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Medical Business Journal

GAO releases first annual review of NQF Shows NQF’s progress related to MIPPA quality measures

The National Quality Forum (NQF) was awarded a contract in Jan. 2009, with the Department of Health and Human Services (HHS), in order to monitor quality measures mandated by the Medicare Improvements for Patients and Providers Act (MIPPA). The US Government Accountability Office (GAO) released its first required annual review of NQF’s progress. NQF, a nonprofit member organization, has five duties required of it by MIPPA: 1) Make recommendations on a national strategy and priorities 2) Endorse quality measures, which involves a process for determining which ones should be recognized as national standards 3) Maintain—update or retire—endorsed quality measures 4) Promote electronic health records 5) Report annually to Congress and the Secretary of HHS While the GAO report stated that it was too soon to judge the effectiveness of NQF at accomplishing these duties, the report gave an account of NQF’s progress thus far. NQF has established a committee of stakeholders to recommend strategies and priorities for quality measurement. The committee published a list of recommended priorities in May 2010. NQF is developing a national standard to be proposed to HHS, which will then submit their proposal to Congress by Jan. 1, 2011. NQF has also established a process for endorsing quality measures. Organizations develop quality measures and submit them to NQF in response to solicitations by NQF. NQF then forms a committee of experts collected from its member organizations to consider these (Cont. Page 2 NQF)

Medical Business Journal - - Issue 5, Volume 1 - December 2010


Medical Business Journal

NQF cont. from page 1

measures against pre-determined criteria. A period for public comment is then provided. NQF’s board of directors then makes a final decision on the national standard, which is formally endorsed by NQF and submitted to HHS. Once a measure is established, NQF will provide annual updates and every three years a comprehensive review of the measure. The comprehensive review is similar to the initial process for endorsing a quality measure, going from committee to public review then to the board of directors. NQF is currently reviewing 191 measures that were already in place at the start of its contract. NQF has begun developing a standardized set of data that all electronic health records (EHRs) must include. This is intended to provide a standard by which EHRs may be judged on a national level. Two annual reports have been submitted by NQF, one in March 2009 and the second in March 2010. HHS has then reviewed the reports and approved annual plans developed by NQF. A full copy of the report in pdf format is available at:

NimbleTM EMR ClearPractice



Comprehensive EMR created specifically for iPadTM One of the main draws of adopting electronic medical records (EMRs) is their mobility, compared to paper records. It only makes sense to put these mobile records on a mobile device, in this case the iPadTM. Doctors need to be able to access their patient’s records on the go, whether doing their rounds or sitting at home. One of the largest sources of resistance to EMR technology has been the inability for a doctor to carry a large desktop computer around with them when they are seeing their patients. It is for this reason that ClearPractice developed the NimbleTM EMR for the iPadTM. NimbleTM connects via a wireless or 3G network to the ClearPractice cloud, where it stores all of its data. This makes the app both secure and HIPPA compliant. NimbleTM allows doctors to access patient charts while making their rounds, and lets the doctors show the patients charts and graphics to better explain their condition and course of treatment. Additionally, NimbleTM integrates with ClearPractice’s practice management and billing systems to automatically capture charges and submit them for payment electronically. NimbleTM relies on ClearPractice’s Software as a Service (SaaS) system, meaning that the software and data is stored remotely and accessed by the user via NimbleTM. This allows for instantaneous updates managed remotely by ClearPractice.

2011 Final Rule – Effective Jan. 1, On Nov. 2, Centers for Medicare and Medicaid Services (CMS) released the finalized 2011 Medicare Physician Fee Schedule (MPFS). Peers from all over the country submitted 8,500 comments to CMS regarding the proposed rule but CMS implemented most changes featured in the 1,250-page proposal in the 2000+ Final Rule. This issue includes basic articles concerning some of the changes that are to take effect January 1, 2011. The full Final Rule can be downloaded at Want to become active in the Medical Business Journal? Email inquiries to

2011 Payment Policies and Rates Below are some highlights from the Final Rule: The conversion factor (CF) for 2011 has been reduced to $25.5217, which is roughly 30% lower than the current CF of $36.8729. What kind of impact does this have on your practice? Look at it this way, currently the national payment for a level-3 office visit, for an established patient (99213) is $66.74. After the new conversion factor takes effect, the reimbursement will fall to $51.81 – that’s more than a 20% reduction! Meanwhile, CMS is rebasing and revising the Medicare Economic Index (MEI) to use a 2006 base year in place of a 2000 base year. What does that mean? This will shift the MEI to increase practice expense RVUs and malpractice RVUs while leaving work RVUs the same. Therefore, CMS is not making an adjustment directly to the work relative value units (RVU), but instead is increasing the PE RVUs by an adjustment factor of 1.181 and the malpractice RVUs by an adjusted factor of 1.358 (see Addendum B in the final rule). The end result is to promote pay for specialties with high expenses (e.g. diagnostic imaging, radiation oncology, etc) The final rule also discusses CMS’ analysis of practice expense geographic practice cost index (PE GPCI) data and methods as it incorporates new data as part of the sixth GPCI update, while keeping the GPCI cost share weights the same. A large number of RVU changes will also take effect in 2011 with CMS adopting recommendations by the AMA’s RUC (Relative Unit Update Committee). The RUC is the AMA’s effort to revalue codes that were deemed as “potentially misvalued”. The 2011 MPFS final rule with comment period will appear in the Nov. 29th Federal Register. Stay tuned for more information regarding the final rule in upcoming issues of the Medical Business Journal.

A video advertisement for NimbleTM is available on YouTube at: http:// More information about the product is also available at:


Medical Business Journal - - Issue 5, Volume 1 - December 2010

Medical Business Journal

CPT Changes 2011 E/M: Observation Codes New:

99224 99225 99226



Surgery Section: Integumentary System Codes New:



11045 11046 11047


11010 11011 11012 11042 11043 11044 11040 11041

Surgery Section: Musculosketal System Codes New:

22551 22552 29914 29915 29916


20005 20664 20930 20931 22315 22851 27065 27066 27067 27070 27071



Surgery Section: Respiratory System Codes New:

31295 31296 31297

37226 37228 37229 37230 37231 37232 37233 37234 37235

Surgery Section: Cardiovascular System Codes


33620 33621 33622 33411 33860 33863 33864 34900 35471 35526 35626 37205 37206 37207 37208 33861 35454 35456 35459 35470 35473 35474 35480 35481 35482 35483 35484 35485 35490 35491 35492 35493 35494 35495 37220 37221 37222 37223 37224 37225

Surgery Section: Hemic and Lymphatic System Codes New:



39502 39520 39530 39531

Surgery Section: Digestive System Codes New:



43283 43327 43328 43333 43334 43335 43336 43337 43338 43753 43754 43755 43756 43757 49412 49418 43605 47480 47490 49419 49421 49422 43324

43326 43600 49420

Surgery Section: Urinary System Codes New: Revised:

53860 50250 50542

Surgery Section: Male Genital System Codes Revised:

55866 55876

Surgery Section: Female Genitial System Codes New: Revised:

57156 57155

Surgery Section: Nervous System Codes New:

61781 61782 61783 64566 64568 64569 64570 64611


64479 64480 64483 64484 64575 64708 64712 64713 64714


61795 64573

Surgery Section: Eye and Ocular Adnexa New:

Medical Business Journal - - Issue 5, Volume 1 - December 2010

65778 65779


Medical Business Journal 66174 66175 Revised:

75954 75960 75962 75964 77003


75992 75993 75994 75995 75996 76350 76880

82926 82928 86903 89100 89105 89130 89132 89135 89136 89140 89141 89225 89235

80104 82930 83861 84112 85598 86481 86902 87501 87502 87503 87906 88120 88121 88177 88363 88749

93463 93464 93563 93564 93565 93566 93567 93568 95800 95801 96446 Revised:

Medicine Section Codes: New:

Pathology and Laboratory



74176 74177 74178 76881 76882



82952 85597 86480 87901 88172 88332 88334

65780 66761 69801 69802

Radiology Codes New:


90460 90461 90644 90664 90666 90667 90668 90867 91013 91117 92132 92133 92134 93451 93452 93453 93454 93455 93456 93457 93458 93459 93460 93461 93462


90560 90662 90663 90670 91010 93224 93225 93226 93227 93228 93229 93268 93270 93271 92172 95857 95953 95956 97597 97598

93231 93232 93233 93235 93236 93237 93501 93608 93510 93511 93514 93524 93526 93527 93528 93529 93539 93540 93541 93542 93543 93544 93545 93555 93556 96445

Category II: New:

90465 90466 90467 90468 91000 91011 91012 91052 91055 91105 91123 92135 93012 93014 93230

Medical Business Journal - - Issue 5, Volume 1 - December 2010

0545F 1200F 1205F 1400F 3008F 3015F 3038F 3293F 3294F 3323F 3324F 3328F 3650F 3700F 3720F 4004F 4063F 4255F 4256F 4324F

Medical Business Journal



4325F 4326F 4328F 4330F 4340F 4400F 5200F 6070F 6080F 6090F 3110F 3111F 3112F 3216F 4047F 4048F 7010F

0232T 0233T 0234T 0235T 0236T 0237T 0238T 0239T 240T 0241T 0242T 0243T 0244T 0245T 0246T 0247T 0248T 0249T 0250T 0251T 0252T 0254T 0255T 0256T 0257T 0258T 0259T

1127F 1128F

Category III New:

0253T 0208T 0209T 0210T 0211T 0212T 0213T 0214T 0215T 0216T 0217T 0218T 0219T 0220T 0221T 0222T 0223T 0224T 0225T 0226T 0227T 0228T 0229T 0230T 0231T



0184T 0191T 0016T 0017T 0104T 0105T 0130T 0140T 0160T 0161T 0176T 0177T 0187T 0193T 0203T 0204T

Another HHS Federal Funding Opportunity $335 million to increase access to primary health care Under the Expanded Services (ES) initiative, the availability of $335 million for existing community health centers was announced Oct 26. The funds intend to help the health centers accommodate more patients, regardless of the patient’s insurance status. This action is in line with the Department of Health and Human Services’ (HHS’s) focus on preventative and primary health care. Applicants for this funding must demonstrate how these funds will be used to increase healthcare access to underserved populations. The following categories of health centers are eligible: • • • •

Community Health Centers (CHC) Section 330(e) Migrant Health Centers (MHC)-Section 330(g) Health Care for the Homeless (HCH)-Section 330(h) Public Housing Primary Care (PHPC)-Section 330(i)

Applications are due by 8 pm ET, January 6, 2011. Information on how to apply for this funding is available at:

HHS Announces “Early Innovator” Grants Competitive funding for States to develop health insurance Exchanges Health insurance Exchanges are set to open 2014 and only one thing is left to do: actually make them. To help accomplish this elusive goal, The Department of Health and Human Services (HHS) has announced a competitive funding opportunity for States wishing to lead the way. The Exchanges are intended to be one-stop-shopping centers for health insurance, which will drive down prices for individuals and small businesses. However, in order to actualize this goal, a strong and efficient IT infrastructure is needed. The grants, which will be awarded Feb. 15, 2011 to up to 5 States, are intended to fund the development of this IT infrastructure. The States receiving the grants will need to develop models serving as blueprints by which the rest of the country can develop the Exchanges. The focus emphasized by HHS is to make the exchanges consumer friendly. The grants will be awarded to States which best demonstrate this, while keeping cost-effective use of tax dollars in mind.

Medical Business Journal - - Issue 5, Volume 1 - December 2010


ICD-10 Preparation:

Medical Business Journal

Provided CMS’ previous track record for implementation (remember NPI?), the 2013 compliance date may not spark much urgency for providers across-the-board. However, according to professionals, trust that CMS has their act together on this one. In short, for those who are not ready when the “switch” flips on October 1, 2013, the penalty will simply be: you won’t get paid. As a matter of fact, there is an even earlier deadline you need to consider – January 1, 2012. This is when practices’ must fully adopt HIPAA Transactions and Codes Sets version 5010. This conversion is required before you can switch to the new ICD-10 coding system. CMS has promised to be ready to test 5010 one full year before the compliance date. This is reason enough to believe the October 1, 2013 deadline will stand, and you should not believe rumors of enforcement delays. If you haven’t started already, you will want to aggressively begin making implementation plans today or begin looking for another job.

HCPCS 2011: Sneak Peek The Centers for Medicare and Medicaid Services (CMS) posted 2011 HCPCS II changes, which include 147 new codes and modifiers and more than 286 deleted codes. Changes also include the addition of pass-through codes, a large number of G procedure/professional service codes, and many injectable drugs. Overview Deleted Codes: Of the 286 deleted codes for 2011, the majority are in the G codes section (between G0430 and G8521). This includes procedures/professional services like the following: •Diabetic, heart failure and coronary artery disease services; •Osteoporosis and hearing assessment; •Urinary incontinence; •E-prescribing system codes; •Intraocular pressure; •ESRD

Don’t mistake the 5010 adoption for the full ICD-10 implementation. The move to ICD-10 is not merely a software upgrade. The new list of ICD-10 codes will be exponentially more detailed than the current ICD-9. With as much detail on the horizon, practices will have to think about whether superbills will remain practical for use. On the same note, don’t count on an ICD-9/ICD-10 crosswalk to save you from being unprepared either. The government has adopted a standard crosswalk – yes, but there is no guarantee that private health plans will follow. Furthermore, roughly 20% of the new codes are unable to be crosswalked!

C Codes: C9255 C9256 C9258-C9269 C9271

Here are some suggested starting points:

Additions: •Q codes Q4117-Q4121, to support healing of burns or ulcers •Q flu vaccination codes for patients 3 years and older •Skilled services codes (G0162-G0164) •G tobacco/smoking related codes •Risk-adjusted functional status change residual score G codes •G blood pressure codes

Get in touch with your vendors to determine software, hardware and other upgrades you will need for the conversion. How much will it cost under your contracts? Outline timelines for testing and other implementation steps. Contact your health plans to discuss testing and other steps they are taking on their end. Set a budget and arrange training for the appropriate personnel. Research has varied about how much ICD-10 implementation will cost. An MGMA study determined the average, three-physician practice can expect to spend somewhere around $80K-$85K on education, process analysis and other changes. ICD-10 professionals advise considering teaming up with local practices to coordinate on-site trainings to offset some of this cost. For ICD-10 questions or 5010 vendor recommendations, please contact


E Codes: E0220 E0230 E0238

There are many injection code addition and deletions in the code range J0558 – J0580 for penicillin G benzathine injection codes. There are also many skin protection wheelchair seat cushion K codes deleted, as well.

Description Changes: •Skin graft codes Q4101-Q4116 (pain assessment and acceptable EHR system G codes) have received changes to their long descriptions. •Wheelchair code, K0669, has been changed as well. These are only part of the changes in store for 2011. To view all HCPCS Level II code changes for the New Year, the Alphanumeric Index and Table of Drugs, go to:

Medical Business Journal - - Issue 5, Volume 1 - December 2010

Medical Business Journal

CLIA Waived Tests for First Quarter Notice to Patients: 2011 Medicare Open Enrollment Centers for Medicare and Medicaid Services (CMS) updated its list of waived tests approved by the Food and Drug Administration (FDA) under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) on Nov. 5th. To ensure accurate claims payment, CMS instructed Medicare administrative contractors (MACs) to do likewise and clinical diagnostic labs should follow shortly thereafter. In order to perform each test, CLIA regulations require facilities to be appropriately certified. Here is a chart of the latest tests approved by the FDA under CLIA. Effective January 1, 2011, the CPT codes for the tests listed below must have the QW modifier to be recognized.

CPT Code G0430QW

Effective Date Jan. 1, 2010


Mar. 2, 2010

84443QW G0430QW

Mar. 4, 2010 Apr. 21, 2010


Apr. 21, 2010


May. 10, 2010


Jul. 1, 2010


Jul. 4, 2010


Jul. 4, 2010

82274QW, G0328QW

Jul. 8, 2010


Jul. 19, 2010


Jul. 19, 2010


Aug. 18. 2010


Aug. 18, 2010

Description American Screening Corporation One Screen Drug Test Cups Aventir Biotech LLC, Forsure TSH Test (Whole Blood) BTNX CLIAwaived, Inc. Rapid Drug Test Cup (OTC) Millennium Laboratories Clinical Supply, Inc. Multi-Drug Pain Med Scren Cup US Diagnostics ProScreen Drugs of Abuse Cup (OTC) Ameditech, Inc. ImmuTest Drug Screen Cup Quik Test USA, Inc. MultiDrug of Abuse Urine Test Screen Tox Multi-Drug of Abuse Urine Test Consult Diagnostics Immunochemical Fecal Occult Blood Test (iFOBT) Alfa Scientific Designs, Inc. Instant-View Drug of Abuse Urine Cassette Test Alfa Scientific Designs, Inc. Instant-View Drug of Abuse Urine Cup Test America Screening Corporation Reveal Multi-Drug Testing Cups PSS Consult Doagnostic Strep A Dipstick

Starting November 15, all Medicare beneficiaries can choose a new Medicare plan or simply review their current coverage. Starting January 2011, thanks to the Affordable Care Act (ACA) most people with Medicare will be provided with important new benefits including a lower cost on brand name drugs for those who fall into the coverage gap, free annual wellness visits and free mammograms, colonoscopies and other screenings. For more information on Open Enrollment, go to: aspx For more information on ACA, go to:

Medical Business Journal Volume 1, Issue 2

Managing Editor Assistant Editor Contributors Layout and Design Production

Jennifer Donovan, RMC, CPC, RMM Christopher Myers Christopher Myers Jennifer Donovan, RMC, CPC, RMM Mike Calkins, ADN, RMC Chris Rottmann Clockwork Graphics

Medical Business Journal is a monthly publication available through subscription for $99.95 per year or $159.95 for two years (additional copies and reprints are available for $20/issue). The Medical Management Institute is not affiliated in any way with the Department of Health and Human Services, Medicare, or the Centers for Medicare and Medicaid Services. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting or other professional services, and is not a substitute for individualized expert assistance. The CPT codes, descriptors, and modifiers are copyrighted by the American Medical Association. For more information, please call MMI at 1-866-892-2765.

Medical Business Journal - - Issue 5, Volume 1 - December 2010


Medical Business Journal

The Registered Medical Manager Online Certification Sample Topics Goals & Strategic Planning Setting Goals Personal Goals Professional Goals Practice Goals Goal Statements Planning for Success Marketing and Medicine Marketing and Healthcare Patient Relations Practice Newsletters Survey for Managed Care Patients Benefits & Wages Minimum Wage Laws Healthcare Benefits COBRA ERISA Compliance Overview What is Compliance? Structure of the Compliance Plan Internal Auditing & Monitoring Process Developing a Disciplinary Standard & Guidelines

Financial Outcomes and Controls Budgeting Cash Flow Management Receipt Controls Internal Auditing and Billing Controls Management Review Guidelines Compliance Coding & Billing Coding & Billing Modifiers Retention of Records Educational Training in the Medical Practice

The coursework is all self-paced. You can move through the material as your schedule allows, call into your instructor when you have questions or discuss topics with other students online.

Organizations/Income Distribution Practice Organization Physicians as Managers Executive Committees Income Division Formula

Just Added Health Care Reform Impletementation Explanation Effective Dates

Leadership & Management Leadership: Be a Big Thinker A Philosophy of Leadership Personnel & Policies Management Reporting LEARN MORE ABOUT THE REGISTERED MEDICAL MANAGER PROGRAM Call: 866.892.2765 or visit us online:


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Using the Webex application, Instructors can conduct live presentations when needed. Also, you will find course materials and reference manuals are included in your tuition fee. You can also use it to access the school’s online classroom!

Medical Business Journal - - Issue 5, Volume 1 - December 2010