California Podiatric Physician January/February/March 2013

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Get All the CECH and Radiology CECH You Need at the 2013 Western Foot and Ankle Conference Doctors of podiatric medicine can earn up to 26 continuing education contact hours (CECH) at The 2013 Western Foot and Ankle Conference, including 10 radiology units needed to meet their California license requirements. Podiatric medical assistants may earn up to 14.75 radiology contact hours.

The Western’s inviting location in Anaheim, California is easy to get to from anywhere, but that’s not the only draw for the 1,000 attendees who come from across the country. Hosted by the Disneyland Hotel and Convention Center, The Western provides an exhilarating environment for registrants to learn from superlative lecturers and network with peers and vendors. Podiatric physicians and medical assistants make it a tradition to convene annually not only to keep their skills sharp and learn new techniques, but also to bring their colleagues, family, and friends together to make memories in The Happiest Place on Earth.

The Western’s esteemed faculty and range of topics promise an outstanding educational experience – one that many come back for year after year. This year’s DPM program will cover the ACA, the pediatric patient, wound care, biomechanics, sports medicine, chronic pain, and more. Also offered are workshops on osteoarthritis, trauma, evolving healthcare, diabetes, surgical techniques, and the popular arthroscopy lab. Of course, doctors won’t want to miss the billing and coding workshop with the experts on ICD-10 changes, contracts and appeals.

See CECH you need on Page 3

2013 Western Foot and A nkle Conference - The P lace To B e !

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PRESIDENT’S MESSAGE “All boats are safe in a harbor. But that is not why they build boats.”

Anonymous “The only way to improve is to step out of your comfort zone.”

That is what an elite trainer said to me. He is one who knows a little something about comfort zones, challenges and change.

It’s as true in the gym as it is in our personal and professional lives; and in our Association too. Little comes from doing the same routine and hoping for a different result.

I predicated my term as President on just this concept: Stepping outside of our collective comfort zone to achieve that which had remained elusive. Our reach will likely always exceed our grasp. But we cannot allow that to be a rationalization for failure to act.

Many days the best we can do is to keep the wolves from the door, staying even, and audacious undertakings must wait for another day. But this is not a winning strategy. Doing nothing is actually an invitation to the wolves. As we know, even in the harbor we can be attacked. So, we must be proactive. We will not advance externally or internally with half measures.

We often stay inside our comfort zones because they are, well…, comfortable. But we must all challenge ourselves not only for what See PRESIDENT’S MESSAGE on Page 3

- In This Issue -

4 Changing

the Game

8 Drugs and the Law

Jon Hultman, C. Keith Greer, DPM, MBA Esq. j a n ua r y | F e b r ua r y | m a r c h | 2013

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22 Most Important Attributes of an Office Manager

Tina Del Bouno, PMAC

Update 25 Duals K W , aren

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Ballerinas Don’t Know

Baseball.

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CECH you need from Page 1

After general sessions, attendees may indulge in outstanding restaurants and lounges (like the one-of-a kind Trader Sam’s – Enchanted Tiki Bar), relax in new pools and spas, and network in the Downtown Disney® District – all just steps from the hotel. Plus, Western attendees can purchase specially-priced tickets to the two Disneyland® Resort Theme Parks.

Need more reasons to attend The Western this year? Here are just a few: • Economically-conscious registration rates • Support of your local Association • 3 full days of exhibits • Complimentary morning and afternoon refreshments • Podiatric medical assistant program • Free guest passes to the exhibit hall • Exciting raffle prizes • Helpful and friendly staff • Up to 15% discount on your PICA renewal premium • AAA Four Diamond Award accommodations at the Disneyland Hotel • A myriad of dining and entertainment options • Significantly reduced prices on theme park tickets

Register Now at www.THEWESTERN.ORG PRESIDENT’S MESSAGE from Page 1

it will reap in concrete terms, but what it will create within us, in terms of strength and character. If we do not, we squander our future; and that is a true shame.

Whether it’s knocking on the door of a potential referral source or visiting our elected officials, there are opportunities available every day that we must seize.

That is where our legacy to those who follow lies, and frankly that is where our responsibility lies as well.

Change will come, inevitably. But it can be a future we help to shape or one we just allow as bystanders.

I imagine it’s as true for you as it is for me, my most valued achievements occurred when I was brave enough to risk rejection and even humiliation. But, those moments have made all the difference between where I am and a lesser life.

The most successful among us are the bravest and the boldest. We admire their success, but have not always seen the extra efforts they have made; the captaining j a n ua r y | F e b r ua r y | m a r c h | 2013

of their fears. Courage is not the absence of fear but the mastery over it to move forward.

• We are closely monitoring the Governor’s special legislative session on healthcare this month

And small victories matter too. Our lives are a series of small victories if successful and small defeats if not.

• Membership in CPMA has continued to rise, and we have one more delegate to the APMA HOD this year. Though that is important, much more encouraging to me is that more are recognizing the value of CPMA

The victory to go to the gym that day, to sign up to serve as coach, to make that phone call - that is where success lies, but we must act. Be willing to be uncomfortable.

And so CPMA will continue to be bold.

In these pages, on our calpma.org site (dedicated members only section), and in the correspondence you regularly receive as a member, you remain informed of much of the work being done.

• One of our most exciting projects, the Physician and Surgeon taskforce, moves steadily forward in very measurable steps.

• We continue to engage on every front with regard to the Duals issue, the Health Exchange, and all aspects of Health Care Reform here in California.

• CPMA continues to support the LACPMS GPO which is growing and will therefore soon be able to offer even more products and services (and save us all more $$).

Here is another opportunity for you: Our CPMA LLC is the week of March 18th. Visit your local legislators and inform them about Podiatric Medicine. Tell our wonderful story.

Will it be uncomfortable? Maybe. Will you grow? Undoubtedly.

CPMA needs your continued active participation and support. I personally thank all of you for your dedication and contributions to our great specialty.

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Changing the game On Tuesday, February 5, while waiting for a flight at LAX, I happened to pick up a copy of USA Today and quickly skimmed through the headlines. One in particular caught my attention. It read, “Hillary’s Not Bad, She Did an OK Job.” The sub-headline went on to say, “A great person does something game-changing. Clinton did not.” While this headline was not critical of her performance as Secretary of State, it certainly was not complimentary. I doubt that any of us would want to be remembered as having performed “OK” as a podiatrist, or if we have had the responsibility of holding leadership positions on a hospital committee or professional organization, we hope that our impact would have been better than simply, “not bad.”

James S. Robbins, a senior fellow in national security affairs at the American Foreign Policy Council, authored this article. He opened with the following assessment: “To her credit, Clinton managed her department well and worked tirelessly to implement Obama’s foreign policy vision. She was a team player under a leader who landed the job she expected for herself. But this alone is not enough.

Competently executing her duties is just what is expected. Even being consistently above average is true of any B student. A great person does something game-changing. Clinton has not cleared that bar.”

To achieve a “game-changing” event, one must employ a strategy in which s/he does something novel and unexpected. This approach not only attracts attention, but has the potential of moving others to think differently – not simply give an expected “knee-jerk” response.

Within the “imbalance of power” in medicine, physicians generally find themselves in a position of relative weakness, and because of the small numbers of podiatric physicians, we, in particular, face a formidable challenge. Whether we seek to expand our scope, attain fair rates with payers, demonstrate our true value to hospitals or group practices, we are usually negotiating with entities significantly larger and more powerful than we, affording us little ability to “win” when we play their games by their rules.

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What can we do to level this playing field? A paperback book in my library on racquetball strategy states, “If you are winning the game, keep doing what you are doing. If you are losing, try something different.” How do we find this “something different?” When planning strategies directed at achieving your future goals in the healthcare arena, the most effective framework to employ is one based on economic game theory, with the most powerful strategy being to change the game itself. If you can find a novel way to change the game to one in which all parties come out winners, you will have a compelling strategy that gains everyone’s attention. Generally, it is possible to find the “win-win” in most situations – even in ones where it at first appears you can win only if another loses. You can only find such solutions if you are looking for them and have a framework from which to pursue such an outcome. To help you develop this type of framework, I have included a section from “Use Leverage to Your Advantage,” taken from “Chapter Two” of my book entitled, The Medical Practitioner’s Survival Handbook.

Economic Game Theory Offers Strategic Leverage Game Theory dates back to 1944 with the publishing of Theory of Games and Economic Behavior by mathematician Jon von Neumann and economist Oskar Morgenstern. Game Theory is a useful tool in business situations where the fortunes of players or companies are interdependent and decisions made by one will affect or influence decisions made by the others. This describes virtually every situation encountered in today’s healthcare environment. Game Theory was brought to the forefront more recently in a 1995 article,“The Right Game: Use Game Theory to Shape Strategy,” written by Adam Brandenburger (a Harvard Business School professor) and Barry Nalebuff (a Yale Business School professor). This article was followed by their 1996 book Co-optition which put forth the concept that a combination of cooperation and competition are inherent in most business situations.

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Game Theory is demonstrated in the strategy used when playing competitive sports or games like chess and bridge. Using the type of strategic thinking necessary for game playing – combined with mathematic, economic, financial, statistic, operational and business management concepts – can lead to better business decisions for those employed in today’s competitive healthcare environment. Game theory can provide significant leverage in a wide variety of strategic situations. Rapid changes in healthcare and technology require rapid, strategic responses, and this is where Game Theory excels. This type of thinking helps a “player” to understand what is going on and how to improve a situation strategically. Let’s take a closer look at four Game Theory principles that I feel are indispensable tools, ones that can sharpen your thought process for making strategic decisions and simultaneously provide leverage.

Principle One: Look forward and reason backward I believe Yogi Berra has been attributed with the quote,“Making predictions is difficult, especially when you are predicting the future.”

Business projections are typically made by analyzing historical data and then using a combination of subjective experience and objective tools taught in business schools (such as econometrics and regression analysis) to project forward. This approach is a useful exercise, but it rarely leads to a superior decision – especially when the environment and technology are changing as rapidly as they are in today’s healthcare environment. This method of using historical data to project forward has been compared to having a blindfolded driver dependant on the eyes of a navigator looking out a car’s rear window and telling the driver when to turn and what direction to go.

A Game Theory approach often contradicts conventional wisdom.

In most games, the future is “forecast” by looking forward to a desired outcome, or goal, and then thinking backwards to determine the moves necessary to reach that goal. For example, a short-term goal in chess might be to remove a bishop that is positioned to interfere with the long-term goal of advancing towards the king. The thinking process is begun at the point where the bishop (the obstacle) is “gone,” and from there, the player reasons backwards through the moves needed to reach this goal. Throughout the “backwards thinking” process, the player is forced to consider any moves the competitor might make to prevent the removal of the bishop at each step. In chess, moves are predicted, based on the assumption that the opponent is trying to win the game and is assessing your ability (strengths and weaknesses) in order to more accurately “predict” your moves. The same is true in business. We determine who the decision makers are and ascertain what we can about their motives and abilities. In business, we also add the assumption that a player “wins the game” by maximizing profit and that s/he makes moves based on reaching this goal.

While this approach may seem obvious, few people in the business world tend to think this way. Those who do so have a significant advantage, and their decisions improve as they gain more experience and knowledge about their competitors.

Principle Two: Determine the value that you bring to the game This one principle defines why the Physician Practice Management Industry (PPMCs) failed and why HMOs have not yet become the j a n ua r y | F e b r ua r y | m a r c h | 2013

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preferred healthcare model. Business is all about meeting the needs of customers and creating value in the process. Physicians perceived that the value they received from PPMCs was lower than the fees they charged, and HMOs did not meet the customer service needs of patients. In fact, patients contend that customer service has only become worse. Most business situations require a “player” to have good understanding of the value s/he brings to the other players. In other words, how does s/he meet the needs of customers and/or add to profit?

Business transactions require negotiation, and a critical first step in your negotiating process (whether we are speaking of a managed care contract or becoming a partner in a practice) is determining the value that you bring to the table. In the “old days,” some physicians took greater value from the “treatment game” (relative to other doctors) than they brought to it, simply by using higher paying treatment codes. In Game Theory, this strategy does not work – an operative principle of Game Theory is that players cannot take more value from a game than they bring to it. The importance of adopting this principle is that it clearly directs a player towards a strategy intended to make him/her a more valuable player.

The best way to determine the value a player brings to a game is to estimate the impact that would be made on the other players if s/ he were removed from the game. Since the real game of business is about creating value, this can be an eye opener for a doctor – recognizing the true value (or lack of value) that he/she as a player actually brings to the “game.” Undergoing this process will lead to a better strategy – one directed at finding ways of becoming a more valuable player.

Principle Three: Develop a perspective that focuses on the positions of the other players, rather than on your own Unlike typical games where there are winners and losers,“business games” present an opportunity for developing strategies whereby everyone can win. This is the fun of “playing” these games. Finding moves that allow all payers to win can lead to positive outcomes, creating synergistic opportunities in which collaboration (such as strategic partnerships or sharing infrastructure) can benefit all companies involved – especially in areas that save cost or accelerate growth.

Game Theory changes the focus from egocentric (What’s in this for me?) to allocentric (What’s in this for us?). By placing yourself in the “minds” of the other players and assessing your value in terms of what you can bring to others, the game changes from win-lose (or even lose-lose) to win-win. This “strategy” has broad applications to all areas of healthcare delivery and will achieve its optimum results when all players – payers, doctors, and patients alike – win. By applying the principles of game theory, this optimum will be reached much sooner.

See changing the game on Page 7

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changing the game from Page 5

Principle Four: Can’t win? Change the game It is important for players to recognize that when the deck is stacked against them, or other players are holding all the “good cards,” they don’t have to play the game they find themselves in. You may have faced such a situation – when applying for hospital privileges or to become a provider on a managed care panel, negotiating a managed care contract or your salary as an associate in a practice, or even applying for a loan. The only way to enter this kind of game is with a strategy directed at changing the game itself. For example, as I watched the NCAA basketball tournament, I saw “underdogs” win using strategies directed at changing the game of the other team – after all, the top seeds have already demonstrated that they will win if allowed to play their own games. This same strategy can work equally well in the game of business.

According to “The Right Game” authors Brandenburger and Nalebuff, changing the game requires changing one or more of a game’s five elements – the players, added value, rules, tactics, or scope. Focusing on these five elements will provide a framework and a systematic way for developing a strategy for changing the game.

Start by asking the questions: “Who are the players? Who should the players be? How will the other players react to my actions? How much value do I bring? How valuable am I to the other players? What are the boundaries? If the other players are expanding boundaries into my area, how do I expand into theirs?”The most powerful aspect of

this process is that by simply entering the game, you change it. Any physician who has been first to challenge a prevailing “conventional wisdom” understands how significantly s/he changed the game just by entering. Knowing that your entry automatically changes the game can build a level of confidence that will take you quickly to the next level. Just be certain to take steps that assure your entry creates a winwin for other players as well as yourself.

The strategic options in the “game” of business are far greater than in board or card games. We use tactics in both types of game; yet, our strategies are very different for each. Because we can’t change the boundaries or rules in a card or board game, our value remains constant throughout. If we lack the necessary piece to win a game of chess, we are in trouble. In business, however, when a “piece” which we consider essential to reaching our goal, we can change the game by acquiring that piece through strategic partnerships – or, if we have access to capital, we can purchase it. Without knowledge of the strategy of Game Theory, it is difficult to recognize which pieces are missing – or why they are necessary to our goal. This, perhaps, is the key difference between traditional games and business: in business we can change the game. While changing tactics is common to both, in business we are free to change the boundaries, rules, added value, and players. This opportunity often leads our thought process in a new direction – one that more consistently arrives at the goal of everyone winning – something we should all be striving for.

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Drugs and the Law the doctor was reported to the Board by an ex-in-law for treating his grand children, and another case where a jealous boyfriend filed a complaint. Although it may be socially challenging to just say no, it is often the best approach when dealing with family and friends, and the only acceptable approach when being asked by provide treatment outside your scope of practice. Remember, no good deed goes unpunished.

Imhotep could not have known that a multi-billion dollar industry regulated by untold numbers of governmental agencies would, some four and a half millennia later, arise from the first therapeutic elixirs he prescribed to King Zoser. He did know, however, that the potential harm that could be caused by misusing the knowledge and skill he had acquired mandated strict secrecy and protection to avoid it falling into unethical hands. There are now nearly as many laws regulating pharmaceuticals as there are medications, with an equally impressive cost of enforcement. In this article I will address some of these laws and how they impact the practice of Podiatric Medicine.

It probably goes without saying that a doctor should not self-prescribe for any reason. Period! Self-prescribing can result in licensing board sanctions as well as criminal prosecution. And although it does not violate California law to treat family and friends, the Medical Board recommends against it. If you do treat family or friends, it is important to ensure that you do not exceed your scope of practice or expertise, and that you meet all the criteria applicable to treating any patient, including performing a reasonable examination and preparing a proper medical record. I have handled many cases where the doctor provided proper care for a friend or family member, but faced potential sanctions for failing to prepare proper documentation.

It is also important to correct the common misperception that helping a friend or family member will fall under the radar since neither you nor the patient is going to tell anyone. First, on the rare occasions that the treatment fails or leads to further complications, there is no guarantee that your acquaintance or family member won’t file a complaint. Second, just because the patient is happy, doesn’t mean that someone else in the family with an axe to grind won’t step forward and turn you in to the board. I had a case where 8|

Moreover, due to the reporting requirements for prescription drugs, the authorities can easily run a report on your prescribing history and identify to whom you subscribed as well as what you prescribed.

Prescriptions to people with your same last name will be suspect, and your name on the list would be fatal. Certain types of medications will also be suspect. Sleep aids and psychotropic medications will be scrutinized. If they are related to the treatment of lower extremity pain, and properly documented, you should be fine. If you are prescribing those same medications for reasons not related to lower extremity pain, there may be serious consequences.

Reports on your prescribing practices can also reveal the overuse of medications, particularly pain medications. Once a patient with what appears to be chronic or excessive use of pain medications is identified, they will be scrutinized to determine whether they are drug seeking, addicted or, in some cases, candidates for referral to a pain management specialist. Each of these situations warrants analysis.

First, it is important to identify drug seeking patients. Typical signs to look for include: (1) subjective pain which appears out of proportion to objective findings; (2) the patient refuses to attempt non-narcotic medications; (3) the patient asks for a specific type of medication or knows a lot about controlled substances; (4) a history of heavy prescription usage; (5) excuses of lost prescriptions; (6) the patient calls in for prescriptions with promises to later set a follow up examination or frequently misses appointments; (7) the patient treats with and receives medications from multiple doctors; (8) finding out that the patient is treating with other doctors that were not previously disclosed; (9) the patient refuses to undertake alternative therapies in an effort to reduce the need for pain medications; and (10) an established long term history of chronic pain medication usage.

Since patients with these signs may have drug seeking issues or serious underlying conditions, such as CRPS, it is important to seek outside consultations from a pain management specialist.

The sooner the better since the common allegation in CRPS cases is the doctor’s failure to question the existence of CRPS and promptly implement treatment. If you are the pain management C P MA | C a lifo r n i a P odi at r i c M e di c a l Asso c i atio n

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specialist, it is helpful to get a psychological consult to provide you with additional input. These types of patients create a high risk of subsequent malpractice suits and licensing board actions. Cases where the doctor failed to promptly diagnose and treat CRPS with aggressive physical therapy along with a regimen of medications are difficult to defend and can lead to very large litigation losses. Even where the patient lies and covers up drug seeking or addiction issues, the doctor has a duty to be on the lookout for these issues and can be sanctioned or sued for not acting reasonably to protect the patient from themselves. Thus, it is never a bad idea to at least get a second opinion when dealing with these types of patients.

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Lastly, although it is not illegal for doctors to prescribe medications for uses other than the use approved by the FDA (i.e., off-label usage), it should be noted that there is an increased risk of liability to the prescribing doctor. Thus, it is helpful to have reliable medical literature to support the prescribed usage. It is also important to make sure that the patient is aware of the off-label use and the risks associated with such use. Since there is a higher risk of legal exposure, it is very important to clearly document the consent process in a way that leaves no doubt that the patient was properly informed.

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In addition to these legal issues, recent studies and debates on the subject reveal a trend away from the level of prescribing that has resulted in nearly half of the American population regularly taking prescription medication, and toward a philosophy of preventive therapies and more healthy life styles. This isn’t surprising in light of average annual prescription rates in the United States of four prescriptions per child (under the age of 18) and thirty-one prescriptions per senior (over the age of 65). The Center for Disease Control, Medicare and most healthcare organizations are spending substantial resources in efforts to offset the billions of dollars spent by pharmaceutical companies to condition patients to associate medications with wellness. This has resulted in countless studies showing not only the cost benefits of preventive and alternative care, but also improved outcomes from addressing the ailment rather than pharmaceutically dealing with one symptom and concurrently creating another.

If you have legal questions relating to these or other issue in your practice, please feel free to call our toll free legal hotline at 1-800-FOOTLAW.

Special thanks to Dr. Jack Morgan who once again went above and beyond to bring this event to fruition.

LACPMS wishes to thank event sponsors for their unwavering support and belief in podiatric medicine: DJO Global, Arthrex, Bako Labs, Westwood Open MRI, Biomet, Lifecare Solutions and Neurometrix Please remember to give your support those who support and believe in us.

Dr. D erick A. Ball • Chair, CalPPAC

The Los Angeles County Podiatric Medical Society (LCPMS) celebrated its 5th Annual “One Voice” event this year at the ultra-chic Peninsula Hotel in Beverly Hills. Dining, dancing and entertainment were shared with friends, colleagues and spouses.

Once again, the event broke its’ own record of raising money for our PAC. LA’s leadership was all in attendance to support the event. CPMA President Dr. Karen Wrubel shared the latest news regarding CPMA’s efforts at the state level, as well as the Physician and Surgeon Task Force.

LACPMS’ President-elect Dr. Gabriel Halperin gave an update on the CCI Duals Project status.

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(l to r) CPMA President Karen Wrubel, DPM; CalPPAC Chair Derick Ball, DPM; CPMA Executive Director Jon Hultman, DPM, MBA with spouse Patti Hultman

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medicare - Jurisdiction 1 Part B Full Implementation of Edits on the Ordering/Referring Providers in Medicare Part B, DME and Part A Home Health Agency (HHA) Claims (Change Requests 6417, 6421, 6696 and 6856) MLN Matters® Number: SE1305 Related Change Request (CR) #: 6421, 6417, 6696, 6856 Related CR Release Date: N/A Effective Date: May 1, 2013 Related CR Transmittal #: R642OTN, R643OTN, R328PI and R7810TN Implementation Date: May 1, 2013 Note: This Special Edition MLN Matters® article is a consolidation and update of prior articles SE 1011, SE 1201, SE 1208 and SE 1221. Effective May 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will turn on the Phase 2 denial edits. This means that Medicare will deny claims for services or supplies that require an ordering/referring provider to be identified and that provider is not identified, is not in Medicare’s enrollment records, or is not of a specialty type that may order/refer the service/item being billed.

Provider Types Affected This MLN Matters® Special Edition article is intended for: • Physicians and non-physician practitioners (including interns, residents, fellows and those who are employed by the Department of Veterans Affairs (DVA), the Department of Defense (DoD) or the Public Health Service (PHS)) who order or refer items or services for Medicare beneficiaries • Part B providers and suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) who submit claims to Carriers, Part A/B Medicare Administrative Contractors (MACs) and DME MACs for items or services that they furnished as the result of an order or a referral • Part A Home Health Agency (HHA) services who submit claims to Regional Home Health Intermediaries (RHHIs), Fiscal Intermediaries (FIs who still maintain an HHA workload) and Part A/B MACs • Optometrists may only order and refer DMEPOS products/services and laboratory and X-ray services payable under Medicare Part B Provider Action Needed If you order or refer items or services for Medicare beneficiaries and you do not j a n ua r y | F e b r ua r y | m a r c h | 2013

have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) or by completing the paper enrollment application (CMS-855O). Review the background and additional information below and make sure that your billing staff is aware of these updates.

What Providers Need to Know Phase 1: Informational messaging: Began October 5, 2009, to alert the billing provider that the identification of the ordering/referring provider is missing, incomplete or invalid, or that the ordering/referring provider is not eligible to order or refer. The informational message on an adjustment claim that did not pass the edits indicated the claim/ service lacked information that was needed for adjudication.

Phase 2: Effective May 1, 2013, CMS will turn on the edits to deny Part B, DME and Part A HHA claims that fail the ordering/ referring provider edits. Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record and must be of a specialty that is eligible to order and refer.

All enrollment applications, including those submitted over the Internet, require verification of the information reported.

Sometimes, Medicare enrollment contractors may request additional information in order to process the enrollment application.

Waiting too long to begin this process could mean that your enrollment application may not be processed prior to the May 1, 2013 implementation date of the ordering/ referring Phase 2 provider edits.

Background The Affordable Care Act, Section 6405, ‘Physicians Who Order Items or Services are Required to be Medicare Enrolled Physicians or Eligible Professionals,’ requires physicians or other eligible professionals to be enrolled in the Medicare Program to order or refer items or services for Medicare beneficiaries. Some physicians or other

eligible professionals do not and will not send claims to a Medicare Contractor for the services they furnish and therefore may not be enrolled in the Medicare program.

Also, effective January 1, 1992, a physician or supplier that bills Medicare for a service or item must show the name and unique identifier of the attending physician on the claim if that service or item was the result of an order or referral. Effective May 23, 2008, the unique identifier was determined to be the National Provider Identifier (NPI). The Centers for Medicare & Medicaid Services (CMS) has implemented edits on ordering and referring providers when they are required to be identified in Part B, DME and Part A HHA claims from Medicare providers or suppliers who furnished items or services as a result of orders or referrals.

Below are examples of some of these types of claims: • Claims from laboratories for ordered tests • Claims from imaging centers for ordered imaging procedures • Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) for ordered DMEPOS Only physicians and certain types of non-physician practitioners are eligible to order or refer items or services for Medicare beneficiaries. They are as follows: • Physicians (doctor of medicine or osteopathy, doctor of dental medicine, doctor of dental surgery, doctor of podiatric medicine, doctor of optometry, optometrists may only order and refer DMEPOS products/services and laboratory and X-ray services payable under Medicare Part B) • Physician Assistants •Clinical Nurse Specialists • Nurse Practitioners •Clinical Psychologists • Interns, Residents and Fellows • Certified Nurse Midwives • Clinical Social Workers CMS emphasizes that generally Medicare will only reimburse for specific items or See medicare on Page 13

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services when those items or services are ordered or referred by providers or suppliers authorized by Medicare statute and regulation to do so. Claims that a billing provider or supplier submits in which the ordering/referring provider or supplier is not authorized by statute and regulation will be denied as a non-covered service. The denial will be based on the fact that neither statute nor regulation allows coverage of certain services when ordered or referred by the identified supplier or provider specialty.

that the identification of the ordering/ referring provider is missing, incomplete, or invalid, or that the ordering/referring provider is not eligible to order or refer. The informational message on an adjustment claim that did not pass the edits indicated the claim/service lacked information that was needed for adjudication. The informational messages used are identified below:

CMS would like to highlight the following limitations:

N264

• Chiropractors are not eligible to order or refer supplies or services for Medicare beneficiaries. All services ordered or referred by a chiropractor will be denied.

• Home Health Agency (HHA) services may only be ordered or referred by a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.) or Doctor of Podiatric Medicine (DPM). Claims for HHA services ordered by any other practitioner specialty will be denied •Optometrists may only order and refer DMEPOS products/services, and laboratory and X-ray services payable under Medicare Part B

For Part B providers and suppliers who submit claims to Carriers: Missing/incomplete/invalid ordering provider name

N265 Missing/incomplete/invalid ordering provider primary identifier For adjusted claims, the Claims Adjustment Reason Code (CARC) code 16 (Claim/service lacks information which is needed for adjudication.) is used.

DME suppliers who submit claims to Carriers (applicable to 5010 edits):

544

1. What are the ordering and referring edits?

Alert: Although this was paid, you have billed with referring/ordering provider that does not match our system record. Unless, corrected, this will not be paid in the future

The edits will determine if the Ordering/ Referring Provider (when required to be identified in Part B, DME, and Part A HHA claims):

For Part A HHA providers who order and refer, the claims system initially processed the claim and added the following remark message:

Questions and Answers Relating to the Edits

1) has a current Medicare enrollment record and contains a valid National Provider Identifier (NPI) (the name and NPI must match); and 2) is of a provider type that is eligible to order or refer for Medicare beneficiaries (see list above).

2. Why did Medicare implement these edits?

These edits help protect Medicare beneficiaries and the integrity of the Medicare program.

3. How and when will these edits be implemented?

These edits were implemented in two phases: Phase 1: Informational messaging: Began October 5, 2009, to alert the billing provider j a n ua r y | F e b r ua r y | m a r c h | 2013

N272 Missing/incomplete/invalid other payer attending provider identifier.

names of physicians and non-physician practitioners who have current enrollment records in PECOS and are of a type/ specialty that is eligible to order and refer.

The file, called the Ordering Referring Report, lists, in alphabetical order based on last name, the NPI and the name (last name, first name) of the physician or nonphysician practitioner. To keep the available information up to date, CMS will replace the Report on a weekly basis. At any given time, only one Report (the most current) will be available for downloading. To learn more about the Report and to download it, go to http://www.cms.gov/Medicare/ Provider-Enrollment-and-Certification/ MedicareProviderSupEnroll/index.htm; click on ‘Ordering & Referring Information’ (on the left). Information about the Report will be displayed.

Phase 2: Effective May 1, 2013, CMS will turn on the Phase 2 edits. In Phase 2, if the ordering/referring provider does not pass the edits, the claim will be denied. This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral.

Below are the denial edits for Part B providers and suppliers who submit claims to carriers and/or MACs, including DME MACs:

254D Referring/Ordering Provider Not Allowed To Refer

255D Referring/Ordering Provider Mismatch

289D Referring/Ordering Provider NPI Required

For adjusted claims the CARC code 16 and/or the RARC code N272 was used.

CARC code 16 and/or the RARC code N264 and N265 shall be used for denied or adjusted claims.

CMS has taken actions to reduce the number of informational messages.

Below are the denial edits for Part A HHA provider who submit claims:

In December 2009, CMS added the NPIs to more than 200,000 PECOS enrollment records of physicians and non-physician practitioners who are eligible to order and refer but who had not updated their PECOS enrollment records with their NPIs.1

37236 This reason code will assign when:

On January 28, 2010, CMS made available to the public, via the Downloads section of the ‘Ordering Referring Report’ page on the Medicare provider/supplier enrollment website, a file containing the NPIs and the

• The statement ‘From’ date on the claim is on or after the date the phase 2 edits are turned on • The type of bill is ‘32’ or ‘33’ • Covered charges or provider See medicare on Page 15

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reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claim is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from EPCOS or the specialty code is not a valid eligible code

37237 This reason code will assign when: • The statement ‘From’ date on the claim is on or after the date the phase 2 edits are turned on • The type of bill is ‘32’ or ‘33’ • The type of bill frequency code is ‘7’ or ‘F-P’ • Covered charges or provider reimbursement is greater than zero but the attending physician NPI on the claim is not present in the eligible attending physician file from PECOS or the attending physician NPI on the claims is present in the eligible attending physician files from PECOS but the name does not match the NPI record in the eligible attending physician files from PECOS or the specialty code is not a valid eligible code Effect of Edits on Providers I order and refer. How will I know if I need to take any sort of action with respect to these two edits?

In order for the claim from the billing provider (the provider who furnished the item or service) to be paid by Medicare for furnishing the item or service that you ordered or referred, you, the ordering/ referring provider, need to ensure that: a. You have a current Medicare enrollment record.

• If you are not sure you are enrolled in Medicare, you may: i. Check the Ordering Referring Report and if you are on that report, you have a current enrollment record in Medicare and it contains your NPI ii. Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in Medicare and it contains the NPI j a n ua r y | F e b r ua r y | m a r c h | 2013

iii. Use Internet-based PECOS to look for your Medicare enrollment record (if no record is displayed, you do not have an enrollment record in Medicare) iv. If you choose iii, please read the information on the Medicare provider/ supplier enrollment Web page about Internet-based PECOS before you begin b. If you do not have an enrollment record in Medicare.

• You need to submit either an electronic application through the use of internetbased PECOS or a paper enrollment application to Medicare. i. For paper applications - fill it out, sign and date it, and mail it, along with any required supporting paper documentation, to your designated Medicare enrollment contractor ii. For electronic applications - complete the online submittal process and either e-sign or mail a printed, signed, and dated Certification Statement and digitally submit any required supporting paper documentation to your designated Medicare enrollment contractor iii. In either case, the designated enrollment contractor cannot begin working on your application until it has received the signed and dated Certification Statement iv. If you will be using Internet-based PECOS, please visit the Medicare provider/supplier enrollment web page to learn more about the web-based system before you attempt to use it.

Go tohttp://www.cms.gov/Medicare/ Provider-Enrollment-and-Certification/ MedicareProviderSupEnroll/index. htm, click on ‘Internet-based PECOS’ on the left-hand side, and read the information that has been posted there.

Download and read the documents in the Downloads Section on that page that relate to physicians and non-physician practitioners. A link to Internet-based PECOS is included on that Web page. v. If you order or refer items or services for Medicare beneficiaries and you do not have a Medicare enrollment record, you need to submit an enrollment application to Medicare. You can do this using Internet-based PECOS or by completing the paper enrollment application (CMS-855O). Enrollment

applications are available via internetbased PECOS or .pdf for downloading from the CMS forms page (http:// www.cms.gov.Medicare/CMS-Forms/ CMS-Forms/index/html) c. You are an opt-out physician and would like to order and refer services.

What should you do?

• If you are a physician who has opted out of Medicare, you may order items or services for Medicare beneficiaries by submitting an opt-out affidavit to a Medicare Contractor within your specific jurisdiction. Your opt-out information must be current (an affidavit must be completed every two years, and the NPI is required on the affidavit). d. You are of a type/specialty that can order or refer items or services for Medicare beneficiaries.

• When you enrolled in Medicare, you indicated your Medicare specialty. Any physician specialty (Chiropractors are excluded) and only the non-physician practitioner specialties listed above in this article are eligible to order or refer in the Medicare program. e. I bill Medicare for items and services that were ordered or referred. How can I be sure that my claims for these items and services will pass the Ordering/ Referring Provider edits?

• You need to ensure that the physicians and non-physician practitioners from whom you accept orders and referrals have current Medicare enrollment records and are of a type/specialty that is eligible to order or refer in the Medicare program. If you are not sure that the physician or non-physician practitioner who is ordering or referring items or services meets those criteria, it is recommended that you check the Ordering Referring Report described earlier in this article.

• Ensure you are correctly spelling the Ordering/Referring Provider’s name • If you furnished items or services from an order or referral from someone on the Ordering Referring Report, your claim should pass the Ordering/Referring Provider edits See medicare on Page 17

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• The Ordering Referring Report will be replaced weekly to ensure it is current. It is possible that you may receive an order or a referral from a physician or nonphysician practitioner who is not listed in the Ordering Referring Report but who may be listed on the next Report. f. Make sure your claims are properly completed.

• Do not use ‘nicknames’ on the claim, as their use could cause the claim to fail the edits • Do not enter a credential (e.g., ‘Dr.’) in a name field • On paper claims (CMS-1500), in item 17, you should enter the Ordering/Referring Provider’s first name first, and last name second (e.g., John Smith) • Ensure that the name and the NPI you enter for the Ordering/Referring Provider belong to a physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner who generated the order or referral • Make sure that the qualifier in the electronic claim (X12N 837P 4010A1) 2310A NM102 loop is a 1 (person).

Organizations (qualifier 2) cannot order and refer.

If there are additional questions about the informational messages, Billing Providers should contact their local carrier, A/B MAC or DME MAC. Billing Providers should be aware that claims that are denied because they failed the Ordering/Referring Provider would not expose the Medicare beneficiary to liability.

Therefore, an Advance Beneficiary Notice is not appropriate. g. What if my claim is denied inappropriately?

• If your claim did not initially pass the Ordering/Referring provider edits, you may file an appeal through the standard claims appeals process.

Additional Guidance 1. Terminology: Part B claims use the term ‘ordering/referring provider’ to denote the person who ordered, referred, or certified an item or service reported in j a n ua r y | F e b r ua r y | m a r c h | 2013

that claim. The final rule uses technically correct terms: i) a provider ‘orders’ non-physician items or services for the beneficiary, such as DMEPOS, clinical laboratory services, or imaging services; and ii) a provider ‘certifies’ home health services to a beneficiary. The terms ‘ordered,’‘referred’ and ‘certified’ are often used interchangeably within the health care industry. Since it would be cumbersome to be technically correct, CMS will continue to use the term ‘ordered/referred’ in materials directed to a broad provider audience.

2. Orders or referrals by interns or residents: The IFC mandated that all interns and residents who order and refer specify the name and NPI of a teaching physician (i.e., the name and NPI of the teaching physician would have been required on the claim for service(s)). The final rule states that State-licensed residents may enroll to order and/or refer and may be listed on claims. Claims for covered items and services from un-licensed interns and residents must still specify the name and NPI of the teaching physician.

However, if States provide provisional licenses or otherwise permit residents to order and refer services, CMS will allow interns and residents to enroll to order and refer, consistent with state law.

3. Orders or referrals by physicians and nonphysician practitioners who are of a type/ specialty that is eligible to order and refer who work for the Department of Veterans Affairs (DVA), the Public Health Service (PHS) or the Department of Defense(DoD)/Tricare: These physicians and non-physician practitioners will need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries. They may do so by filling out the paper CMS-855O or they may use Internet-based PECOS. They will not be submitting claims to Medicare for services they furnish to Medicare beneficiaries.

4. Orders or referrals by dentists: Most dental services are not covered by Medicare; therefore, most dentists do not enroll in Medicare. Dentists are a specialty that is eligible to order and

refer items or services for Medicare beneficiaries (e.g., to send specimens to a laboratory for testing). To do so, they must be enrolled in Medicare. They may enroll by filling out the paper CMS-855O or they may use Internet-based PECOS. They will not be submitting claims to Medicare for services they furnish to Medicare beneficiaries.

Additional Information For more information about the Medicare enrollment process, visit http://www.cms. gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/ index.html or contact the designated Medicare Contractor for your state. Medicare provider enrollment contact information for each state can be found at http://www.cms. gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/ downloads/Contact_list.pdf on the CMS website. The Medicare Learning Network® (MLN) fact sheet titled, ‘Medicare Enrollment Guidelines for Ordering/Referring Provider,’ is available at http://www.cms.gov/Outreachand-Education/Medicare-LearningNetwork-MLN/MLNProducts/downloads/ MedEnroll_OrderReferProv_factSheet_ ICN906223.pdf on the CMS website.

Note: You must obtain a National Provider Identifier (NPI) prior to enrolling in Medicare. Your NPI is a required field on your enrollment application. Applying for the NPI is a separate process from Medicare enrollment. To obtain an NPI, you may apply online at https://nppes.cms.hhs.gov/ NPPES/Welcome.do on the CMS website. For more information about NPI enumeration, visit http://www.cms.gov/Regulationsand-Guidance/HIPAA-AdministrativeSimplification/NationalProvIdentStand/ index.html on the CMS website.

MLN Matters® article MM7097, ‘Eligible Physicians and Non-Physician Practitioners Who Need to Enroll in the Medicare Program for the Sole Purpose of Ordering and Referring Items and Services for Medicare Beneficiaries,’ is available at http://www.cms. gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/ Downloads/MM7097.pdf on the CMS website.

MLN Matters® article MM6417, ‘Expansion See medicare on Page 19

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of the Current Scope of Editing for Ordering/ Referring Providers for Claims Processed

by Medicare Carriers and Part B Medicare Administrative Contractor(MACs),’ is available at http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/ MM6417.pdf on the CMS website.

only copyright 2012 American Medical Association.

MLN Matters® article MM6421, ‘Expansion of the Current Scope of Editing for Ordering/ Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Suppliers’ Claims Processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs),’ is available at http://www. cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/ MLNMattersArticles/Downloads/MM6421. pdf on the CMS website.

The Jurisdiction D DME MAC Medical Review Department is conducting a widespread complex review of HCPCS code A5500. The fifth quarter edit effectiveness results from September 2012 through November 2012 are as follows:

MLN Matters® article MM6129, ‘New Requirement for Ordering/Referring Information on Ambulatory Surgical Center (ASC) Claims for Diagnostic Services,’ is available at http://www.cms.gov/Outreachand-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/ MM6129.pdf on the CMS website.

Primary documentation errors that resulted in denial of claims

MLN Matters Article, MM6856, “Expansion of the Current Scope for Attending Physician Providers for free-standing and providerbased Home Health Agency (HHA) Claims processed by Medicare Regional Home Health Intermediaries (RHHIs),” is available at http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/ MM6856.pdf on the CMS website.

1 NPIs were added only when the matching criteria verified the NPI. Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations or other policy materials. The information provided is only intended to be a general summary.

It is not intended to take the place of either the written law or regulations.

We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT j a n ua r y | F e b r ua r y | m a r c h | 2013

Shoe Review from Noridian The Fifth Quarter Results of Widespread Prepayment Review of Claims for Therapeutic Shoes (HCPCS A5500) Current Review Results

The A5500 review involved 2178 claims of which 1950 were denied. This resulted in an overall error rate of 90%.

Historical Data of the Error Rate for A5500 Review

*26% of A5500 claims received a denial as Criterion 2 was not met per Policy Article (PA) A37076.

There must be documentation to support that the certifying physician has documented in the patient’s medical record one or more of the following conditions: a. Previous amputation of the other foot, or part of either foot, or b. History of previous foot ulceration of either foot, or c. History of pre-ulcerative calluses of either foot, or d. Peripheral neuropathy with evidence of callus formation of either foot, or e.

Foot deformity of either foot, or f. Poor circulation in either foot; In order to meet criterion 2, the certifying physician must either: a. Personally document one or more of criteria a - f in the medical record of an in-person visit within 6 months prior to delivery of the shoes/inserts and prior to or on the same day as signing the certification statement; or h. Obtain, initial/sign, date (prior to or on the same day as signing the certification statement), and indicate agreement with information from the medical records of an in-person visit with a podiatrist, other M.D or D.O., physician

assistant, nurse practitioner, or clinical nurse specialist that is within 6 months prior to delivery of the shoes/inserts, and that documents one of more of criteria a - f.

Note: The certification statement is not sufficient to meet the requirement for documentation in the medical record.

*20% of A5500 claims received a denial as Criterion 3 was not met per PA A37076.

There must be documentation to support that the certifying physician has certified that indications (1) and (2) are met and that he/she is treating the patient under a comprehensive plan of care for his/her diabetes and that the patient needs diabetic shoes. For claims with dates of service on or after 1/1/2011, the certifying physician must: a. Have an in-person visit with the patient during which diabetes management is addressed within 6 months prior to delivery of the shoes/inserts; and b. Sign the certification statement (refer to the Documentation Requirements section of the related Local Coverage Determination) on or after the date of the in-person visit and within 3 months prior to delivery of the shoes/inserts.

Note: Per Policy Article A37076 the Certifying Physician is defined as a doctor of medicine (M.D.) or a doctor of osteopathy (D.O.) who is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care. The certifying physician may not be a podiatrist, physician assistant, nurse practitioner, or clinical nurse specialist.

*8% of A5500 claims received a denial as there was no documentation from the supplier to support an inperson visit at the time of delivery per Local Coverage Determination (LCD) L157 and PA A37076 There must be documentation from the supplier to support an in-person visit at the time of delivery. The supplier must conduct and document an in-person visit See medicare on Page 21

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Western University’s College of Podiatric Medicine Dean lauded for pioneering work in amputation prevention The Center’s mission is to use the diagnostic skills of its highly-trained team of physicians, top-tier equipment, and innovative treatment techniques to prevent amputation, enhance mobility, and preserve quality of life.

The Limb Preservation Center is part of a unique collaborative care environment – The Patient Care Center at Western University of Health Sciences – that brings together specialists from a broad range of health sciences to comprehensively diagnose and treat patients throughout the PCC’s seven sub-centers.

When Dr. Harkless came to Pomona to establish a new College of Podiatric Medicine, he studied the area’s population and found that it was similar to the one he had experienced in South Texas.

Both regions have a majority Hispanic population, and therefore he knew the need for diabetic foot care would be great. National survey data shows a higher prevalence of diabetes in Hispanic populations compared to other ethnicities.

“The need is great, and I knew that we could -- and more important, should -- develop a Center of Excellence in Limb Preservation here, training students and residents to serve the people. We want to be able to reach out to everybody,” Harkless said.

Dr. Harkless addresses the a full room Western University of Health Sciences College of Podiatric Medicine Founding Dean Lawrence B. Harkless, DPM, has been named the 2013 honoree for the Edward James Olmos Award for Advocacy in Amputation Prevention, presented by the DFCon Global Diabetic Foot Conference.

The award will be presented at the DFCon meeting March 21-23, 2013 at the Loews Hollywood Hotel in Los Angeles. DFCon, considered the foremost interdisciplinary, international conference on the diabetic foot and amputation prevention, is co-chaired by George Andros, MD, and David G. Armstrong, DPM, PhD, MD. Dr. Harkless has taught and mentored thousands of podiatric students, residents and interns. He is widely viewed as a leading pioneer in integrating podiatric medicine into mainstream medicine.

“No one has done more than Dr. Harkless in educating generations of young physicians about treating the complications of diabetes and about preventing the tragedy of amputation,” said Dr. Armstrong, a former Diabetic Foot Fellow trained by Dr. Harkless while at the University of Texas Health Science Center at San Antonio.

Dr. Harkless continues to advocate for early treatment of diabetes and the prevention of amputations as the leader of WesternU’s Limb Preservation Center, set to open in April 2013 on WesternU’s Pomona, Calif. campus.

The Limb Preservation Center at Western University of Health Sciences was initiated to serve a growing population – patients at risk for amputation as a result of acute conditions or lack of treatment.

20 |

The co-chairs of the DFCon Global Diabetic Foot Conference, Drs. Armstrong and Andros, lead phenomenal amputation prevention teams at the University of Arizona and at Valley Presbyterian Hospital in Van Nuys, respectively, Harkless said.

The public is familiar with transplant teams, trauma teams and even stroke teams, but they haven’t been introduced yet to a team that is equally needed – the amputation prevention team. There are only a handful of these operating around the country; in areas where they do exist, the numbers of amputations decrease.

“The question from an advocacy perspective is how do you change the culture of the system to add an amputation prevention team, or a limb salvage team, and give us the same resources that you give those other teams to be successful?” Harkless said. “The limb salvage team should be given the same type of authority and status as the others. The challenge is the limitation of resources.”

But the reality is that if funds are judiciously spent to prevent an amputation, huge savings are often realized. The amputation of a limb, and after-care for the patient, has huge medical and personal expenses associated with it.

A diabetic limb salvage team should include at minimum a vascular surgeon and a podiatrist, supported by a brace shop on site that has the necessary equipment for prevention, Harkless said.

“In a diabetic limb salvage team, the podiatric physician leads the team as the wound care specialist and makes appropriate referrals to other members of the team as needed for revascularization or specialized shoes,” Harkless said. “If people in decision-making positions see the data, they will definitely include podiatry on the diabetic limb salvage team.”

See western University on Page 38

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with the patient. The in-person evaluation of the patient by the supplier at the time of delivery (refer to related Policy Article, NonMedical Necessity Coverage and Payment Rules, criterion 5) must be conducted with the patient wearing the shoes and inserts and must document that the shoes/inserts/ modifications fit properly.

*7% of A5500 claims received a denial as there was no documentation from the supplier to support an in-person visit prior to selection of the item billed per Local Coverage Determination (LCD) L157 and PA A37076.

There must be documentation from the supplier to support an in-person visit prior to selection of the item billed. Prior to selecting the specific items that will be provided, the supplier must conduct and document an in-person evaluation of the patient. The in-person evaluation of the patient by the

supplier at the time of selecting the items that will be provided must include at least the following: 1. An examination of the patient’s feet with a description of the abnormalities that will need to be accommodated by the shoes/inserts/modifications.

2. For all shoes, taking measurements of the patient’s feet.

For custom molded shoes (A5501) and inserts (A5513), taking impressions, making casts, or obtaining CAD-CAM images of the patient’s fee that will be used in creating positive models of the feet.

Going Forward Based on high error rate, Noridian Administration Services will continue with the Prepayment Widespread Review.

Education resources It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Therapeutic Shoes for Persons with Diabetes Local Coverage Determination (LCD) L157

and Policy Article A37076.

Suppliers can also review specific policy resources for Therapeutic Shoes for Persons with Diabetes on the NAS website at https://www.noridianmedicare.com There, you will find, information related to proper documentation requirements including a physician letter, documentation checklists, FAQs, and a presentation used during Web-based workshops.

Noridian Administrative Services’ provides educational offerings by scheduling for supplier workshops, training opportunities, and presentations. Educational training and events are located at https://www. noridianmedicare.com/dme/train/index. html#tools.

Information about probe/error validation reviews may be found in CMS Publication 100-8, Program Integrity Manual (PIM), Chapter 3 located at: http://www.cms.gov/manuals/ downloads/pim83c03.pdf (Source: Tony Poggio, DPM, MS)

April is Foot Health Awareness Month April is National Foot Health Awareness Month. The month-long observance serves as an opportunity to get the word out to the general public about the importance of good foot health and the vertual role podiatric physicians play in the health care delivery system.

For more information on Foot Health Awareness Month please go to www.CALPMA.org. j a n ua r y | F e b r ua r y | m a r c h | 2013

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The Most Important Attribute of an Office There are three stages of the listening process: Receiving – We take in messages most notably through hearing and seeing. One listens as much with sight as with the sense of hearing. The eyes help read the nonverbal cues that play a part in how the speaker expresses him/herself.

Processing – This is done in the mind. It involves analyzing, evaluating, and trying to make sense of what the speaker said so an appropriate answer can be given. Most listening problems happen at this level, such as distraction, attention level, or stress. When one is distracted he/she does not fully get the message, only bits and pieces. Processing requires concentration.

Responding – This is when the speaker finds out if the listener understood because he/she hears the response. If the message was understood, then a connection and a bond occur. If not, there has been a process breakdown, which causes stress and frustration on the part of the speaker.

What happens most often?

Most conversations are not speaker to listener. They end up being speaker to speaker. People talk at each other, reacting immediately to what was said, rather than listening. This results in little understanding because there is no real communication.

One can see how frustrating it could be for employees when they work for someone who lacks active listening skills. They never feel that they are heard, and most likely they have not been.

Good managers have mastered the active listening skill. They take the time to gain understanding of what their employees are saying so they can respond appropriately to them.

When someone takes the time to really listen, it makes one feel respected, cared for, satisfied, and understood. It is a positive experience, and the results are better relationships, better quality of work, greater cooperation, and less stress.

Being an office manager is a great responsibility. Many times a person is promoted to the position without any prior experience or training in management, yet the expectation is that they know how to do the job.

Business owners should strive to get their management staff the education and management tools that they need in order to do the best job for them. Along with education, to be considered good managers in the eyes of their staff members, office managers need to possess another important attribute: they must be excellent communicators.

Communication can be broken down into two vital components: listening and responding. The most proficient communicators have the ability to both understand what is being asked and also to appropriately and fairly respond.

1. Listening.

Employees who highly regard their managers will tell you the reason why they do: their managers listen. Hearing what people are saying is one thing; listening to what people are saying is another.

Managers need to possess active listening skills. These skills take time and training to achieve.

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“The most basic of all human needs is the need to understand and be understood. The best way to understand people is to listen to them.” ~ Ralph Nichols

2. Responding.

Having heard what the employees have said, more often than not, will require a response from the manager. A good manager responds to employees as soon as possible when they have questions, concerns or issues.

The example below is true and often happens in small businesses where open communication and active listening are not part of the workplace environment.

Mary was struggling to keep up with the workload assigned to her. She felt overwhelmed and stressed. She told her manager that she felt her workload was too much. His response was that he would discuss it with her later when he had more time.

Several days went by and Mary had not heard from her manager. She really didn’t want to bug him, as she knew he was busy, but she was falling further behind in her work.

Mary saw her manager in the break room and mentioned that she really needed to discuss her problem, as she was concerned C P MA | C a lifo r n i a P odi at r i c M e di c a l Asso c i atio n

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Manager about falling behind.

Her manager patted her on the back and told her, “Do the best you can; we all have a lot of work to do, and it will eventually get done.”

The stress was too much for Mary, and she eventually quit. Her manager’s response to the employer was, “She wasn’t the right person for the job.” He never addressed the issues that Mary had expressed to find out what the problem really was.

Businesses with managers who turn a “deaf ear” to employees’ questions and complaints will have a high employee turnover rate.

Their reason for this will always point to an outward problem, not inward where the issue actually lies.

Managers who listen to employee issues and then respond show employees that they are valued and what they have to say is valued.

Most of the time employee questions can be answered quickly.

Very few employee issues require “fast action.” What they do require is acknowledgement and being given a time frame in which they will be resolved or discussed further.

Good managers will value those who work on their team. Mutual respect for each person’s position in the workplace creates a more balanced work environment. Keeping balance will allow for all staff members to do their best at taking care of the patients and the physician’s practice.

Join Us

June 20-23 at The Disneyland Hotel and Convention Center, Anaheim, CA

The Place to Be!

Student Recruitment Challenge THERE’S STILL TIME Put Our Money Where Your Mouth Is! TELL THEM ALL ABOUT IT! Between now and May 31, 2013, non-faculty members of CPMA who give a recruitment lecture to high school or college students may enter their name in a drawing good for one $250 Visa gift card. One entry to the drawing will be allowed per lecture given. The winner of the gift card will be drawn at the 2013 House of Delegates in Anaheim in June.

NEED HELP? Not sure how/when/where to set up a lecture in your area? Looking for handouts to complement your presentation? Contact Ronda Swain, Professional Marketing Program Special Assistant at APMA. Call 800 ASK APMA ext. 281 or email lnswain@apma.org.

ENTER TO WIN! For an entry to be considered complete please send your name, daytime phone number/email, the date of the pro-Podiatric Medicine Career lecture, and the group contact person’s name and number/email to Jeannette Steed by May 31, 2013 at jsteed@calpma.org or fax to (916) 448-0258.

Happy Recruiting! j a n ua r y | F e b r ua r y | m a r c h | 2013

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Duals Update Here is the newest information on the Duals Issue.

Governor Jerry Brown has released his proposed budget for Fiscal Year 2013-14. The following specific items in the budget are related to the Dual Eligible Conversion to managed care, referred to as the Coordinated Care Initiative (CCI).

Three main points: 1. The duals demonstration is still pending federal approval.

2. Timeline.

The proposed budget calls for implementing both parts of the CCI, the duals demonstration and transition to managed care for Long Term Supports and Services, in September 2013. a. This means that the first notices that any beneficiaries would receive about these transitions would come no earlier than June 2013. These letters have not yet been submitted by DHCS to stakeholders for comment.

3. Enrollment Phase-in. There are eight counties in the CCI: Alameda, Los Angeles, San Bernardino, San Diego, San Mateo, Santa Clara, Orange and Riverside. According to the budget announcement: a. In Los Angeles County, enrollment will phase in over 18 months. b. In San Mateo, enrollment will occur all at once in September 2013.

c. For all other counties, enrollment will phase-in over 12 months.

It is important to understand this from the DHCS communication: “Opting out of the demonstration does not mean people will lose any benefits....

Beneficiaries may choose to stay in traditional Medicare and enroll in managed care for ONLY their Medi-Cal benefits.”

For more information about the CCI, please go to www.calduals.org In addition, CPMA has developed a Duals Resource Center in the Members Resources are of the Association’s website, which contains information, including letters and flyers to help educate your patients, as well as providing more information and details.

For more information please go to the CPMA Duals Resource Center Please use your new CPMA ID card to access the Members Only Area of the CPMA website.

Please be assured that, even with this latest delay, your CPMA BOD remains on top of this issue. However this is not all we do.

I do recommend that we all focus on other items including the Health Exchanges and CA implementation of the ACA. You will be receiving further information on these soon, and I urge you to read these materials to best position your practice for success.

K aren Wrubel, DPM

outstanding student Student Natalie Thanh Hua was chosen as “Outstanding Podiatric Medical Student of 2012” by the American Podiatric Medical Students Association (APMSA).

Hua, who will graduate from the California School of Podiatric Medicine (CSPM) this year, won the award out of a field of nine nominees representing each of the nine podiatric medical schools across the country. She also received a $1,000 scholarship, sponsored by the APMSA. “It is a great honor to have represented CSPM and to be recognized with this award,” Hua said. “The award solidifies my belief that our professionalism as aspiring podiatrists is judged both by how much knowledge and skill we gain at school and how much good we are willing to do with it.”

Hua is the founder of the Podiatry Clinic at Clinica Tepati at the University of California, Davis. The student-run clinic provides podiatric care for the underserved and uninsured population of Sacramento. She single-handedly oversees the fundraising, volunteers, and supplies at the podiatry clinic.

“I wanted to provide the much-needed care to the underserved community and to provide an opportunity for CSPM students to apply their medical knowledge they have gained while doing community service,” said Hua. j a n ua r y | F e b r ua r y | m a r c h | 2013

Hua immigrated to the United States with her family from Vietnam in 2002 while only a junior in high school, and said she has always been grateful for the medical care she received as a new immigrant.

In addition to Clinica Tepati, Hua is heavily involved at CSPM, serving as the student body treasurer and workshop coordinator for the American Association for Women Podiatrists. She also submitted a poster about her work at Clinica Tepati at the American Public Health Association Annual Conference.

David Applegate, current President of the APMSA, praised Hua for her accomplishments.

“Podiatric medical school is extremely demanding,” he said. “The fact that Ms. Hua was able to make such an amazing difference in the community while enduring the rigors of a medical education is truly commendable.”

D ebra Holtz, Samuel M erritt University | 25

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on your toes Sequester Will Hit Both Medicare Reimbursement Rates and EHR Incentive Program Payments Medicare providers can expect to see a 2% cut in reimbursement rates for services provided on or after April 1, due to sequestration, which calls for 2% across the board spending cuts. In addition hospitals and “eligible professionals” will be hit by a 2% cut in EHR Incentive Program Payments. CMS has also announced that it will be spending significantly more time on education and performing

targeted audits to make sure that the EHR program is being implemented properly. Medicaid (Medi-Cal) is exempted from the sequestration cuts.

Medicare Reimbursements Avoids “Fiscal Cliff” Dive A 13th-hour deal averted the 26.5-percent cut in Medicare payments that were scheduled to take effect on January 2, freezing the current rates for 2013. The 2013 fee schedule will not be exactly the same as the 2012 fee schedule.

Although Congress stopped the 26.5 percent SGR cut, there were other components of the fee schedule formula that affect payment that may have changed, such as the relative value units (RVUs).

The final deal also postponed the additional 2-percent sequestration cut to Medicare reimbursement rates that are part of the automatic across-the-board spending cuts. The cuts are now scheduled to go into effect April 1, unless Washington can come to an agreement. CPMA is working to prevent this further erosion of reimbursement rates to its members.

-25 Modifier: Providers Receiving Results of Follow-up Coding Study from Blue Cross Blue Cross recently completed two follow up studies on physician coding – one on evaluation and management (E/M) visits, levels 4 and 5 (99204-99205 and 99214-99215), and the other on usage of modifier -25.

In September 2012, physicians who billed these codes at “considerably higher” frequencies for claims paid between May 1, 2011, and April 30, 2012, were notified of their individual results and informed that if subsequent analyses showed continued “excessive usage”, they may at a later date, be required to provide additional documentation to support the codes billed.

The recently completed follow up analyses looked at claims paid between October and December 2012. Blue Cross will soon be sending notices to physicians with the results of the analyses.

One notice (for modifier -25 and 97 for E/M issues) indicates that the use of the codes or modifier has “notably decreased” since the last analysis. Practices will receive notices indicating that the follow-up analysis indicates use of either the E/M codes or modifier -25 remains high and that EquiClaim, the company contracted to perform the studies, may contact them with a request for records.

Practices who receive a request for records from EquiClaim will have 14 days in which to comply. If after reviewing the records, EquiClaim identifies the documentation does not support the coding, they will pursue a refund request from the practice.

EquiClaim will also be performing studies on physician usage of modifiers -24, -57 and -59 at a later date.

Questions about the analyses can be directed to EquiClaim at (866) 481-1479 (select option 4).

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CPMA has been actively addressing this issue with items in past issues of The California Podiatric Physician, DPMemo, and on the CPMA website at www.calpma.org. Members may direct questions to CPMA at 800-794-8988 or afinley@calpma.org.

CMS Releases Final Rule on ACA’s Physician Payments Sunshine Act On Feb. 1, the Centers for Medicare & Medicaid Services (CMS) issued the final regulations implementing the Physician Payments Sunshine Act (Sunshine Act) provisions of the Affordable Care Act (ACA). The intention of the law is to increase transparency and reduce the potential for conflicts of interest that can influence research, education and clinical decision making.

Details of Final Rule Under the final rule, manufacturers of pharmaceutical and biological drugs, medical devices and medical supplies -- covered

by Medicare, Medicaid and CHIP -- starting Aug. 1 will must begin tracking and reporting all payment and payments and items of value—including consulting fees, travel reimbursements, research grants and other gifts with a monetary value over $10 —given to physicians and teaching hospitals.

The Sunshine Act also requires manufacturers and group purchasing organizations (GPOs) to report certain ownership interests held by physicians and their close family members. While the first reporting period will only be five months from Aug. 1 to Dec. 31, 2013, thereafter the reporting period will be a full calendar year. The majority of the information contained in the reports will be made available on a public, searchable website beginning in September 2014. Providers have the right to review their reports and to challenge any information that is false, inaccurate or misleading. By statute, doctors will have at a minimum, 45 days to review the transparency reports and make corrections before they are made public.

The final regulation contained important changes to address concerns raised by CPMA and APMA and others in organized medicine. Most significant, the final regulation excludes from reporting certified and accredited continuing medical education and expands the time providers have to challenge inaccurate, false and misleading reports.

The final regulation, however, contains provisions that continue to cause concerns, including: (1) the agency’s decision to not require manufacturers to provide ongoing notice to physicians of transfers or payments that the manufacturer intends to report; and (2) the agency’s broad interpretation of reportable indirect transfers. The latter may have implications that require careful consideration of financial interactions between manufacturers and organizations or businesses that employ or provide services to physicians.

The Sunshine Act covers all physicians who have an active state license, even if they do not participate in federal health care

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programs, but excludes residents and medical students. APMA has published a Policy Brief on the final rule and AMA has established a page on its website with detailed information on the types of payments, transfers of value and ownership interests covered by this reporting requirement as well as the exceptions. Members should are encouraged to direct questions to APMA’s Health Policy and Practice Department at healthpolicy.hpp@apma.org.

(Source; APMA 2/25/2013; CMA 2/8/2013)

CMS Reduces Value of Common Routine Foot Care Code In the Medicare Physician Fee Schedule final rule issued by CMS, the value for CPT 11719, Trimming of nondystrophic nails, any number, has been reduced by 50 percent. This action was taken unilaterally by CMS without guidance and input from APMA or AMA’s Specialty Society Relative Value Scale Update Committee (RUC). An unanticipated change of this nature is a change in protocol from previous CMS actions, which generally involve the RUC process. APMA has submitted comments to CMS to express opposition to this change.

(Source; APMA 1/22/2013)

Palmetto Publishes Comparative Billing Reports on E/M services Palmetto GBA, California’s Medicare contractor, has released the Comparative Billing Reports (CBRs) for evaluation and management (E/M) services billed between January and June 2012.

The reports allow individual physicians to review their billing patterns for various codes and procedures as compared to the national average for physicians in their jurisdiction with the same specialty. These comparative studies are designed to help providers review their coding and billing practices and utilization patterns with an eye on taking proactive compliance measures.

The reports are available to download from the Palmetto website at www.palmettogba.com/J1B. (Source: Tony Poggio, DPM)

AFO Height Requirement Removed On February 6, Jurisdiction C DME MAC announced that the AFO policy is being revised to remove the height restriction in their policy article. To date, all four DME MAC Jurisdictions have announced they are revising this policy article. The effective date on the policy article is January 1, 2013.

These actions come after a concentrated effort by APMA’s DME subcommittee and outside stakeholders to reverse the new height restrictions. APMA believed the change to the height requirements was not backed up by scientific evidence, and therefore was not consistent with the devices many members prescribe. See APMA’s comments on this topic.

In order to avoid confusion in the future, members who prescribe AFOs are reminded to include in their documentation 1) the rationale for prescribing the specific device to be supplied/ dispensed and 2) specific relevant lower extremity measurements See on your toes on Page 28

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(e.g., height of the apex of the fibular head from the floor) as well as the proximal trim line height of the device ordered.

The revised set of federal privacy rules is expected to have a significant impact on the way physicians run their practices.

For more information, read the posts from DME MAC Jurisdiction B, Jurisdiction C, and Jurisdiction D. APMA will provide additional information as it is available.

Revised privacy notices will need to be displayed in prominent areas of doctors’ offices and on practices’ websites. Patients will be able to ask for copies of their electronic health records or restrict the information given to health plans if they self-pay for services.

And perhaps most important, practices might be subject to serious fines if any of their business associates cause security breaches.

(Source; APMA 2/7/2013)

Providers Now Required to Formally Notify Patients Before Referring Out-of-Network Effective March 1, Blue Cross contracting doctors will be required to formally notify patients in writing before making out of network referrals.

Anthem Blue Cross notified physicians in November that it would begin requiring use of a payor-provided form any time they are referring a patient out of network. The new policy does not apply to emergencies.

While Blue Cross has included language in its contracts since 2008 requiring physicians to disclose to patients and document the same type of information included in the APN form, it was not often enforced.

According to Blue Cross, it frequently receives complaints from patients who were unaware that they were being referred to out-of-network providers. The payor says that its new policy is not intended to deter patients from using their out-of-network benefits.

Rather, it is intended to help patients make informed decisions about their coverage and options.

The form can be downloaded from the Blue Cross website at www.anthem.com/ca/home-providers.html. Click on “Advance Patient Notice for Use of a Non-Participating Provider” under Providers > Spotlight.

Providers with questions or concerns are encouraged to contact Blue Cross Network Management at (855) 238-0095.

(Source; CMA 2/25/2013)

New, Greatly Expanded HIPAA Rules and Regs Much Tougher on Docs New privacy regulations mean practices face more legal scrutiny and higher fines in case of an information breach.

The rules -- called for under the 2009 federal economic stimulus package’s HITECH Act and the Genetic Information Nondiscrimination Act -- implement tougher privacy and security provisions. The rules: • Clarify when breaches must be reported to HHS’ Office for Civil Rights; • Establish new standards for the use of patient-identifiable information for fundraising and marketing; • Expand liability to “business associates” of hospitals and other “HIPAA-covered entities,” such as data miners and health information technology service providers); and

Under the new privacy rules, doctors now must assume the worst-case scenario in the event of a possible privacy breach.

Previous regulations had required a practice to notify affected patients and the federal government only if it determined that a breach involving patient records had occurred and that it carried a significant risk of financial or reputational harm to patients. The new rules eliminate that standard and replace it with a stricter one. Now any incident involving patient records is assumed to be a breach, and unless a practice conducts a risk assessment that proves a low probability that any protected information was compromised, the breach must be reported.

HIPAA Rules; Final Rule,” Dept. of Health and Human Services, Federal Register, Jan. 25 (www.gpo.gov/fdsys/pkg/FR-2013-0125/pdf/2013-01073.pdf) (Sources; California Healthline 1/18/2013; AMA 2/4/2013)

California Implements New Workers’ Comp Changes Beginning January 1, 2013, new provisions of California’s workers’ compensation insurance system reform bill (SB 863) were implemented by the Department of Industrial Relations (DOI) and Division of Workers Compensation (DWC). The new provisions, approved on an interim basis, are effective for 180 days while DWC initiates formal rulemaking procedures to adopt permanent regulations. Details of the newly implement regulations include:

Utilization review, independent medical review For injuries on or after Jan. 1, 2013, and effective July 1, 2013 for all dates of injury, medical treatment disputes will be resolved through an independent medical review (IMR) process. Injured workers who receive denials, delays or modifications to a physician’s request for medical treatment because the treatment is deemed not medically necessary by the workers’ comp carrier can request an independent review of that decision through the IMR process.

Independent bill review For dates of service on or after January 1, 2013, billing disputes involving payment for medical services may be submitted through a process known as independent bill review (IBR). Medical providers disagreeing with the amount paid by a claims administrator and seeking an independent determination on payment may submit a request for IBR providing details and/or supporting documentation along with the non-refundable IBR fee of $335.

• Raise the maximum penalty for noncompliance to $1.5 million per violation.

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Electronic document filing and lien filing fee The new law allows certain claims for payment for services or benefits provided to or on behalf of injured workers to be filed as a lien against an the employee’s claim for workers’ compensation benefits. Any lien for reasonable medical expenses incurred by or on behalf of the injured employee and filed on or after January 1, 2013, is now subject to a lien filing fee of $150. For liens filed before January 1, 2013, there will also be a $100 activation fee, which must be paid prior to January 1, 2014, or the lien will be subject to dismissal by operation of law.

Effective March 1, 2013, Disability Insurance Claims can only be filed electronically using SDI Online or by ordering NEW Optical Character Recognition (OCR) Claim for Disability Insurance Benefits, DE 2501 Rev. 78 (4-12) form available on the EDD’s website http:// www.edd.ca.gov/disability/PP_Forms_and_Publications.htm.

Orders may take two to four weeks for delivery.

To register for an SDI Online account, visit our website at www. edd.ca.gov/disability. For more information, call the phone line dedicated to physicians/practitioners at 855-342-3645.

(Source: CMA 2/15/2013)

White House Backs States’ Power to Cut Medicaid Reimbursement Rates The Obama administration has filed a brief supporting states’ discretion to reduce Medicaid reimbursement rates.

In October 2011, CMS approved California’s plan to reduce certain Medi-Cal payments by 10%. State officials projected the cuts save more that $600 million. However, in January 2012, U.S. District Court Judge Christina Snyder tentatively blocked the cut, saying it could cause irreparable harm to patients.

In the brief -- filed in the 9th Circuit Court -- the administration defended the decision by California to reduce Medicaid payment rates and urged judges to uphold the cuts. The brief also affirmed states’ “wide discretion” to set Medicaid rates. The cuts are being challenged by a number of stakeholders, including beneficiaries, physicians, hospitals, pharmacists and other providers.

The administration stated, “It is entirely appropriate for a state to review its Medicaid plan to determine whether it can continue to satisfy its statutory obligations at lower payment rates,” adding that such reviews should be conducted regularly “to avoid the perpetuation of payment rates that are unnecessarily high.”

Gov. Jerry Brown (D) commended the brief and said that the cuts were essential for controlling budgetary costs, but he also noted that governors need “more authority than we now have ... to manage the Affordable Care Act and the expansion of Medicaid”.

(Source: California Healthline 2/26/2013)

Palmetto Announces New Audit Palmetto GBA, California’s Medicare contractor, has expanded its procedure specific audits, called probes, to include procedure codes 99204 and 99205 when rendered by providers with specific

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specialties: • 99204 performed by general practice (CMS specialty designation 01), otolaryngology (04), family practice (08), ophthalmology (18), physical medicine and rehabilitation (25), podiatrist (48) and rheumatology (66) • 99205 performed by cardiology (06), family practice (08), internal medicine (11), neurology (13), podiatry (48) and hematology/ oncology (83) Palmetto conducts complex reviews based on data analysis. An analysis of these procedure codes when performed by physicians in these specialties indicated a significant incidence of errors and a higher utilization by California providers when compared to national claim payment ratios for the same services by the same specialties.

Palmetto will be randomly selecting for audit a percentage of claims billed for these services on a daily basis for a minimum period of three months.

If you receive an “additional documentation request” (ADR) from Palmetto, please return the requested documentation with a copy of the ADR to the J1 Part B Medical Review department address within 30 days of the date listed on the ADR. Failure to provide the requested information will result in a denial.

Use the J1 Part B ADR Cover Sheet and view instructions on the Palmetto GBA J1 Part B website. http://www.palmettogba.com/palmetto/palmetto.nsf/DocsCat/Home (Source: Tony Poggio, DPM)

California Considers Changing Non-Physicians’ Scope of Practice California lawmakers are considering expanding the scope of practice for non-physicians in an effort to address a shortage of doctors to treat individuals who will gain health insurance coverage under the Affordable Care Act. A Los Angeles Times report found that only 16 of the state’s 58 counties have the supply of physicians recommended by the federal government.

In addition, the Association of American Medical Colleges says that nearly 30% of California’s doctors are nearing retirement age.

Meanwhile, California is preparing to expand Medi-Cal and require most residents to have health insurance under the Affordable Care Act (ACA).

Sen. Ed Hernandez (D-West Covina) -- Chair of the Senate Health Committee -- plans to offer legislation that would allow physician assistants and nurse practitioners to establish independent practices. It also would allow pharmacists and optometrists to act as primary care providers and diagnose and manage certain chronic conditions.

Introduction of the legislation and hearing on the matter are expected sometime this March.

(Source: California Healthline 2/11/2013) See on your toes on Page 31

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Palmetto Loses Medicare Contract Protest The U.S. Government Accountability Office (GAO) has denied Palmetto GBA’s protest and awarded the Medicare contract for Jurisdiction E (previously referred to as J1) to Noridian Administrative Services.

The Centers for Medicare & Medicare Services (CMS) first announced in September 2012 that Noridian has been named the new Medicare Administrative Contractor for Medicare Parts A and B in California, Nevada and Hawaii, as well as the U.S. territories of American Samoa, Guam and the Northern Mariana Islands (Jurisdiction E, previously called Jurisdiction 1).

Both Noridian and Palmetto are awaiting further direction from CMS on the transition plan, including a transition date, which could take up to six months or more. CPMA will work closely with the two companies to ensure a smooth transition. Until further direction is received, members should continue with business as usual.

PLEASE NOTE: Palmetto will be moving ahead with the announced audits for codes 99204 and 99205.

Nation’s Top Court Rejects Hospitals’ Medicare Claims Suit The United States’ Supreme Court rejected an attempt by a group of 18 hospitals to reopen a specialized group of Medicare reimbursement claims that are up to 25 years old.

The hospitals, which are entitled to extra compensation for treating a large number of low-income patients, claimed the Centers for Medicare & Medicaid Services miscalculated those payments between 1987 and 1994.

missed their opportunity to appeal. Finding that relaxing the deadline would “essentially gut” the requirement that an appeal be filed within six months, or three years for good cause.

(Source; Reuters 1/22/2013)

Lawsuit Filed Against DHCS Over Medi-Cal Managed Care Shift A legal aid group has filed a lawsuit on behalf of five Medi-Cal beneficiaries, alleging that the state violated beneficiaries’ rights by forcing them into managed care, the Los Angeles Times reports.

The group -- Legal Aid Foundation of Los Angeles -- filed the lawsuit on Dec. 21, 2012, against the California Department of Health Care Services (AP/San Jose Mercury News, 12/21/12).

(Source: California Healthline 1-3-2013)

Brown’s Budget Includes 10% Medi-Cal Provider Pay Cut Gov. Jerry Brown proposed budget for the 2013-2014 fiscal year cludes $97.7 billion in general fund spending, plus an additional $48.1 billion in special funds, for a total of $145.8 billion. For the first time in five years, the state is not facing a deficit, and in fact Gov. Brown’s proposal includes a $1 billion reserve.

Despite the state’s improved budget outlook, the proposal does include roughly $1 billion per year in Medi-Cal provider reimbursement rate cuts. The Ninth Circuit Court of Appeals ruled that the state could move forward with the rate cuts, passed by the Legislature in the spring of 2011, despite an earlier district court ruling that found that the cuts would irreparably harm the millions of patients who rely on Medi-Cal for health care.

The hospitals based their claim on a separate lawsuit that found in 2006 that the Centers for Medicare & Medicaid Services used a flawed process to determine the number of low-income patients treated by hospitals. The miscalculation resulted in underpayments, the hospitals said.

A request for an en banc (all judges) review has been filed with the Ninth Circuit Court of Appeals.The review is part of an effort to stop the State of California from implementing a 10 percent cut to Medi-Cal provider reimbursement rates.

When the hospitals appealed the payments, however, the agency’s Provider Reimbursement Review Board rejected many of the claims as too old. In 2006, shortly after the lawsuit exposed the calculation mistake, the hospitals sued for the proper reimbursements.

Bill Would Repeal Antitrust Exemption for Insurance Companies

The government argued the hospitals missed their opportunity to challenge the payments because the Medicare law imposes a six-month limit for appeals. Although the review board could have extended that deadline up to three years for “good cause,” the hospitals filed their claims more than 10 years after the six month deadline expired.

The hospitals said it was unfair to impose the deadline under the circumstances, alleging the agency knew about and failed to disclose its calculation errors.

The district court sided with the government, but the U.S. Court of Appeals for the District of Columbia Circuit reversed the decision in 2011. The government appealed to the Supreme Court, which heard oral arguments in the case in December.

The high court, in a unanimous ruling found the hospitals had j a n ua r y | F e b r ua r y | m a r c h | 2013

(Source: Capitol Desk, California Healthline 1/10/2013)

Congressional Representatives Peter DeFazio (D-Ore.) and Louise Slaughter (D-N.Y.) reintroduced legislation (HR 743) that would repeal a provision in a 1945 law that exempts health insurers from federal antitrust laws. DeFazio and Slaughter argue that protections under the McCarran-Ferguson Act increase health care costs by allowing insurers to inflate the cost of care and limit competition.

(Source: California Healthline 2/21/2013)

18-Region Plan for Setting Health Insurance Rates Unveiled California Insurance Commissioner Dave Jones (D) released a proposal to divide California into 18 geographic regions for setting health insurance rates.

Jones’ plan would replace legislative proposals that would establish six regions in 2014 or 13 regions in 2015 Under the Affordable Care Act, insurers no longer can deny See on your toes on Page 33

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New BPM Members Governor Brown and his Appointments staff have worked overtime filling the rosters of boards and commissions. In December, the Governor reappointed current Board President Neil B. Mansdorf, DPM and added two additional podiatric physicians, Drs. John Y. Cha and Michael A. Zapf.

Michael’s probably zee last in most alphabetical listings, so we’ll start with him. Out of CCPM, he’s been in private practice since 1985. Before this career he worked in clinical microbiology and was also an examiner for the California Department of Health. He earned a MPH from UCLA. John also is a CCPM graduate, having received his BS from UC Berkeley, and has been in private practice since 2001. Both John and Michael participated in the Baja Project for Crippled Children.

Dr. Michael A. Zapf, DPM

BPM Begins Planning Executive Search Twenty-four years ago, then BPM President Rodney J. Chan, DPM swore in Jim Rathlesberger as the Board’s new Executive Officer, at a public meeting guarded by two State Police officers BPM had requested to maintain order. Previous meetings had sometimes been raucous with contention, a pattern soon to change.

The Board will begin planning its new recruitment February 22, with the search going live early next year. Planning to retire in July 2014, Jim will highlight in the next issue some of the Board’s transitions and evolutions over the last quarter century.

High Standards • Continuing Competence Reducing medical errors • Preventing patient harm

Dr. John Y. Cha, DPM

California Board of Podiatric Medicine Department of Consumer Affairs 2005 Evergreen Street, Suite 1300 • Sacramento, CA 95815 • www.bpm.ca.gov 916-263-2651 fax • 916.263.2647

It will take more than the Luck of the Irish

TO PROTECT THE PATIENTS, PRACTICE AND SPECIALTY OF PODIATRIC MEDICINE IN CALIFORNIA CalPPAC opens doors for dealing with an array of legislative and regulatory issues of interest or concern to California’s podiatric physicians, including – licensure, scope of practice, hospital privileges, insurance, professional discipline, and practice regulations.

Help ensure that the voice of podiatric medicine is heard when and where it counts.

Send your contribution today to CalPPAC, 2430 K Street, Ste. 200, Sacramento, CA 95816. To utilize your VISA, MasterCard or AMX please call (800) 794-8988

SPORT YOUR SUPPORT Contribute $500 and receive a 2013 CalPPAC Gold pin Contribute $250 and receive the 2013 CalPPAC Silver pin (Contributions must be made directly to CalPPAC) 32 |

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2012/2013 board of directors

On your toes from Page 27

coverage based on pre-existing conditions or place lifetime limits on medical care. They also cannot charge older policyholders more than three times what younger enrollees pay.

Observers say that these restrictions leave geography as one of the only factors that insurers can use to adjust premiums.

The federal government has proposed that states avoid creating more than seven geographic rating areas to prevent insurers from charging excessively high rates in certain regions.

However, California’s health exchange has proposed using 19 rate-setting regions to accommodate the state’s size and diversity.

(Source: California Healthline 2/20/2013)

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President Karen L. Wrubel, DPM Hawthorne, CA 90205 P: (310) 675-0900 drkw@cox.net

Directors John A. Chisholm, DPM Chula Vista, CA. 91910 P: (619) 427-3481 dr_triguy@yahoo.com

President-Elect Carolyn E. McAloon, DPM Castro Valley, CA 94546 P: (510) 581-1484 drmcaloon@bayareafootcare.com

Devon Glazer, DPM Newport Beach, CA 92660 P: (949) 272-0007 drdev01@yahoo.com

Vice President Thomas J. Elardo, DPM Los Gatos, CA 95032 P: (408) 358-6234 painfulfeet1@gmail.com Immediate Past President William Tarran, DPM Daly City, CA 94015 P: (650) 757-3338 wtarran@sbcglobal.net Secretary-Treasurer Ami A. Sheth, DPM Los Gatos, CA 95032 P: (408) 358-6234 amishethdpm@gmail.com

Rebecca A. Moellmer, DPM San Bernardino, CA 92404 P: (909) 886-3668 rebeccamoellmer@hotmail.com Thomas J. Tanaka, DPM Ontario, CA 91761 P: (909) 724-5052 drtanaka@doctor.com Jonathan J. Uy, DPM Hercules, CA 94547 P: (510) 724-4674 flipdpm@sbcglobal.net Student Representatives Nathan Hansen (CSPM) P: 510-909-2264 nathan.hansen@samuelmerritt.edu

Executive Director Jon A. Hultman, DPM 2430 K St Ste 200 Sacramento, CA 95816 P: (916) 448-0248 (800) 794-8988 F: (916) 448-0258 CPMA fax jhultman@calpma.org General Counsel C. Keith Greer, Esq. San Diego, CA 92128 P: (858) 613-6677 greerkeith@aol.com Governmental Representative Barry Broad, Esq. Sacramento, CA 95814 P: (916) 442-5999 broad@bglaw.org Parliamentarian/ Recording Secretary Roderick Farley, DPM/ Albuquerque, NM 87122 drrodfarley@gmail.com/ rodnedrafarley@aol.com

Binoy Sheth (Western U) P: (832) 483-9278 bsheth@westernu.edu

2012/2013 COMPONENT SOCIETY PRESIDENTs MONTEREY BAY AREA Bobby Yee, DPM Monterey, CA 93940 P: (831) 646-8242 yeedoc@comcast.net

SAN FRANCISCO/SAN MATEO David Tran, DPM San Francisco, CA 94127 P: (415) 681-2022 DTran@samuelmerritt.edu

CENTRAL VALLEY Clifford Endo, DPM Modesto, CA 95355 P: (209) 544-6088 endoc@sutterhealth.org

NORTHERN CALIFORNIA KAISER Thomas DaSilva, DPM Walnut Creek, CA 94596 P: (925) 295-7099 thomasdasilva@hotmail.com

SAN LUIS OBISPO/SANTA BARBARA David Sterling, DPM Santa Maria, CA 93455 P: (805) 928-5645 sterlingfamily4@gmail.com

COACHELLA VALLEY Harvey Danciger, DPM Palm Desert, CA 92260 P: (760) 568-0108 docofeet@hotmail.com

ORANGE COUNTY Gregory Eirich, DPM Tustin, CA 92780 P: (714) 669-1780 eirichdpm@sbcglobal.net

SANTA CLARA VALLEY Adam Howard, DPM Cupertino, CA 95014 P: (408) 446-5811 footdoc4u@gmail.com

INLAND Jeffrey Bruening, DPM Pomona, CA 91766 P: (909) 622-4501 brueningdpm@yahoo.com

REDWOOD EMPIRE Paul Weiner, DPM Vallejo, CA 94590 P: (707) 643-3687 mdweiner@scrserv.com

SHASTA REGION Gordon Shumate, DPM Redding, CA 96001 P: (530) 246-4800 g.shumate.dpm@frontiernet.net

LOS ANGELES COUNTY Vladmir Zeetser, DPM Encino, CA 91316 P: (818) 907-6100 drzeetser@gmail.com

SACRAMENTO VALLEY Mark Warford, DPM Fair Oaks, CA 95628 P: (916) 548-0218 markwarforddpm@att.net

SOUTHERN CALIFORNIA HMO Anthony Cannizzaro, DPM Pasadena, CA 91188 P: (626) 405-5478 doctoracann@aol.com

MID-STATE Richard Motos, DPM Visalia, CA 93291 P: (559) 734-1171 moetoes@hotmail.com

SAN DIEGO/IMPERIAL Kenneth Charp, DPM Carlsbad, CA 92007 P: (760) 931-9353 zfootdr@roadrunner.com

VENTURA COUNTY Heather McGuire, DPM Ventura, CA 93003 P: (805) 648-2016 drhmcguire@me.com

ALAMEDA/CONTRA COSTA COUNTY Timothy Dutra, DPM 450 30th Street P: (510) 869-6511 x7564 tdutra@samuelmerritt.edu

The California Podiatric Physician is the official publication of the California Podiatric Medical Association.

CPMA and the California Podiatric Physician assume no responsibility for the statements, opinions and/ or treatments appearing in the articles under an authors’s name. For editorial or business information and advertising, contact California Podiatric Medical Association, 2430 K Street, Suite 200, Sacramento, California 95816; telephone, (916) 448-0248; facsimile; (916) 448-0258; e-mail; calpma.org.

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Tax Breaks Extended for Small Businesses

The changes wrought by the American Taxpayer Relief Act of 2012 (ATRA) apply mainly to individual tax planning. But business owners have some things of which to take note as well. The ATRA extends through 2013 (and in some cases also retroactively to Jan. 1, 2012) a variety of tax breaks to which your company has perhaps grown accustomed. These include valuable depreciation-related items such as 50% bonus depreciation; higher levels of Section 179 expensing; and accelerated depreciation for qualified leasehold, retail and restaurant improvements.

qualifying assets placed in service in tax years beginning in 2012 and 2013, the ATRA restores the maximum Section 179 deduction to $500,000 (same as for tax years beginning in 2011). Without this change, the maximum deduction would have been only $139,000 for 2012 and only $25,000 for 2013. The Act also restores the Section 179 deduction phase-out threshold to $2 million for tax years beginning in 2012 and 2013 (same as for tax years beginning in 2011). Without this change, the phase-out threshold would have been only $560,000 for 2012 and only $200,000 for 2013.

50% Bonus Depreciation Extended. The ATRA extends 50% first-year bonus depreciation for an additional year to cover qualifying new (not used) assets that are placed in service in calendar-year 2013. However, the placed-in-service deadline is extended to 12/31/14 for certain assets that have longer production periods including transportation equipment and aircraft. Under the extended deadline privilege, only the portion of a qualifying asset’s basis that is allocable to costs incurred before 1/1/14 is eligible for 50% bonus depreciation.

Somewhat surprisingly, the temporary rule that allowed up to $250,000 of Section 179 deductions for qualifying real property placed in service in tax years beginning in 2010 and 2011 was retroactively restored for tax years beginning in 2012 and extended through tax years beginning in 2013.

For a new passenger auto or light truck that is subject to the luxury auto depreciation limitations, the 50% bonus depreciation provision increases the maximum first-year depreciation deduction by $8,000.

15-year Depreciation for Leasehold Improvements, Restaurant Property, and Retail Space Improvements Extended. The ATRA retroactively restores the 15-year straightline depreciation privilege for qualified leasehold improvements, qualified restaurant property, and qualified retail space improvements for property placed in service in 2012 and extends the deal to cover property placed in service in 2013.

Generous Section 179 Deduction Rules Extended and Qualifying Real Estate Expenditures Are Again Eligible. For

Key Point: For tax years beginning in 2014, the maximum Section 179 deduction is scheduled to be only $25,000, the phase-out threshold is scheduled to fall to $200,000, and the Section 179 deduction privilege for real estate expenditures will be off the table.

Darla A. Colson, CPA, MST, Shareholder Gilbert Associates, I nc., CPAs and Advisors Gilbert Financial Services, LLC

j a n ua r y | F e b r ua r y | m a r c h | 2013

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California Radiology Update this test during their routine maintenance. At some point, you may wish to consider moving to a digital x-ray system and eliminate all of the maintenance, cost and testing required for the analog systems.

Below is a copy of the Title 17 Regulation. These new policies must be incorporated into your current X-ray Policies and Procedures Manual:

§ 30308.1. Quality Assurance for Radiographic Installations (Other Than Mammography, Dental, and Veterinary Medicine) (a) Each user subject to this article, as specified in section 30305(a) (1), who develops clinical radiographs for diagnostic purposes with automatic film processors for other than mammographic, dental, or veterinary use, shall assure all of the following: (1) Each processor used to develop clinical radiographs is adjusted and maintained to meet the manufacturer’s processing specifications for the highest speed radiographic film used clinically.

Some of you may recall in last year’s report, I made mention about anticipated changes to Title 17 that would have a substantial effect on offices still using analog x-ray film processing equipment.

These changes are both a financial and time consuming burden.

Effective January 1, 2013, the regulations are being enforced and some offices are already feeling the sting by not implementing the quality control measures required under the new Title 17 update.

To be more specific, the “Medical and Dental Quality Assurance Regulations” require medical offices to perform quality assurance procedures to ensure proper functioning of x-ray film and chemical processors. The purpose is to reduce the risk of retakes and ensuring best possible x-ray quality. The goal, of course, is to reduce patient radiation exposure. It is important to note that these quality assurance regulations do not apply to digital x-rays.

So what are the direct effects on you? You will need to purchase both a sensitometer and densitometer as well as sensitometric strips. New equipment at a discount seems to be running around $1600. You may be lucky in finding some used equipment from offices that are closing or on eBay. Next, each morning after your x-ray film processor has warmed up and prior to processing patient films, you or your staff is required to expose film or a sensitometric strip in the sensitometer and develop the film. The processed film is then read using the densitometer and the result recorded in a log book. It is recommended that you date and keep the strips for proof of your quality assurance performance. This will be requested by the Radiologic Health Branch, not if, but when they field inspect your office.

Every three months you are also expected to test the residual fixer level retained on your films. Staff may perform this test if you purchase the chemical test kit. If you have a service that comes to your office regularly to replenish your x-ray chemicals and clean your processor, you may be able to contract with them to perform 36 |

(2) Measurements are performed each day before clinical radiographs are processed, so as to determine that the processor is operating within the following limits: (A) The base-plus-fog density is within plus 0.05 of the operating level established with the highest speed radiographic film used clinically; (B) The mid-density is within plus or minus 0.15 of the operating level established with the highest speed radiographic film used clinically; and (C) The density-difference is within plus or minus 0.15 of the operating level established with the highest speed radiographic film used clinically.

(3) Tests are performed at intervals not to exceed three months to determine that the residual fixer level retained in clinical radiographic films is not more than 5.0 micrograms per square centimeter.

(4) Tests are performed at intervals not to exceed six months to determine that the optical density attributable to darkroom fog is not more than 0.05 when the highest speed of each type radiographic film used clinically, which has a mid-density of no less than 1.20 optical density, is exposed on the counter top for one minute under typical darkroom conditions with the safelight on.

(5) For any test result falling outside the criteria specified in this section, the problem is identified and corrective action is taken before clinical radiographs are processed.

(6) Records of the tests specified in this section, including the problems detected, corrective actions taken, and the effectiveness of those corrective actions, are maintained for at least one year from the date the test was performed.

Neil M ansdorf, DPM Chair, R adiological Taskforce C P MA | C a lifo r n i a P odi at r i c M e di c a l Asso c i atio n

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Member Get a Corporate Member and $$$ CPMA is kicking off its 2013 Corporate Member drive with the Member Get a Corporate Member Campaign, where any CPMA member who signs up a new Presidential Level CPMA Corporate Member will receive a $100 Visa Gift Card, or for signing up an Executive Level Corporate Member a $25 Visa Gift card. The campaign will run from April 1 to June 1, 2013.

Members can download a Corporate Member benefits list/application from the CPMA website calpma.org/corporatemembers or contact CPMA at (800) 794-8988 to have a Corporate Member brochure faxed to you.

CPMA Corporate Members are companies that go the extra mile to support YOU! Funds received through this program enable CPMA to offer enhanced services to its members while also providing public information and education to the general population on

podiatric medicine and the important role podiatric physicians play in healthcare delivery. CPMA’s Corporate Member program also allows companies to learn about the activities of CPMA and work with the Association to support the podiatric medical profession, physicians, and patients.

CPMA gratefully acknowledges the companies in our Corporate Member program and their commitment to excellence in the podiatric medical community. Please visit their websites to learn more about their products, services, and efforts to promote quality foot health.

Remember to Support Those That Go the Extra Mile to Support YOU!

Support Those That Go The Extra Mile to Support YOU!

April 5th is National Walk to Work Day Held the first Friday in April, National Walk to Work Day 2013 will celebrate its 9th Anniversary on April 5th. Created by the US Department of Health and Human Services and endorsed and promoted

by CPMA, Prevention Magazine, and now many other professional organizations across the nation, National Walk to Work Day was implemented to help counteract Americans’ increasingly sedentary, unhealthy lifestyles, which are linked to damaging results including obesity, diabetes and heart disease. j a n ua r y | F e b r ua r y | m a r c h | 2013

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Call for Nominations 2013 The 2013 CPMA House of Delegates will convene Wednesday, June 19th the Disneyland Hotel and Convention Center in Anaheim, during which time the House will consider nominees for CPMA’s Board of Directors as well as the California Delegates to the 2014 American Podiatric Medical Association House of Delegates.

“Strong, effective leader-ship at the helm of our Association is critical,” said CPMA Past President and Nominating Committee Chair William Tarran, DPM. “We need knowledgeable, capable and committed leaders who can provide a clear vision, creativity and energy in our efforts to advance and enhance our medical specialty during these uncertain times.”

The purpose of the Association’s Nominating Committee is to conduct a broad-based search for qualified candidates to fill CPMA Offices. Names of candidates for consideration to the CPMA Board of Directors must be submitted in writing to CPMA Headquarters, 2430 K Street, Suite 200, Sacramento, CA 95816, ATTN: Nominating Committee. Names may also be submitted via fax to (916) 448-0258.

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The only way to influence decision makers such as CEOs and administrators of hospitals and politicians is with data, Harkless said.

In a 5 percent sampling of Medicare patients in 1995-96, the cost was $15,309 to treat a diabetic foot ulcer versus $5,226 for the general population with a foot ulcer, Harkless said. What was alarming was that 70 percent of those patients had little to no follow-up, which often leads to further hospitalizations and spiraling costs. Foot problems account for six percent of admissions for diabetes but 20 percent of hospital days, Harkless said.

“By screening the foot, placing patients in the appropriate risk category, and treating them with local preventative care, data supports that half of those ulcers can be prevented,” he said.

Podiatrists should help train the next generation of physicians and

other disciplines through residency programs, lectures and rounds, said Harkless, who accomplished this while at the University of Texas Health Science Center at San Antonio, and is developing these programs at WesternU. “Until you integrate podiatric medicine into mainstream medicine, it is not going to have the impact it needs to have for better patient outcomes. The best results come from having everyone on the team,” he said.

He is realistic about where the battle against diabetic foot amputations stands. “To receive this award honoring me is humbling because the problem still exists, however it gives me resolve to continue my work until we are successful.”

Rodney Tanaka, Western University of Health Sciences

CPMA Convenes 101st Annual House of Delegates June 19, 2013 More than 100 doctor delegates representing their various geographic communities from throughout the state will gather for the 2013 California Podiatric Medical Association Annual House of Delegates for briefings and to consider policy resolutions at the Disneyland Hotel in Anaheim, California on Wednesday, June 19, 2013.

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western foot and ankle conference june 20 – 23, 2013

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2013 visit www.TheWestern.org

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get more for your money: • Economically conscious registration rates • 25 CE contact hours • 12 radiology CE contact hours • Dynamic lecture tracks • Distinguished faculty • Innovative instructional courses

• Hands-on surgical workshops • Billing & Coding updates • PICA presentation • 3-day educational seminar for podiatric medical assistants including radiology credits • 3 days of exhibits

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