants you to have a test to show the absence of significant atherosclerotic heart disease (ASHD), or if present, treat the problem prior to an unwanted event. Your physician as a neighbor, friend, or partner wants to order this testing for you. However, your physician, the scientist, must evaluate data. There is the consideration of pre-test likelihood of an illness1, testing risks2, false positive test results,
and out of pocket cost to the patient. The advances of medical technology allow many choices. Which test would be best for this patient3? Should it be a standard treadmill with more safety, less cost, and more availability, but less sensitivity and specificity4? Or should we select a nuclear stress test with greater sensitivity and specificity but with greater cost, the added exposure to an isotope, more difficult to accomplish, and less availability? How do we interpret the data regarding CT scanning and the calcium score? Should that be a choice? Is stress echocardiography available in my institution? As a physician, you ask, what is my index of suspicion? Is it high and do I feel this may be ASHD, or is it low and is the test more likely providing patient reassurance than finding disease? If I am looking for a reassurance test, a less expensive and less invasive test may be our choice. If my worry level is higher, perhaps the testing choice is something more involved in cost and risk in an effort to more fully exclude disease. Patients routinely have a preconceived opinion. They “know” from friend or family experience that nuclear testing is unreliable, standard treadmill testing is the “cheap” approach, or a heart catheterization is the only “definitive” test. Their pre-discussion position on how to proceed must be taken into account. What if medical necessity, needed for approval of testing, indicated no testing is the appropriate approach? A patient with no symptoms, no risk factors, and a normal electrocardiogram may not benefit from evaluation. Can this be explained to the patient and their grieving family? Hospitals have always tracked their own data—surgical infection rates, death rates,
etc. With rising healthcare costs, insurance companies have begun to try and record data to assist with buying value for their insured. Electronic medical records (EMR) have allowed intense data mining of each physician’s practice. The government center for Medicare and Medicaid (CMS) has begun to publically release this information.5 But much more is known than your physician’s medical outcomes. We now know economic outcomes as well. We know the hospital’s money that the physician spent in providing care. How long were you in the hospital? How many tests did you order? What were the costs of the tests you ordered? How many of the hospital’s resources did your care require? Decisions on giving a physician preferred provider status can be made on both the quality of medical care as well as the amount of economic resource utilized. How does this affect care? Would I be more likely to choose the less expensive test? If you were in the hospital for chest pain and I find an unrelated problem on exam—a skin lesion—would I avoid asking a dermatologist to evaluate in an effort to keep the cost down? From a medical standpoint, the skin lesion evaluation can likely be delayed to outpatient status. But for patient convenience, would doing it now be more helpful? What if the patient’s insurance plan was such that the out of pocket cost would be less if the evaluation were done now as an inpatient? Would I pick my own economic statistics over the patient’s expense? Let’s stay with ASHD. A 71-year-old male presents to the emergency department (ED) with chest pain. He lives 150 miles away and was in town at the state fair when he experienced chest pain short-
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ly after the evening meal. His pain of 10 minutes resolved before arrival to the ED. His cardiac biomarkers and electrocardiogram (EKG) are normal. It appears there is not an acute myocardial infarction (MI), but this discomfort may still represent angina (chest pain due to ASHD). If it is angina, due to its new onset, it is by definition unstable angina. The physician brings him in to the hospital under observation status and proceeds with a common evaluation: that of chest pain, rule out MI. Through the night additional testing of cardiac biomarkers remains negative and there is no change in serial electrocardiography. Upon morning rounds the decision is made to proceed with more definitive testing. But which test to choose? An ambulatory patient with a normal EKG may be a good candidate for a standard treadmill. However, if the patient has a preconceived notion of wanting a nuclear treadmill test over a standard treadmill, what is our next step? Do we explain we feel the lesser cost and lesser invasive test is sufficient? Or do we order the patient-preferred test? The former will spend fewer dollars but potentially have a less satisfied patient or family. The latter may make the patient happy but yields a higher electronic score card of that physician’s resource utilization (cost of care) to the payer and hospital. Regardless of the test chosen, let us say that it returns normal, no disease shown. But the schedule, timing, and interpretation of the results are such that an answer to the test is not available until 9 PM. Do we discharge a 71-year-old to drive 150 miles late at night after an exhausting hospital stay? That is the correct choice for the physician’s length of stay and cost of care numbers. What if the patient states that he no longer drives at night and wants to stay until the following morning? What if he states that his daughter is driving into town tomorrow and does not want her father discharged until she arrives? Do we worsen our score card and absorb worse statistics with an extra half-day length of stay and the cost associated with that? Do we try and communicate with the patient and daughter about cost, resources, and the economics of medicine and proceed with a discharge at night? We have all seen statistics that any given Medicare patient has the greatest percentage of their cost of care in the last year of life6,7. When should efforts be moved from extending life into comfort care?
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If an elderly nursing home patient with severe dementia appears to be more short of breath than normal or develops a fever, should she be sent to the ED? If she is in the ED, should she be admitted? Is the ICU, ventilation by machine to breathe, multiple CT scans, specialty consultations, etc. appropriate? What if the family and physician have a different opinion? The physician’s opinion is “I would treat her like my mother; I would use comfort as our goal” but the family disagrees and wants “everything” done. Many families refrain from thinking about end of life. When forced, the family member present wants to reach other family members rather than solely make the decision. Days may pass to reach a decision. Family members may disagree with each other and not reach a unified decision. What is the role of the physician in these settings? Volunteering your opinion or only speaking if asked? Stating your opinion or encouraging your opinion to be accepted by the family? With the physician in the middle, a “middleman” is defined as a mediator, one who negotiates equally for the involved parties. If you recognize the difference of coding for the patient or for the payer, are aware of both the economic outcomes and the medical outcomes, and understand the definition of medical necessity, ethics will be upheld.
James S. Dunnick, M.D., FACC, CPC, CHCQM is a physician, board certified in internal medicine and cardiology and is the founder of SESEDN LLC. He has twenty five years of clinical practice experience and is also a certified professional medical coder and boarded by the national quality assurance and utilization group. Dr. Dunnick now focuses on health systems’ needs to meet today’s challenges and uses physician to physician teaching to gain group buy in. He has expertise in ICD 10, EHRs (use, misuse, and meaningful use), correlating E/M levels with documentation and medical necessity, and algorithms for best practice outcomes and cost control.
1. http://plato.stanford.edu/entries/bayes-theorem/ 2. http://www.heartsite.com/html/regular_stress.html#safe 3. https://circ.ahajournals.org/content/96/1/345.full 4. http://www.choosingwisely.org/doctor-patient-lists/ekgs-and-exercisestress-tests/ 5. ACC Advocate. 04.03.14 6. http://www.thirteen.org/bid/sb-howmuch.html 7. http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ ActuarialStudies/downloads/Last_Year_of_Life.pdf
Auditors, We have “THE” conference for you! It is refreshing to attend a seminar where the speakers are also working consultants and can handle questions outside of the outline/ PowerPoint. I can always count on returning to work with ideas and tools that I can directly apply fairly quickly and immediately.” — Steven A. Wahl, DPM, CPC, CPMA, CPO, CHCQM
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29
OFFICE BASED SURGICAL PROCEDURE AUDITS:
HOW TO HANDLE THEM Regrettably, many physicians are receiving a letter from an insurance carrier informing them that they must repay a substantial amount of money as a result of what has been billed to the insurance carrier and paid without objection.
THERE IS NO STATUTORY REQUIREMENT THAT A FACILITY BE AN APPROVED ARTICLE 28 FACILITY TO BE ABLE TO BILL FOR A FACILITY FEE.
P
erhaps the most frustrating part of all is that the physician has billed the insurance company in a particular manner for years with full disclosure and the approval from the insurance carrier. Without warning, the insurance carrier informs you that it is changing its policy as to the physicians past billing and is changing the method of billing for future services. That is the current situation faced by an increasing number of physicians, who for years, with
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BC Advantage Magazine
the explicit approval of insurance companies, have been billing a separate facility fee in connection with the performing of office-based surgical procedures. The typical scenario is one in which a physician sets up a private dedicated room for performing procedures. A separate entity, owned by the physician, is established to receive payments for these services. That entity has a separate tax ID number and payments for the costs incurred in the use of sep-
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arate dedicated room are made to that new entity. These facilities are approved by the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF) or another accrediting organization such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO) or the American Association for the Accreditation of Ambulatory Plastic Surgery Facilities (AAAAPSF). Full disclosure has been made to the insurance carrier concerning the formation of the separate entity and, in fact, in many cases, insurance carriers have explicitly, in writing, acquiesced to this arrangement and informed the provider that it will pay for a separate facility fee in connection with the performance of office-based surgical procedures. In most cases the payments are made for years in the regular course of business without any objection by the insurance carrier. Recently, however, in concert with the increasing emphasis on retrospective audits (industry wide) as a mechanism for cost savings and to collect funds already paid out, the insurance carriers have sent out notices to hundreds of providers that not only will the insurance company not reimburse the physician for this facility fee in the future but it is also seeking repayment of past claims that were paid. Clearly
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the insurance companies had complete knowledge of the status of the facility (letters were issued) where the surgery was performed and with the implicit or explicit approval from the insurance carrier. The insurance carrier is claiming that no provider, whether participating or non-participating, can bill for a facility fee if that facility has not been licensed under Article 28 of the New York State Public Health Law. This is a misinterpretation of existing law. There is no statutory requirement that a facility be an approved Article 28 facility to be able to bill for a facility fee. In fact there are no statutory or regulatory guidelines that either explicitly permit or prohibit a physician from billing for a facility fee for a procedure performed in a separate operating room located in a physician’s facility. The Department of Health has issued an opinion in which it acknowledges that there is no statute or regulation that prohibits billing for a separate facility fee and that “the wide variety of fact patterns must be analyzed on a case-by-case basis before specific conclusions can be reached about the criminal, civil, or disciplinary consequences of particular conduct by corporations or physicians.” This statement supports our position that the payment of a facility fee is a contractual issue between a physician and an insurance company and that there is
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no absolute prohibition against paying such a fee, if agreed to by the insurance carrier and the physician. The contractual nature of this issue is demonstrated by the fact that with the merger of United and Oxford, Oxford, which paid a facility fee for the performing of office-based surgical procedures, has notified participating providers that it will no longer pay a facility fee in order to conform with United’s policy which does not allow for the payment of a facility fee. Physicians should be aware, however, that the Department of Health has also advised that under certain circumstances, where the entity being paid the facility fee is owned by a non-professional, such an arrangement may constitute professional misconduct and/or criminal violations. Both Kern Augustine and The Medical Society of the State of New York have advised the Department of Health that its opinion is based upon a misinterpretation of existing law. In conclusion, it is this the position of this firm that an insurance carrier who has explicitly acquiesced to the billing of a facility fee and has continually paid such facility fee without objection, where full disclosure of the accreditation status of the facility has been made, has no legal grounds to seek repayment of claims already paid to providers who relied upon this representation in submitting claims for facility fees.
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Mathew J. Levy, Esq. is a Principal of Kern Augustine Conroy & Schoppmann, PC. Mr. Levy is nationally recognized as having extensive experience representing healthcare clients in transactional and regulatory matters. Mr. Levy has particular expertise in advising health care clients with respect to contract issues, business transactions, practice formation, regulatory compliance, mergers & acquisitions, professional discipline, criminal law, healthcare fraud & billing fraud, insurance carrier audits, litigation & arbitration, and asset protection-estate planning. You can reach Mathew Levy at 516-294-5432 or mlevy@drlaw.com.
5
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SUCCESSFUL INSURANCE
REIMBURSEMENT
D
Does your office experience a rejection rate in insurance denials that’s higher than you’d like it to be?
oes your front-desk and
Remember, “garbage in IS garbage out.”
A simple question by the staff can elimi-
billing staff know the
Clean claims are those that contain all of
nate this problem. “Is this your insurance
type of information that’s
the correct information necessary to pro-
or are you on someone else’s policy?” will
important to obtain when
cess the claim for payment the first time.
elicit the response you need. This alone
registering a patient? Do they know
can save a ton of time on denials of
WHY the information they’re collecting is
The most common data-entry errors—and
“patient not found” or “insured not found.”
important?
lack of knowledge areas—that we’ve
The insured is the person who carries
come across include:
the insurance policy. At minimum, the
We have found that the first step in
information you need on the insured is
decreased denials is employee under-
• Insured Information.
their full name, birthday, and relationship
standing! If the employees who are
Oftentimes when we help an office audit
to the patient.
registering your patients—or processing
their denials, this is one of the major
your claims—don’t know the significance
problem areas we find. If the informa-
• Patient ID Numbers, Birthdays, Etc.
of the information they are processing,
tion is not right in front of them, most
Make sure your employees are clear on
chances of errors increase dramatically.
employees will automatically assume that
the information that they’re entering. Is
the insured is “same as patient.” If they
that a 4 or a 9? An S or a 5? An L or
Paying attention to detail is crucial to
don’t know that for sure, have them take
a 1? If they’re not sure, make sure you
effectively processing “clean claims”!
the time on the front-end to make sure.
have processes in place that allow them
34
BC Advantage Magazine
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to confirm the information. A denial for “ID number not on file”
son for rejected claims. If you don’t already, make sure that ask-
is very common and usually is just a simple data-entry error.
ing for this information is part of accepting referrals from other
With all that data, numbers, and logos that are crammed onto
providers and/or part of a patient’s initial setup paperwork.
insurance cards, the information keeps getting smaller. A best practice is to use the features of your scanned image capabilities
• Place of Service (POS) Codes.
to “blow up” the insurance cards until you can legibly read it.
We all know that office visits use a POS 11; therefore, most of us
This will reduce errors due to misreading numbers.
default all of our CPT codes to bill this POS. But does your office also provide nursing home visits? Or in-patient hospital rounds?
• CPT & ICD-9 Codes.
Are you able to default the POS on your CPT codes based on the
Read up and stay current with the procedure and diagnosis
location you choose? If you choose location “office,” will your
codes that you bill out. Doing this ensures that you know exactly
system automatically populate the POS to 11? And if you choose
what you are billing and that the diagnosis being used truly goes
location “hospital,” will your system automatically fill in POS 21?
with the procedure code. You can’t use a hysterectomy CPT code on a male diagnosis code. Similarly, you can’t use a vasectomy
• Type of Service (TOS) Codes.
CPT code on a female diagnosis code. They won’t “match” in the
Again, most of us are in the office setting, and therefore default
carriers system—and thus reject. Make sure they match up prior
our CPT codes to bill a TOS 01 (medical). But do you also pro-
to submitting the claim.
vide DME equipment? Or Home Health Services? Are you making sure the TOS codes are either set up to default per location
• Modifiers.
chosen or manually changing them on each of those claims?
Do you provide extended services to some of your patients? Do you perform more than one distinct service on a single visit?
• Provider NPI Numbers.
Make sure you’re versed in the use of modifiers—and use them
This information should be defaulted into your system as well.
as appropriate!
Make sure you have each provider in your practice set up correctly. Make sure the provider numbers you have on file are.
• Referring Providers. Do the primary services you provide in your office rely on the
If the claim lacks the information, it can make it harder for the
referral of other healthcare providers? Do you have a system in
carrier to find the patient or provider in their system. Don’t
place that ensures you’re obtaining that provider’s name and NPI
leave it up to the carrier to determine what you “mean,” make
number with every new referral your office receives? The lack of
sure your claim is complete—and accurate! As they say, make
(or incorrect) referring provider number is another common rea-
sure to “dot all the I’s and cross all the T’s.”
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These types of errors will affect your overall denial rate. If the
Ultimately, you can—and should—involve your patients and hold
information you submit on the original claim is incorrect, the
them accountable for their responsibility in knowing their ben-
claim will be denied. You’ll then need to figure out why it was
efits. Get them involved for those hard-to-deal-with carriers.
denied and work that denial. You must then determine if you
Sometimes that’s all it takes. We’ve found that carriers do not
can simply send in a corrected claim or if you must take it a step
like unhappy patients/insureds.
further and request an adjustment or an appeal of the claim. FREE DENIALS ASSESSMENT: send us your three trickiest All of these scenarios take up precious time. More time to work
denials and we’ll provide a FREE assessment on how to proceed.
the claim, thus increased employee expense. More time to actually get paid on that claim, thus decreased cash flow. Ranadene Tapio is the president of Business Office Consultants, You should also know your carrier contracts and fight for the
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cessfully be reprocessed or appealed. Persistence is key, so stay
medical reimbursement specialist) through AMBA. To find
on top of your A/R. We have found that the more the carriers
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ANNOUNCING
CIC™ Certification
Certified Inpatient Coder CIC™ Certified Inpatient Coder The new inpatient medical coding certification standard, CIC (Certified Inpatient Coder), is the only certification dedicated exclusively to inpatient hospital/facility coding. The CIC validates expert level knowledge and experience in abstracting information from the medical record for ICD-9-CM Volume 1-3 coding, and specialized payment knowledge in MS-DRGs and Inpatient Prospective Payment Systems (IPPS).
The CIC’s Abilities Include: Proficiency in assigning accurate medical codes for diagnoses and procedures performed in the inpatient setting Knowledge of coding rules and regulations, along with keeping current on issues regarding medical coding, compliance, and reimbursement under MS-DRG and IPPS systems Ability to integrate coding and reimbursement rule changes in a timely manner to include updating the Charge Description Master (CDM), fee updates, and the Field Locators (FL) on the UB04 Knowledge of anatomy, physiology, and medical terminology commensurate with ability to correctly code facility services and diagnoses A working knowledge in the assignment of ICD-9-CM codes from Volumes 1-3
CORE CODING CERTIFICATIONS
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MARKETING YOUR PRACTICE
IN TODAY’S HEALTHCARE ARENA Building a medical practice is harder than ever. Many specialists face a crowded market, and primary care physicians are getting direct competition from retail clinics. A phone book listing and a hospital affiliation are no longer enough to establish a strong patient base. shifting payer patterns, introducing new services, recruiting new providers, entering new marketplaces, or combating negative publicity. We believe that marketing a practice in a manner that aligns with its strategic business plan, highlights its brand, focuses on its positive attributes, and determines and corrects any deficiencies will pay off in higher revenues and business sustainability or growth as the new patients begin looking for physicians. That’s true whether the marketing comes through social media, websites, advertising, or other means. There are a number of activities that might be considered good marketing practices or management. These include strategic planning, patient relations, insurance plan contracting, recall systems, practice hours, practice acquisition, office location, and ancillary products and services. To help navigate through some of these, here are 10 basic marketing tips as it applies to medical practices today:
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hysicians today must take an entrepreneurial approach to marketing—actively seeking out new patients and referral sources. Entrepreneurial marketing does not need to be expensive. Practices can achieve good results with a few effective techniques. Administrators and managing physicians often view marketing solely as advertising to attract new patients. Marketing is stereotyped as newspaper ads, billboards, and direct mail campaigns. Marketing is in fact however any activity that moves your practice in a desired direction. Directions might include increasing income, deterring new competitors, retaining market share,
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Tip #1 - Create Electronic Connections Consumers increasingly expect to be able to manage their lives using digital tools. Medical practices that fulfill this expectation will succeed in forging powerful links with a strong patient base. Most electronic health record (EHR) systems can support an electronic patient portal. A portal allows your patients to check test results, view clinical visit summaries, receive health reminders, request physician appointments, and download records to services like Google Health Vault and Microsoft Health. You can also build electronic connections with patients by upgrading your website. The secret is to provide strong content. In addition to providing downloadable forms, update your site
often with seasonal health reminders, healthy lifestyle tips, preventive care information, and other resources. You can also distribute content via Facebook, LinkedIn, Twitter, and/or a simple e-newsletter. Tip #2 - Have a Written One-Year and Five-Year Marketing Plan Practices with a plan typically out-perform practices without a plan. The first and most important part of a marketing plan is the goal, as it is a foundation for all the other decisions. First, develop your fiveyear goal(s), since your one-year goal(s) should fit within the context of your fiveyear plan. A five-year goal is broader in scope and strategy. After each year, you should evaluate and amend next year’s goal(s) based upon whether or not you achieved this year’s goal(s). Concentrate on developing strong, well-crafted goals. In order to accomplish this, limit your goals to no more than five. The components of a properly crafted goal are that the goal is: - Challenging yet attainable - Clear and specific - Written and measurable - Time-sensitive Different practices have different business plans and as-such should have different marketing goals. A new practice in an urban area will obviously have different goals than a mature practice in a rural setting. The rest of the steps in the marketing plan are factors that may impact the outcome of your goal:
- Define your target (age, gender, race, location, diagnosis, language, insurance coverage, etc.) - Define target desires (availability, affability, ability, etc.) - Competition-assessment (as above) - Budget (3 percent to 8 percent typical, 10 percent or more to enter a market or for elective services) - Decide strategies (internal/external, conservative/assertive, hundreds of choices) - Create a calendar of implementation (production lead-time, seasonality, pacing, etc.) - Execute (engage support services, involve staff, implement the plan) - Review and adjustment (track and review results monthly, adjust plan as needed, experiment) Tip #3 - Tune-Up Your Recall System I have seen practices where many patients who were supposed to get a follow-up service or surgery fell through the cracks due to scheduling problems and weak recall-systems. Audit 100 charts (at the rate of 20 per day) for clinical recall compliance. If many charts are out of compliance, audit the last three to five years’ charts over the next six months. Call and attempt to schedule all patients who are out of compliance. Tip #4 - Demonstrate Availability, Affability, and Ability That old cliché about what makes a successful practice still holds true today, perhaps even more-so in our “go-go” society. Your patients are busy and require convenience. Scheduling is still the most important function in your office after the initial physician-patient contact, for patient-retention and new referrals.
See new patients and referrals as soon as possible, preferably within the same week of the call. See patients on time. We all prefer to interact with people we like so make sure everyone who interacts with your patients is friendly and pleasant. - Address the patient by name. - Make an effort to engage the patient in light conversation. - Ask patients about their kids, work/ school, or the weather. - Patients often perceive higher ability in physicians who have affiliations with academic centers or who publish articles in peer-reviewed journals. If your physicians participate in either of these, post it to the practice website, practice brochure, and in patient communication materials. Tip #5 - Get Out in Public Again One of the first, basic, and most successful marketing techniques is oftentimes ignored by maturing practices. Build relationships with other doctors. Physician referrals will be crucial under the ACA, particularly with its emphasis on rewarding team-based care, making it important to continue networking with other doctors through medical associations and other professional organizations. Just remember, compensating others for referrals is usually illegal. Tip #6 - Keep Your Name in Front of Patients and Referrals It is estimated that it takes five or more encounters with your practice’s name for it to be recognized. Your name should appear anywhere potential patients would
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look. That means at least the minimal listing information in all the appropriate categories of various publications, including the local phone book, society directories, physician-listing services, and perhaps the local paper. Free-standing office signs are one of the most effective marketing investments, if the location allows it. Twice-yearly mailings to patients and local residents can also be effective. Your practice’s name, address, phone number, and web address should also appear on every single piece of paper that leaves your office. This includes all those patient-education pamphlets, which would otherwise be generic pieces of information doing nothing to promote your office in the case where a patient passes them on to friends. Every patient should leave your office with a piece of literature at every visit. Quality pamphlets, like those offered by the Academy, better reflect a quality image than most freebies available from vendors. Consider using name-stickers with black ink on a clear background, rather than ink-stamps that may smear. Put the name-stickers on the front of the pamphlet to increase your exposure, as most pamphlets are laid down face-up. Tip #7 - Have an Appropriate Web Page Here again is a marketing strategy that depends on your goals and plan. Most physicians serve a local community and would waste marketing dollars trying to build a web page that directly attracts new patients searching the web for your specialty. You don’t need patients outside of your community to view your web page. A better strategy is to build a website that reflects the office brochure and patient-education materials, so that it serves as a destination-point for local patients in the process of making a choice among physicians. Make sure these potential-patients find your web address on all your print, ad, and media materials. It is a good idea to provide patients with a method to communicate with your office, but make sure you are using a secure messaging service, not regular e-mail, so that your office continues to meet HIPAA compliance regulations. Subspecialty practices that serve broader regions may consider websites set up to draw patients directly to your practice, increase your visibility among other specialties researching information, or to stimulate referral requests. In either case, a “bells-and-whistles” website is not necessary, just a clean, fast-loading, attractive image with quality-content. Nothing turns-off a Medicare patient using a 26K modem more than a slow-loading, plug-in-dependent web page that crashes their browser three times in a row! Make sure your web page is
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W3C-validated (http://validator.w3.org) and promoted properly to search engines and directories (referred to as SEO or “web-optimized”). Tip #8 - Maintain a Commitment to Quality Focus on providing extraordinary service to patients to increase patient retention and patient referrals. By doing so, you should reduce the need for further marketing cash-expenditures. Think about examples of extraordinary service you have experienced at other businesses and how those behaviors might be applied to your office. Particularly pay attention to how problems and disputes were resolved to your satisfaction. Examples might include resolving billing disputes or handling appointment tardiness that was not the patient’s fault. Tip #9 - Change Your Sign If you have a free-standing sign in front of your practice, after a while it becomes invisible to passers-by who see it regularly. Changing the size, shape, and/or color will attract more attention. Tip #10 - Drop Your Worst Insurance Plans If your physicians are booked more than two weeks in advance more than 75 percent of the time—and you don’t want to expand—consider shrinking your patient panel by dropping poor-paying insurance reimbursement contracts. By limiting your practice to better-paying contracts, your doctors don’t need to see as many patients for the same income and they can spend more time per patient while reducing waiting times. Drop one plan at a time until a desirable balance of patient-load, waittime, and income is achieved. Practicing quality medicine while maintaining and managing the bottom line is a balancing act that providers face daily. The Physicians Practice S.O.S. Group is committed to and has helped healthcare providers across the country with new practice start ups, IRO needs, streamlining of their A/R and billing process, improving patient flow, and providing practice management and compliance solutions. Feel free to call our office to discuss any needs you might have.
Regina Mixon Bates, IRO, CPC, CPC-I, Approved ICD-10 AHIMA Trainer, CMOM, CMC, CMIS, is the CEO of The Physicians Practice S.O.S Group® based in Atlanta, GA. The Physicians Practice S.O.S. Group® is a healthcare consulting and education firm that provides services such as: long-range planning, practice assessments and management services, A/R management and oversight, new practice set up that includes facility design, IRO auditing services and training to physicians and their staff. www.ppsosgroup.com
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DUE PROCESS UPHELD FOR PHYSICIANS TARGETED FOR TERMINATION
FROM MEDICARE ADVANTAGE PLANS Physicians who receive termination notices from insurers should learn about their rights from a recent case brought by the Fairfield County Medical Association. 1 physicians fought back.
UNITED UNILATERALLY AND UNLAWFULLY TERMINATED THEIR CONTRACTS.
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Medicare Advantage provider contract terminations are governed by 42 C.F.R. § 422.202(d), and they provide several due process guarantees for providers facing termination.
n February 7, 2014, the Second Circuit Court of Appeals upheld the District Court’s injunction2 enjoining United Healthcare (“United”) from: 1) terminating affected physicians in its Medicare Advantage program; 2) notifying customers that the affected physicians would be terminated from the network; and 3) compelling United to reinstate, advertise, and market the affected physicians in its 2014 Medicare Advantage Network directories.3 The District Court for the District of Connecticut classified its preliminary injunction as one in “aid of arbitration,”
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The primary issue focused on whether United’s actions constituted an “amendment” to physician contracts or a “termination” of those contracts. Under the provider contracts, United had broad discretion to amend contract terms upon 90 days written notice, but terminations without cause triggered a longer timeline for resolution. United claimed it simply “amended” the provider contracts at issue, while the affected physicians asserted that United unilaterally and unlawfully terminated their contracts.
since the United provider contracts clearly required physicians to submit disputes to binding arbitration. Those arbitrations are pending.
Before terminating a physician from a Medicare Advantage plan, an insurer must provide: 1. Written notice;
Background The Fairfield County Medical Association commenced this litigation on behalf of the affected physicians. Throughout October 2013, United notified 2,200 physicians that their Medicare Advantage provider contracts would expire on February 1, 2014. United’s abrupt unilateral termination of these contracts risked causing significant disruption to patient care and the affected physician practices, and the
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2. If relevant, standards and profiling data used to evaluate the physician and the numbers and mix of physicians needed by the insurer; 3. Notice to the affected physician of her right to appeal and the process and timing for requesting a hearing.4 Notably, 42 C.F.R. § 422.202(d)(4),
requires a Medicare Advantage insurer to provide a minimum of 60 days written notice before terminating a physician contract without cause. However, the United Medicare Advantage contracts at issue required United to send written notice by certified mail to a terminated physician at least 90 days prior to the anniversary date of a physician’s agreement. Deadline calculation using the contract anniversary date provided more time in most cases for physicians to adjust than United’s October notices provided. For other insurance plans, New York physicians receive protection under Public Health Law § 4406(2)(a). That section is similar to 42 C.F.R. § 422.202(d), in that it requires insurers to first provide written notice to the terminated physician, which must include an explanation of the reasons for the proposed termination. Physicians also have a right under this statute to challenge the determination decision at a hearing before a panel that includes clinical peers. Lessons The lesson learned from the Fairfield County case is that despite insurers’ efforts to shrink their networks, federal courts will not credit strained arguments that mass terminations constitute “amendments” to provider contracts. Further, the courts will enforce the conflict resolution provisions contained within the plain language of provider contracts. In most cases, provider contracts contain provisions creating administrative hearing procedures, in addition to requirements to submit unresolved disputes to binding arbitration. Providers should routinely review their provider contracts with insurers in order to understand the prescribed remedies if they receive a termination notice.
William J. McDonald is Counsel to Campolo, Middleton & McCormick. He heads up the firm’s Healthcare and White Collar Criminal Defense practice groups. Mr. McDonald represents professionals charged with misconduct before the New York State Office of Professions, as well as at Office of Professional Medical Conduct disciplinary hearings. His experience includes the defense of doctors in hospital privileges hearings, and in audits initiated by Medicare Recovery Audit Contractors (“RACs”), the New York Office of the Medicaid Inspector General (“OMIG”), and private insurance companies, including out of network reimbursement disputes. Contact email wmcdonald@cmmllp.com 1 Fairfield Ct. Med. Ass’n v. United Healthcare of New Eng, No. 3:13-cv-1621 (SRU) (D.Conn. Dec. 5, 2013). 2 Fairfield Ct. Med. Ass’n v. United Healthcare of New Eng., No. 13-408 (2d Cir. Feb. 7, 2014). 3 Fairfield Ct. Med. Ass’n v. United Healthcare of New Eng, No. 3:13-cv-1621 (SRU) (D.Conn. Dec. 5, 2013). 4 42 C.F.R. § 422.202(d)(1)(i-ii). 5 See, e.g. 42 U.S.C. §§1395 et. seq. 6 N.Y. Public Health Law § 4406-d (5). 7 See, e.g. Kamhi v. EmblemHealth, Inc., 37 Misc.3d 171 (Sup.Ct. Kings, March 21, 2012).
Both federal5 and New York State Law6 protect physicians from insurer termination based solely because a physician has advocated on behalf of a patient, appealed an adverse coverage decision, or has filed a complaint against a health care plan. Insurers may resort to pretextual “without cause” termination clauses if possible, so physicians are well advised to seek counsel to review the underlying events leading up to a termination. Courts have entertained physician lawsuits against insurers alleging breach of an implied duty of good faith and fair dealing as well as for unjust enrichment. 7 Insurers will continue to shrink provider networks, and physicians have means to protect themselves and preserve their patient base. The moment a physician receives a termination notice from an insurer, she should immediately engage counsel to evaluate options to protect her income source.
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SUCCESS: DON’T TRY CHASING
SOMEONE ELSE’S DREAMS The only measure of success that really matters is your own personal definition. Too many people allow themselves to be influenced by other people’s definitions or expectations. Trying to achieve the expectations of others can lead to a feeling of failure even when we are successful.
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remember back in my school days, people would ask, “Why can’t you be more like your cousin John who gets straight A’s?” Well the answer to that question is because I’m not John, I’m me, and getting straight A’s isn’t on my list of priorities. Many times I’ll hear someone say, almost apologetically, “Oh, I just have a small company.” But there isn’t any clear-cut definition as to what constitutes “small,” and small doesn’t mean the company is not a success. It doesn’t matter what size your company is, whether you’re a sole proprietor, or whether you employ thousands. As long as it is profitable and you
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are content, it’s successful. However, if you’re not living up to your personal definition of success, here are some ideas as to how you can build your own roadmap to get you where you would like to be in the future. Focus on the following three steps to improve upon your current situation: • Establish attainable goals • Develop a strategic game plan • Surround yourself with an excellent supporting cast Establish Goals: What would you like to
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accomplish that would enable you to declare “I’m successful”? First, define an economic target. The number you choose should be comprised of what you need to run the business, your desired disposable income, plus at least an extra 20 percent to put away for the future. Determine what size you would like your company to be. Are you happy as a sole proprietor or would you like to employ others, too? When establishing these goals, it is important to start with the end in mind. Do you want to create a firm to provide you with a long career and then pass your company on to the next generation or are you trying to
If profitability is an issue, ask yourself how you can improve your operational efficiencies or reduce your costs. If lack of growth is throwing you off track, start reading books and attending seminars related to sales and marketing. If you find that there are not enough hours in the day, then delegate responsibilities and utilize others’ capabilities to get things accomplished. Remember, you can’t manage time, only maximize it by involving others to help you reach your goals. Excellent Supporting Cast: Regardless of your goals, it is awfully hard to accomplish anything all by yourself; it is imperative that you surround yourself with people who can assist you in hitting your targets. There are various ways that you can build an excellent team. One way is to bring in qualified folks who have previously accomplished what you want to accomplish. Another option
Take some time to contemplate what success means to you. Remember that you only have to live up to your expectations. Develop your goals, make sure they are attainable, devise a game plan which is a roadmap to success, and surround yourself with a competent supporting cast. You will have a much better chance of hitting the bull’s eye.
Dave Jakielo, CHBME, is an International Speaker, Consultant, Executive Coach, and Author, and is president of Seminars & Consulting. Dave is past president of Healthcare Billing and Management Association and the National Speakers Association Pittsburgh Chapter. Sign up for his FREE weekly Success Tips at www.Davespeaks.com or Text Davespeaks to 22828. Dave can be reached via email Dave@ Davespeaks.com; phone 412-9210976.
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Strategic Game Plan: Based on your target, you will next need to devise a game plan to help you achieve your goals. First, determine where you are and where you’d like to be. Then conduct an honest assessment of what skills you will need to improve upon to help you hit your targets.
is to grow your own. If you chose this second option, you’ll need to become a thoughtful mentor and an efficient delegator. One of the biggest obstacles to achieving our goals is trying to do everything ourselves. Remember that no one person is as smart as a group of people. Trying to do it all yourself is inefficient, stressful, and hinders the development of others.
June / July 2014 | Issue 9.4
build it and sell it within a decade? Either answer is correct as long as you achieve what you desire.
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MAKING EVERYDAY NEGOTIATIONS
A WIN-WIN Like it or not, all day long we negotiate. We are asked favors by our staff, we coax our patients to take their medications, we tell our kids “I’ll read you a story, but first you have to clean up your room.”
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n fact, most human interactions have an element of some form of negotiation which may be a casual, almost unconscious effort by both parties to get their needs met. But despite our everyday experience, most office managers aren’t as skilled in the art of negotiation as we should be. In many cases, we’d rather sign a bad contract or pay list price than sit down and negotiate. The most common mistake people make in negotiation is thinking that their goal is to win at the expense of the other party. Adopting this win-lose approach almost always results in a failed, or less than optimal, negotiation. Whether you’re dealing with a managed care plan, a staff member, or a sales rep, a win-win approach, where each party gets its
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needs met, is the most successful way to negotiate. Don’t think of negotiations in terms of win-lose; it interferes with you getting the most out of any negotiation. Instead, make an attempt to care about the other person and to meet his or her needs as well as your own. The only power the other side has is not to give you what you want. This is a passive power and mostly psychological. Your fear is the other side’s biggest ally. Lose your fear, and they lose their power. Don’t be afraid to negotiate, and don’t be afraid to walk away. Another mistake people make in negotiation is coming across overly confident, even pompous. It’s human instinct to want to let the other side in a negotiation know just
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how good you are. It’s good to be that seasoned veteran, but all you accomplish by posturing is getting the other side’s guard up. Instead, act professional but not smug. Look engaged, interested, maybe even a little vulnerable. If the other side swoops in like a bunch of vultures, walk away. If they come to the table looking for a win-win negotiation, stick with them. If the other party’s initial offer is unacceptable to you, don’t counter with anything concrete. For example, if the insurance company offers you a fee below Medicare allowable for a procedure, don’t say, “I can’t accept anything less than $…...” If you do that, you’ve just backed yourself into a corner. Rather, say, “You’ll have to make a more reasonable offer if we’re going to move forward.”
Exclusive Online Content Whether you’re negotiating a new employment contract, capitation rates or the price of medical supplies or equipment, before you enter the negotiation, have a clear idea of what you want out of the process and what would be minimally acceptable to you. Once you’ve decided on your walk-away point, do not let the other party know what it is. If you make the other party present its offer first, you’ll have a better idea of what you should offer. Never take the first offer. Even if the first offer is reasonable, don’t take it. First, it makes you look overly eager, which gives the other side a greater sense of control. Second, it makes the other side feel as though they’ve lost that part of the negotiation (meaning they’ll probably want to beat you on the next issue if there is one. You don’t have to be unreasonable, but find something to negotiate about. Don’t use your walk-away point as your first offer. Instead, present the other side with an initial offer that is more advantageous to you. Your counter offer is well above your walk-away point, leaving you plenty of room to negotiate. By now, the negotiation has begun, you and the other side have made your initial offers, and they couldn’t be further apart. How do you keep the negotiation moving forward? At some point in the negotiation, you’re going to have to concede something to the other side. This may mean giving up things you really want, or, if you plan it right, giving up things you don’t care about but the
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other side does. For example, early in the negotiations, you might request two weeks for conferences/CEUs, an issue you don’t feel strongly about. Later, when you’re trying to get the salary you want, offer to give up that second week in exchange for the addition in salary. When someone starts talking about “the principle of the thing,” you know you’re about to go head-to-head with a position held by the other person. To get past obstructing positions, talk with the other person, try to care about him or her, and see if you can find a hidden issue. Above all, don’t assume you know what the other person wants. It isn’t always about money. Little negotiations happen all day, every day. They represent your opportunity to practice before the stakes are large. Negotiating can be fun if you go in understanding that you have the power and look for win-win solutions. How you succeed is up to you.
Marge McQuade, CMSCS, CMM has over 35 years experience in the medical field as an office manager, coder, and educator. At present, Marge is the Director of Education for PAHCS (Professional Association of Healthcare Coding Specialists). PAHCS offers their members many benefits, and one of the most relevant and impactful is offering ALL PAHCS Members FREE ICD-10-CM Training! Get yourself and/or your staff ready for the transition today! www.pahcs.org
5 Common EHR Selection Mistakes According to a recent Medical Economics EHR Survey, provider satisfaction levels have been as low as 78%, so I wanted to help our healers by reminding them of a few things that could lead them to a regretful EHR purchase:
Questions from the Internet 4 The Continuing Saga
Are You Ready For The Next HIPAA Compliance Audits? Access over 5,000 online articles at www.billing-coding.com
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5 MINUTES WITH...
DAVID T. WOMACK set to manage it all. A lot of practices have been bought out by health care systems that were once independent hospitals. Groups are forming out of the need to create better leverage and economies of scale to remain profitable.
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C Advantage (BCA): More than two decades ago, in 1991, you were brought on as PMI’s Marketing Director. This year, you were promoted to President and CEO. Tell us what this journey through the business of health care has been like for you? David T. Womack (DW): When you put it like that, it makes it sound like a very long journey, and, looking back, I guess it has been. PMI’s mission has not wavered from when I started. We still primarily teach medical office professionals the skills they need to succeed. Perhaps the biggest change in 24 years is how complex the business of medicine has become. Gone are the good old days of the pegboard payment system. Paper charts have gone digital, contracts and payment systems are changing. I really admire the small to mid-size medical office that continue to operate independently. Running an office today really does take a team with a specialized skill
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BCA: What do you see as the most important aspect of your position as CEO? DW: My role as CEO is to lead on a grand scale, develop our team, expand our footprint, and improve access to our training. I’m also working with more ancillary organizations to expand our visibility and reach. I think of leadership as the difference between mediocrity and excellence. It’s about creating an environment that inspires people to go beyond the call of duty and choose to do the exceptional. It’s also about honest communication, building trust and inspiring confidence. I will be teaching a leadership session at our conference in Las Vegas in November. I’m hopeful that I can provide some inspiration to our attendees. BCA: PMI serves two needs in the health care marketplace. Can you tell us more about this? DW: Yes, we don’t often get an opportunity to address this but it
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is an important distinction that our organization was founded on. We predominantly train small to medium-sized medical offices, the administrative roles from the front desk to the back office and everywhere in between. Our curriculum helps providers and their staffs excel in the business of medicine. Most of our training classes are conducted live in classrooms across the country, anchored by our relationships with hospitals, health care systems, medical societies and colleges. These organizations host PMI training for their community of independently-owned practices or hospital-managed outpatient facilities. Physician liaisons are able to get representatives from several offices in one room, so the program is a networking tool for them. BCA: How were you and your team affected by the one year setback of ICD-10 implementation? DW: It was a Monday in March, my birthday, to be exact. I was dialed into CSPAN on my computer watching the live vote. I couldn’t believe that this decision to delay ICD-10 another year could come about over the course of a few days, but it did. We had been charging full steam ahead and were geared up to meet the growing ICD-10 training demand. By late afternoon on the
day following the vote, participants and clients began calling in to cancel registrations and programs. In the days and weeks that followed, we stood by, helplessly, and watched as three months of business went poof! In all honesty, the delay has given us all an opportunity to fall back and re-group. We have time to add more depth to our ICD-10 curriculum. For example, our participants kept saying they wished their provider or office counterpart had attended the classes to hear the information first-hand. After attending the class, the participants understood the urgency of getting everyone on the same page to move forward with the transition. Our latest offering brings together the coder, provider and manager team into one room to hear the same message. BCA: Have you noticed any main concerns from your class participants when getting their offices prepared for ICD-10? If so, what kind of advice do you offer them? DW: Initially, people walk into the class overwhelmed. But once they understand how it works, they feel a lot better moving forward. I always tell people, you cannot rely on your EMR to magically produce the codes. You have to understand what codes are being assigned. An EMR is not a substitute for a knowledgeable coder. Make sure your provider’s documentation is up to par. Many participants have told us that their physicians aren’t documenting correctly now and they have valid concerns about their documentation once we take the step up to ICD-10. Physicians need to get comfortable with the expanded documentation requirements now.
And coders will need to have a better grasp of anatomy and physiology and medical terminology for accurate code selection in ICD-10. BCA: As President and CEO, what are you focused on the most for the future? DW: I’ve spent more time on the road the past several years reconnecting with our clients and class participants. Through these conversations, I have a deeper understanding of how PMI can further inspire professional growth and development. We are already branching out with more tools to help our members be successful in their roles. We have more distance learning offerings than ever before, we have four certifications, and we are beginning to do more networking via social media. I want to embrace new technologies and continue to expand our tools, news and information, and resources. That is where PMI is headed. BCA: What kind of advice can you give our readers who are looking to obtain a career in practice management and why should they choose to obtain a certification in that area? DW: I tell audiences all the time, the business of healthcare, and specifically running a medical practice can be one of the most challenging and rewarding professions in healthcare. Running the office puts you in the middle of it all. It takes a special personality and unique set of skills to deal with providers, payers and patients. Earning the Certified Medical Office Manager (CMOM) certification helps instill confidence in your abilities and shows others you have achieved a higher level of knowledge.
Practice Management Institute®, the nation’s premier provider of practice management training and credentialing for physician practice staff. Visit Practice Management Institute website for more information - www.pmimd.com
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REVIEW All books are available from www.optumcodingbooks.com
Title: Outpatient Billing Expert Publisher: Optum Price: $199.95
Title: Optum Learning: Understanding Modifiers Publisher: Optum Price: $95.95 It seems that there is a heap of information about modifiers out there and that the topic has been covered to death but it is amazing just how many people still have qualms about using them correctly. As an answer, Optum has developed Understanding Modifiers to those who need clarification of their use. What I liked most about the book is that the book has been broken down into sections. So, if you’re working on anesthesia codes and you have a question about a modifier you can go straight to the section covering anesthesia and know which modifiers are the ones that relate directly to that specialty. Simple! Other chapters covered are evaluation and management, surgery, radiology, pathology and laboratory, medicine, category II and HCPCS modifiers, ASC and hospital outpatient modifiers. There is also a section on modifiers and compliance and descriptors. So, if you’re struggling with the correct use of modifiers or need a handy reference this is the book for you.
This reference tool is a onesource guide for both hospital outpatient departments (HOPD) and free-standing ambulatory surgical centers (ASC) billing outpatient claims. Outpatient Billing Expert provides detailed references with payment information and guidance to improve reimbursement and reduce claim denials. This all-in-one resource also provides APC and ASC groups, reimbursement amounts, coverage issues and information on what is not covered. There is comprehensive coverage of both ASC and APC payment systems so that you can establish the right payment and audit reimbursement processes for your facility. The book also contains the most recent code sets and information from CMS and other industry sources keeping all billing current and accurate using up-to-date rates and groups for the APC and ASC payment systems. You will be able to resolve billing and denial issues and establish payment and audit reimbursement processes. Also use this book to determine fees and payments prior to submitting your claim as it includes fees, formulas, and tables to determine appropriate APC or ASC reimbursement.
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Point your compass to 10. AHIMA is your guide to navigating everything ICD-10. With AHIMA resources at your fingertips you can successfully reach your destination!
Online Education Complete online coder training, from basic to advanced, including: • Coding Basics program for coding training • Essential foundation courses/assessments for ICD-10-CM/PCS learning readiness • ICD-10-CM/PCS courses/assessments, including specific anatomy/ physiology focus areas • Advanced coding practice cases AHIMA CEUs are available with each Assessment/Course, and special offer product bundles stretch budget dollars for comprehensive staff training. To tailor your program to your needs, AHIMA created Online Education Learning Pathways. Visit ahima.org/education/onlineed/Programs/ICD10 for more information and to order.
Meetings For more information on ICD-10, including FREE checklists and toolkits, visit AHIMA.org/ICD10 today!
AHIMA Academy for ICD-10-CM/PCS: Building Expert Trainers in Diagnosis and Procedure Coding Experience a dynamic training program that teaches proficiency in the ICD-10-CM and ICD-10-PCS coding systems and prepare to train other coding professionals in these systems. Upcoming Academies: October 22–24 | Orlando, FL (CM/PCS) November 17–18 | Chicago, IL (CM only) November 17–19 | Chicago, IL (CM/PCS) December 1–3 | Las Vegas (CM/PCS)
Webinar Replays For one low price you and any number of your peers can benefit from reliable and expert information on timely subjects with webinars and webinar replays from AHIMA. Topics include: • ICD-10-PCS and Physician Coders - Bridging The Gap • An ICD-10 Contingency Coding Staff Recruitment and Retention Plan Success Story • Systems-Based Model for the Instruction of ICD-10-CM and ICD-10-PCS Coding • Focus on Behavioral and Physician Coding in ICD-10-CM
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ICD-10-CM Code Book , 2014 Draft Consulting Editor Anne B. Casto, RHIA, CCS Prod. No. AC221013 ISBN: 9781584260851 1,588 Pages Softcover | © 2014 Price: $110 Member Price: $89.95
ICD-10-PCS Code Book , 2014 Draft Consulting Editor Anne B. Casto, RHIA, CCS Prod. No. AC222013 ISBN: 9781584260905 1,440 Pages Softcover | © 2014 Price: $110 Member Price: $89.95
Basic ICD-10-CM/PCS Coding Author Lou Ann Schraffenberger, MBA, RHIA, CCS, CCS-P, FAHIMA Prod. No. AC200512 ISBN: 9781584263685 584 Pages Softcover | © 2013 Price: $99.95 Member Price: $79.95
ICD-10-PCS Coder Training Manual, 2014 Edition Authors Ann Barta, MSA, RHIA, CDIP Kathryn DeVault, RHIA, CCS, CCS-P Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, FAHIMA Prod. No. AC207814 ISBN: 9781584264293 360 Pages Spiral | © 2014 Price: $99.95 Member Price: $79.95
2014
ICD-10-PCS
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Ann Barta, MSA, RHIA, CDIP Kathryn DeVault, RHIA, CCS, CCS-P Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA
2014
ICD-10-CM
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Kathryn DeVault, RHIA, CCS, CCS-P Ann Barta, MSA, RHIA, CDIP Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, FAHIMA
ICD-10-CM Coder Training Manual, 2014 Edition Authors Kathryn DeVault, RHIA, CCS, CCS-P Ann Barta, MSA, RHIA, CDIP Melanie Endicott, MBA/HCM, RHIA, CCS, CCS-P, FAHIMA Prod. No. AC206814 ISBN: 9781584264286 296 Pages Spiral | © 2014 Price: $99.95 Member Price: $79.95
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AHIMA RESOURCES MATCH ANY LEARNING STYLE.