AES 2010 Practice Management Course December 7, 2010 Gregory L. Barkley, M.D. Comprehensive Epilepsy...

AES 2010 Practice Management Course

December 7, 2010

Gregory L. Barkley, M.D.Comprehensive Epilepsy Program

Henry Ford HospitalDetroit, MI

Associate Professor of NeurologyWayne State University

Outline

Consultation Codes 2011 Medicare Conversion Factor and SGR October 2010 ICD-9 coding changes of interest 2011 CPT Codes PQRI update Gearing up for ICD-10 on October 1, 2013

Miscellaneous: Please note, I have removed the cell slice images from this set to keep the file size smaller. Images are at:

http://www.nytimes.com/slideshow/2010/11/29/science/20101130-brain-1.html

Deadline extended until Dec 10. We specifically need members from:

Alaska, Arizona, Arkansas

Colorado, Connecticut

Delaware, Kansas

Kentucky, Maine

Mississippi, Nebraska

Nevada, North Dakota

Rhode Island, South Carolina

South Dakota, West Virginia

Melissa Larson

Manager, Advocacy Development

AAN Professional Association

Ph: 651.695.2748

FAX: 651.361.4848

[email protected]

www.aan.com\advocacy

Consultation Codes Are Gone Forever

• CMS stopped paying for consultations, 9924x and 9925x

– In 2007, > 28 million claims

– Money from Consultation codes redistributed to other physician codes to maintain budget neutrality

• Other payers stopped paying for consults during 2010

• An attempt this year by AAN and other societies to get reconsideration of consult codes was rejected

• CMS commented: "in most cases there is no substantial difference in physician work between E/M visits and services that would otherwise be reported with CPT consultation codes."

Coding an outpatient New Patient visit (3/3 or Hx, PE, and MDM)

History Examelements

Decisionmaking

Time(minutes)

Code

HPI 1-3 facts 1-5 Straight-forward

10 99201

HPI 1-3 factsROS 1 fact

6 Straight-forward

20 99202

HPI 4 factsROS 2, PSFH 1

12 low 30 99203

HPI 4 facts, ROS 10, PSFH 325 moderate 45 99204

HPI 4 facts, ROS 10, PSFH 325 high 60 99205

Coding an outpatient Established Patient visit (2/3 MDM + Hx or PE)


Decisionmaking

Time(minutes) Code

- - Minimal or none 5 99211

HPI 1-3 facts 1-5 Straight-forward 10 99212

HPI 1-3 factsROS 1 6 low 15 99213

HPI 4 facts, ROS 2, PSFH 1 12 moderate 25 99214

HPI 4 facts, ROS 10, PSFH 3 25 high 40 99215

9922x Coding an inpatient Initial Care Day (3/3)

History (CC always needed)

Examelements

Decisionmaking

Time(minutes)

Code(wRVU)

HPI 4 facts,1 PFSH,2-9 ROS

12 Neuro SSE or

5-7 systems

Straight-forward or low

30 99221 (1.89)

HPI 4 facts,3 PFSH,10 ROS

Full Neuro SSE (25) or 8 Systems

Moderate(2 Chronic with 1

exacerbation)

50 99222 (2.57)

HPI 4 facts,3 PFSH,10 ROS

Full Neuro SSE (25) or 8 Systems

HighThreatening, acute or chronic, illness

or injury

70 99223 (3.79)

9923x Coding an inpatient Subsequent Day Care (2/3)


Decisionmaking

Time(minutes)

Code(wRVU)

HPI 1-3 facts 1-5 straight-forward or low

15 99231 (0.76)

HPI 1-3 factsROS 1 fact

6 moderate 25 99232 (1.39)

HPI 4 factsROS 2 facts

12 high 35 99233 (2.00)

Counseling and Coordination of Care

Counseling is a discussion with patient or family about diagnoses, Counseling is a discussion with patient or family about diagnoses, test results, recommended tests, prognosis, treatment test results, recommended tests, prognosis, treatment alternatives, compliance, risk factor reduction, and patient and alternatives, compliance, risk factor reduction, and patient and family education.family education.

Coordination of care is arranging for care with other health care Coordination of care is arranging for care with other health care providers. This includes any type of such activity.providers. This includes any type of such activity.

Counseling and Coordination of Care

• This can be used This can be used in place ofin place of the above HX-PE-MDM. the above HX-PE-MDM.• It uses It uses timetime to set LOS to set LOS• The documentation should state: The documentation should state:

– MinutesMinutes spent face-to-face spent face-to-face

– That That more than 50%more than 50% of time was counseling and/or coordinating of time was counseling and/or coordinating care,care,

– Give some general idea of Give some general idea of whatwhat counsel/coord. care. counsel/coord. care.

• Time is: Time is: – Face-to-face with patient (outpatient)Face-to-face with patient (outpatient)

– At bedside and on unit/floor (inpatient).At bedside and on unit/floor (inpatient).

• No history or exam elements are needed except, of course, for real patient No history or exam elements are needed except, of course, for real patient care purposes!care purposes!

Emergency Room Care

• Most ER services provided by neurologists and neurosurgeons are Most ER services provided by neurologists and neurosurgeons are as “consultants”as “consultants”

• Use Established Patient (99211-99215) codes for Medicare Use Established Patient (99211-99215) codes for Medicare patients seen by anyone in your group in the past three yearspatients seen by anyone in your group in the past three years

• Otherwise use Outpatient New Patient (99201-99205) codesOtherwise use Outpatient New Patient (99201-99205) codes• If the patient is admitted to the hospital, then use the initial hospital If the patient is admitted to the hospital, then use the initial hospital

day codes (99221-99223)day codes (99221-99223)• Critical Care services provided in ER, e.g. tPA or status epilepticus Critical Care services provided in ER, e.g. tPA or status epilepticus

management:management:– Use Critical Care codes 99291 - 99292Use Critical Care codes 99291 - 99292

Critical Care

• 99291 first hour of critical care (31-74 minutes)99291 first hour of critical care (31-74 minutes)• 99292 each additional 30 minutes99292 each additional 30 minutes• Coded by time for bedside and unit physician work for an unstable, critically ill Coded by time for bedside and unit physician work for an unstable, critically ill

patient patient – Not for consultant's time Not for consultant's time

– Need not be continuous in any locationNeed not be continuous in any location

• Generally cannot bill other E/M on same day. Generally cannot bill other E/M on same day.

• Exceptions are if an E & M is performed at one time, then a crisis occurs and Exceptions are if an E & M is performed at one time, then a crisis occurs and critical services are performed. critical services are performed.

• Make sure you document times carefully so you do not appear to be combining Make sure you document times carefully so you do not appear to be combining times of routine care with critical care times or procedure times. times of routine care with critical care times or procedure times.

• Not every day in the ICU is critical care!!!Not every day in the ICU is critical care!!!

– Patients awaiting transfer to GPU are not critically illPatients awaiting transfer to GPU are not critically ill

• Critical care can be provided anywhere including in the clinicCritical care can be provided anywhere including in the clinic

• You must document time spent and what you did in your noteYou must document time spent and what you did in your note

A Very Short Primer on American Health Care Financing:$2.5 trillion spent on health care in 2009. Private insurance covered59% of Americans. Government programs paid for 53% of direct

health care costs and 62% if tax exemptions counted. More than 50 million Americans without health care coverage.

Private insurance policies Private insurance policies - Largely paid for by - Largely paid for by employersemployers- Usually small, but - Usually small, but increasing, out-of-pocket increasing, out-of-pocket costs borne by individualscosts borne by individuals- Thousands of companies - Thousands of companies offering tens of thousands offering tens of thousands of individual policies of individual policies - Range minimal coverage - Range minimal coverage for catastrophic illness to for catastrophic illness to full coverage full coverage

Medicare Trust FundMedicare Trust Fund- Elderly and those qualifying for - Elderly and those qualifying for Medicare disabilityMedicare disability-For outpatient care, covers 80% For outpatient care, covers 80% of professional fee schedule for of professional fee schedule for visits and procedures + APC for visits and procedures + APC for technical charges technical charges - In 2006 outpatient medications In 2006 outpatient medications were coveredwere covered- For inpatient care, covers 80% - For inpatient care, covers 80% of fee schedule for professional of fee schedule for professional costs + DRG for technical costs costs + DRG for technical costs - Covers 55% of psychiatric care - Covers 55% of psychiatric care charges (Chapter 5 of ICD-9)charges (Chapter 5 of ICD-9)

In 2007, U.S per capita health care spending was $7,290, 2.5 times the OECD

average and 16% of GDP

U.S. government alone already pays more than total costs in nearly all other countries

Health Care Spending is 16% of GDP

To Control US Debt

Only options are to: Cut Medicare spending

2010 Accountable Care Act reduces Medicare spending by $350 Billion over 10 years

Cut Defense spending Cut Social Security spending Raise taxes

Reality is that all of the above are necessary

Social Security P. Krugman, NYTimes 12/06/2010

2011 Medicare Proposed Conversion Rate issued 11/02/2010, 2023 pages

In the final rule, the Medicare Conversion Factor will be $25.5217 starting 01/01/2011

– 30% drop compared to 2010 to meet SGR law

– Comment period is open until January 3, 2011

Conversion factor law override from 06/01/2010 until 11/30/2010 was $36.8729

– A 2.2% increase from 2009 and averted a 21.5% cut

Legislation proposals in Congress to override remain contentious at this time

– On 11/18/2010, Senate passed a one month extension of current pay scale

– House passed same bill on 11/30/2010

Rescaling of RVU weights (-8.2%) and (+0.5%) budget neutrality change due to RVU changes mandated by law, so CF likely to be $34.00 if Congress overrides

2011 Medicare Conversion Rate

12/06/2010, 8:17 PM

To: [email protected]

From: [email protected]

Re: SGR Agreement

Dear MEM Members:

The Senate Finance committee just announced a one year delay of the SGR cuts. The deal will be fully paid for. Details to come.

Michael J. Amery, Esq.

Legislative Counsel

American Academy of Neurology

202-506-7468

mailto:[email protected]

SGR Annual Override..• Does not fixed flawed formula and increases the

decrease needed the next year, currently $210-279 B

AMAAMA

$210-279 B

2011 ICD-9 Code Changes On October 1 of each year, the ICD-9 code changes occur

There are new codes as well as new index terms.

– Index terms can be used by coders to map to a specific code New index terms for epilepsy I presented at the ICD Coding and

Maintenance Committee Meeting on 9/25/2008, my presentation is at: http://www.cdc.gov/nchs/icd/icd9cm_maintenance.htm

Epilepsy, epileptic (idiopathic) 345.9

Note: use the following fifth-digit subclassifications with categories 345.0, 345.1, 345.4-345.9

0 without mention of intractable epilepsy1 with intractable epilepsy

pharmacoresistant (pharmacologically resistant)poorly controlledrefractory (medically)treatment resistant

2011 ICD-9 Code Changes

345 Epilepsy and recurrent seizures

Delete Excludes: progressive myoclonic epilepsy (333.2)

780 General symptoms

780.3 Convulsions New code 780.33 Post traumatic seizures

Excludes: post traumatic epilepsy (345.00-345.91)


225 Benign neoplasm of brain and other parts of nervous system

Revise Excludes: neurofibromatosis (237.70-237.79)

237 Neoplasm of uncertain behavior of endocrine glands and nervous

system

237.7 Neurofibromatosis

Delete von Recklinghausen's disease New code 237.73 Schwannomatosis

New code 237.79 Other neurofibromatosis

2011 ICD-9 Code ChangesCodes in Red are in Chapter 5, reimbursed at 55% vs. 80%

278.0 Overweight and obesity

New code 278.03 Obesity hypoventilation syndrome Pickwickian syndrome

307 Special symptoms or syndromes, not elsewhere classified

Revise 307.0 Stuttering Adult onset fluency disorder Add Excludes: childhood onset fluency disorder (315.35) Revise stuttering (fluency disorder) due to late effect of

cerebrovascular accident (438.14) Add fluency disorder in conditions classified elsewhere (784.52)

2011 ICD-9 Code ChangesCodes in Red are in Chapter 5, reimbursed at 55% vs. 80%

315 Specific delays in development

315.3 Developmental speech or language disorder New code 315.35 Childhood onset fluency disorder

Cluttering NOS Stuttering NOS

Excludes: adult onset fluency disorder (307.0) fluency disorder due to late effect of cerebrovascular

accident (438.14) fluency disorder in conditions classified elsewhere (784.52)

315.39 Other

Delete Excludes: stammering and stuttering (307.0)


337 Disorders of the autonomic nervous system

337.3 Autonomic dysreflexia Revise Use additional code to identify the cause, such as: fecal

impaction (560.32) 488 Influenza due to certain identified influenza viruses

488.0 Influenza due to identified avian influenza virus New code 488.09 Influenza due to identified avian influenza virus with other

manifestations

Avian influenza with involvement of gastrointestinal tract Encephalopathy due to identified avian influenza Excludes: "intestinal flu" [viral gastroenteritis] (008.8)


488.1 Influenza due to identified novel H1N1 influenza virus

New code 488.19 Influenza due to identified novel H1N1 influenza virus with other manifestations

Novel H1N1 influenza with involvement of gastrointestinal tract Encephalopathy due to identified novel H1N1 influenza Excludes: "intestinal flu" [viral gastroenteritis] (008.8)

721 Spondylosis and allied disorders

721.4 Thoracic or lumbar spondylosis with myelopathy 721.42 Lumbar region

Delete Spondylogenic compression of lumbar spinal cord


724 Other and unspecified disorders of back

724.0 Spinal stenosis, other than cervical Revise 724.02 Lumbar region, without neurogenic claudication

Add Lumbar region NOS

New code 724.03 Lumbar region, with neurogenic claudication

742 Other congenital anomalies of nervous system

742.8 Other specified anomalies of nervous system Revise Excludes: neurofibromatosis (237.70-237.79)


781 Symptoms involving nervous and musculoskeletal systems

Revise 781.8 Neurologic neglect syndrome

Add Excludes: visuospatial deficit (799.53)

New code V13.63 Personal history of (corrected) congenital malformations of nervous system

V49 Other conditions influencing health status

V49.8 Other specified conditions influencing health status New code V49.86 Do not resuscitate status


784 Symptoms involving head and neck

784.5 Other speech disturbance Revise Excludes: stammering and stuttering (315.35)

Delete that of nonorganic origin (307.0, 307.9)

New code 784.52 Fluency disorder in conditions classified elsewhere

Stuttering in conditions classified elsewhere Code first underlying disease or condition, such as:

Parkinson’s disease (332.0) Excludes: adult onset fluency disorder (307.0) childhood onset fluency disorder (315.35) fluency disorder due to late effect of cerebrovascular accident

(438.14)


799 Other ill-defined and unknown causes of morbidity and mortality

New Subcategory 799.5 Signs and symptoms involving cognition

Excludes: amnesia (780.93)

amnestic syndrome (294.0) attention deficit disorder (314.00-314.01) late effects of cerebrovascular disease (438) memory loss (780.93) mild cognitive impairment, so stated (331.83) specific problems in developmental delay (315.00-315.9) transient global amnesia (437.7) visuospatial neglect 781.8


799 Other ill-defined and unknown causes of morbidity and mortality

New code 799.51 Attention or concentration deficit

New code 799.52 Cognitive communication deficit

New code 799.53 Visuospatial deficit

New code 799.54 Psychomotor deficit

New code 799.55 Frontal lobe and executive function deficit

New code 799.59 Other signs and symptoms involving cognition


992 Effects of heat and light

992.0 Heat stroke and sunstroke Add Use additional code(s) to identify any associated complication of heat

stroke, such as:

Add alterations of consciousness (780.01-780.09)

Add systemic inflammatory response syndrome (995.93-995.94)

2011 Practice Expense (PE) Changes

• Second year of 4 year transition on PE methodology

– CMS is using results of 2009 AMA Physician Practice Information Survey

• www.ama-assn.org/go/ppisurvey

• Neurology $73 PE/hr, $127.21Total PE/hr; Overall increase 3%

• Neurosurgery $81 PE/hr, $132.52 Total PE/hr; Overall increase 2%

– Assume that imaging equipment such as CT and MRI are used 90% of the time instead of current 50%

– Other equipment remains at 50% usage for now

– Work defined as 150,000 minutes/year (48 hour work week)

http://www.ama-assn.org/go/ppisurvey

2011 MFS for Neurology Services**RVUs, excluding the conversion factor

• 95812, EEG 41-60 minutes– Total RVUs: 9.31, +28%

– Practice Expense: 8.16, 33%

– Professional: 1.60, +8%

– Physician Work (wRVU): 1.08, No change

• 95813, EEG > 1 hour– Total RVUs: 10.48, +21%





• 95816, Awake EEG– Total RVUs: 8.39, +26%




• 95819, Awake and Asleep EEG– Total RVUs: 9.62, +32%





• 95822, Sleep EEG– Total RVUs: 7.84, +33%

– Practice Expense: 7.22, +31%



• 95824, EEG for Brain Death– Total RVUs: 0.00, No change

– Practice Expense: 0.00, N/A




• 95827, Overnight EEG– Total RVUs: 16.52, +33%




• 95829, Surgery Electrocorticogram– Total RVUs: 44.12 +20%





• 95950, Ambulatory Cassette EEG– Total RVUs: 7.99, +18%




• 95951, 24 Hour Video EEG– Total RVUs: 0.00, *Carrier-defined technical expense

– Practice Expense: *Carrier-defined technical expense




Codes presented at RUC 04/2010 by M. Spanaki• 95953, 24 hour computerized digital EEG, unattended

– Total RVUs: 12.19, +6%

– Practice Expense: 7.56, +8.78%

– Professional: 4.63, 1.76%

– Physician Work (wRVU): 3.08

• 95956, 24 Hour attended EEG without video– Total RVUs: 29.82, 49.92%

– Practice Expense: 24.6, 57.19%

– Professional: 5.22, +23.11%



• 95954, EEG with administration of drugs– Total RVUs: 9.15, +26.56%

– Practice Expense: 5.8 RVUs, +41.12%

– Professional: 3.35 RVUs, 7.37%


• 95955, EEG during surgery– Total RVUs: 4.96, 25.89%





• 95957, EEG Digital Analysis– Total RVUs: 10.01, +27.68%


– Professional: 2.96 RVUs, 8.03%


• 95958, EEG monitoring, functional mapping (Wada Test)– Total RVUs: 13.39, 20.20%





• 95961, Electrode stimulation, brain, first hour– Total RVUs: 7.41, +16.88%


– Professional: 4.48 RVUs, +7.95%


• 95962, Electrode stimulation, brain, each additional hour– Total RVUs: 6.67, +14.21%

– Practice Expense: 1.8, +33.33%

– Professional: 4.79, +8.13%



• 95970, Analyze neurostimulator, no programming– Physician Work (wRVU): 0.45

• 95975, Cranial neurostimulation, complex analysis and programming– Physician Work (wRVU): 1.70

2009 AAN MEG Payment Policy

In 2008, AAN MEM Payment Policy Subcommittee decided to develop a model payment policy for MEG due to difficulties in getting MEG payments by insurers

– Saty Satya-Murti, William Sutherling, and Gregory L. Barkley wrote the policy

– Joel Kaufman, M.D. & Katie Kuechenmeister lead AAN efforts

– Passed by AAN Board of Directors on May 8, 2009

– Sent by AAN MEM to major insurance companies

– http://www.aan.com/globals/axon/assets/5641.pdf ACMEGS developed a similar policy in 2009

– Anto Bagic, Michael Funke, & John Ebersole wrote the policy

– JClinNeurophys 26 (4) p290-293, 2009 Model payment policy, letters, & meetings changed insurance

coverage by major providers

Secrets to success in dealing with insurance

companies Data, data, data, especially evidence-based The AAN & ACMEGS statements are referenced in the

MEG policy review. I am certain that the AAN MEG policy review was a crucial

piece of information in this change in policy

– Several of the points in the AAN payment policy statement are restated in the AETNA review

Personal Contacts and establishing relationships with the decision-makers were also key factors

CIGNA MEG Payment Policy #0248

For 12/15/2009 to 12/15/2010, “CIGNA does not cover magnetoencephalography (MEG) or magnetic source imaging (MSI) for any condition because they are considered experimental, investigational or unproven.”

The AAN MEM Payment Policy Subcommittee (PPS) met with CIGNA representatives in September 2010

CIGNA requested a letter regarding their policies AAN Response letter sent November 12, 2010 by

Joel Kaufman, Chair of AAN PPS CIGNA has not yet posted MEG policy for 2011

2011 Medicare MEG Medicare Fee Schedule

95965 Spontaneous MEG for epileptic spike mapping– 2011 Professional 12.34 Total RVUs (7.99 wRVUs)

• 2010 11.83 Total RVUs (+8.0%) Payment ?– 2011 Technical (APC 067) $3408.69 (-4.6 %)

95966 Evoked magnetic fields– 2011 Professional 6.16 Total RVUs (3.99 wRVUs)

2010 5.72 Total RVUs (+8,0 %) Payment ?– Technical (APC 066) $977.12

• 2010 $962.61 (+1.5 %) 95967 Each additional evoked magnetic field procedure

– 2011 Professional 5.34 Total RVUs (3.49 wRVUs)• 2010 4.92 Total RVUs (+9.0 %) Payment ?

– Technical (APC 066) $977.12• 2010 $962.61 (+1.5 %)

* When one procedure is performed with another, payment would be reduced by 50%

* Charges to private insurance are set by each laboratory and cannot be compared due to US antitrust (price-fixing) laws

MEG Practice Expense Payment Rate

The Affordable Care Act (ACA) requires that CMS establish the equipment utilization rate for CT, MR and PET at 75 percent. CMS had previously set the equipment utilization rate for this equipment at 90 percent, phasing in reduced payments over four years. This may result in changes to payment rates for CT and MR services.

May affect MEG technical pricing since MEG grouped in imaging APCs

2010 e-Prescribing

• PQRI revision for e-Rx

– For 2011, only have to report at least 25 uses of e-Rx to qualify for PQRI payment

– Failure to register for e-Rx in first half of 2011 and do not qualify for an exemption will face penalties in 2012.

– AAN has signed on to a letter of protest

– Physicians who participate in 2011 EHR cannot participate in e-Rx incentive program

PQRI (Physician Quality Reporting Initiative)

http://www.cms.hhs.gov/apps/media/press/factsheet.asp?

• AAN has developed 8 epilepsy measures lead by N. Fountain and P Van Ness

– Approved by AMA Physician's Consortium for Performance Improvement

– Currently under review by National Quality Forum (NQF)

– If NQF approves, then will be submitted to CMS for possible inclusion in the PQRI

– Being developed by AAN for Maintenance of Certification program as a module

CPT Medicare Payment Relative to Site of Services

Professional Component Technical Component

Inpatient Use -26 modifier; Paid to physician

Single DRG payment made to hospital to cover all technical expenses for that admission (IPPS)

Outpatient medical center (includes EDs)

Use -26 modifier; Paid to physician

APC payment made to medical center (HOPPS)

Outpatient, private office Global bill Submitted for professional and technical components

Paid to physician

Global bill Submitted for professional and technical components

Paid to physician

Mapping of Seizure/Epilepsy DRG

Documentation Principle Diagnosis

Secondary Diagnosis

MS DRG v25

Seizure, psychogenic

nonepileptic seizure,

spells

780.39 (other convulsions)

101 Sz w MCC

100 Sz w/o MCC

Recurrent seizures,

Epilepsy, Seizure

disorder

Specific epilepsies

345.8y(other recurrent seizures)

345.xy

101 Sz w MCC

100 Sz w/o MCC

Psychogenic

conversion disorder 300.11(Conversion disorder)

780.39 880 Acute Adjustment Reaction

2011 Hospital Outpatient Prospective Payment System (HOPPS)

Published 11/24/2010 – 782 pages in the Federal Register

– http://edocket.access.gpo.gov/2010/pdf/2010-27926.pdf

Payment for the technical portion of CPT codes done on Medicare Outpatients

Some outpatient procedures with HOPPS values have no payment assigned in MFS for doctors billing global

– 95951 24 hour video EEG is “carrier priced”

– 95965 MEG is “carrier priced”

Payment for technical portion of Medicare inpatients is bundled into a single DRG payment

Payment for technical fees in outpatients in private offices is in the Medicare Physician Fee Schedule

• Billing “global” in private offices

http://edocket.access.gpo.gov/2010/pdf/2010-27926.pdf

2011 HOPPS APC 0213

• APC 0213 Level 1 Sleep, EEG, and CV studies

– 95812 EEG 41-60 min

– 95812 EEG > 1 hour

– 95816 EEG awake and drowsy

– 95819 EEG awake and asleep

– 96822 EEG sleep and/or coma

– 95827 EEG all night recording

– 95958 EEG monitoring/function test

• 2010 APC rate is $162.06

• 2011 APC rate will be $166.64

• Increase of $4.62 or 2.83%

2011 HOPPS APC 0209

• APC 0209 Level II sleep, EEG, & CV

– 95950 ambulatory cassette EEG

– 95951 24 hour video EEG

– 95953 ambulatory digital EEG

– 95956 24 hour EEG without video

– MSLP and polysomnograms

• 2010 APC Rate is $770.55

• 2011 APC Rate will be $780.77


2011 HOPPS APC 218

• APC 218 Level II Nerve and Muscle Tests

– 95970 Neurostimulation, analysis with no programming

– 95954 EEG monitoring with drug administration

• 2010 payment is $80.65

• 2011 payment will be $80.78


2011 HOPPS APC 216

• APC 216 Level III Nerve and Muscle Tests

– 95961 Cortical Stimulation, 1st hour

– 95962 Cortical Stimulation, each additional hour

• 2010 payment is $180.86



2011 HOPPS APC 0692• APC 0692 Level III Electronic Analysis of Devices

– 95971 Analyze neurostim, simple

– 95972 Analyze neurostim, complex

– 95973 Analyze neurostim, complex

– 95974 Cranial neurostim, complex

– 95974 Cranial neurostim, complex

– 95978 Analyze neurostim brain, 1st hour

– 95979 Analyze neurostim brain, each 1 hour

– 95982 Low gain neurostim subseq w/ reprogram

• 2010 payment is $107.85



2011 MEG HOPPs Technical payments for MEG studies in hospital-

based outpatient care facilities–Does not apply to free standing MEG sites

• Carrier priced–Does not apply to MEG studies done on inpatients

• Technical fees bundled to DRG

2010 HOPPS APC 0067• APC 0065 Level III Stereotactic Radiosurgery, MRgFUS, and

MEG

– 95965 MEG, spontaneous

• 2010 payment is $3571.78

• 2011 payment is $3408.69

• Decrease of $163.09 or 4.57%

• Caught by the change in assumption of work hours for equipment costing more than $1 M. Decrease of $394.54 in past two years.

• New MEG cost reporting may help

– MEG and EEG were combined on Line 54 of the Medicare Cost Report

– Now MEG is moved to a new line, 54.01

2011 HOPPs APC 0065 Level I Stereotactic radiosurgery, MrgGUS, and MEG

– 95966 MEG Evoked Response

– 95967 Additional MEG Evoked Response 2010 payment is $962.61

2011 payment will be $977.12

Increase of $14.51 or 1.5%

Update on HFHS Transition to ICD-10 Coding SystemKickoff: December 9, 2010

Nov 18th , 2010

65

ICD-10-CM/PCS (Clinical Modification/Procedure Coding System)

• ICD-10-CM/PCS will enhance accurate payment for services rendered and facilitate evaluation of medical processes and outcomes.

• ICD-10-CM – The diagnosis classification system developed by the Centers for Disease Control and Prevention for use in all (inpatient and outpatient) U.S. health care treatment settings. Diagnosis coding under this system uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM

• ICD-10-PCS – The procedure classification system developed by the Centers for Medicare & Medicaid Services (CMS) for use in the U.S. for inpatient hospital settings ONLY. The new procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system uses 3 or 4 numeric digits.

• A number of other countries have already moved to ICD-10, including:– United Kingdom (1995);– France (1997);– Australia (1998);– Germany (2000); and– Canada (2001).

Final Rule: HHS published on Jan 2009 Compliance Date: October 1st, 2013

66

HIPAA X12 5010 Electronic Transaction Changes

• All HIPAA X12 Electronic Transactions with payors (e.g., eligibility verification, claims, remittance advise) have to be upgraded from current 4010 version to newer 5010 version

• This will enable payors to request more information in the future electronic transactions (adding extra lanes to electronic freeway system to carry more information)

• This change has to be operational by Jan 1 2012 and it is a pre-requisite for ICD 10 CM/PCS changes

67

ICD-9-CM - Shortcomings

• Shortcomings of ICD-9 include:– ICD-9 is outdated, with only a limited ability to accommodate new procedures

and diagnoses; – ICD-9 lacks the precision needed for a number of emerging uses such as pay-

for-performance and biosurveillance. Biosurveillance is the automated monitoring of information sources that may help in detecting an emerging epidemic, whether naturally occurring or as the result of bioterrorism;

– ICD-9 limits the precision of diagnosis-related groups (DRGs) as a result of very different procedures being grouped together in one code;

– ICD-9 lacks specificity and detail, uses terminology inconsistently, cannot capture new technology, and lacks codes for preventive services; and

– ICD-9 will eventually run out of space, particularly for procedure codes.

68

Expected Benefits from usage of ICD 10 codes

• Adoption of the ICD-10 code sets is expected to:

– Support value-based purchasing and Medicare’s anti-fraud and abuse activities by accurately defining services and providing specific diagnosis and treatment information;

– Support comprehensive reporting of quality data; – Ensure more accurate payments for new procedures, fewer rejected claims,

improved disease management, and harmonization of disease monitoring and reporting worldwide; and

– Allow the United States to compare its data with international data to track the incidence and spread of disease and treatment outcomes because the United States is one of the few developed countries not using ICD-10.

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Next Generation of Coding

S. No.

ICD-9-CM ICD-10-CM / PCS

1. Minimum of 3 digits, maximum of 5 digits, decimal point after the third digit

Minimum of 3 digits, maximum of 7 digits, decimal point after the third digit

2. Numeric, except for supplementary codes — V codes and E codes

Alphanumeric, with all codes using alphabetic lead character; V and E codes have been eliminated and incorporated into the main code set

3. Structure of injuries designated by wound type Structure of injuries designated by body part (location)

4. Diagnosis: 13,000 CodesIP Procedure: 4,000 Codes

67,000 ICD-10-CM Codes87,000 ICD-10-PCS Codes

Structural Changes

One to One: One old code to one new code . 3,458 codes or 24.52 % of all ICD-9 DX codes

Single Entry: One old code to one of many new code. 9,600 codes or 68.07 % of all ICD-9 DX codes

Combination Entry: One old code is split into multiple new code. 629 codes or 4.46 % of all ICD-9 DX codes

No Match: All new codes. 416 codes or 2.95 % of all ICD-9 DX codes

Mapping – ICD-9 To ICD-10

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Difference between ICD-9 and ICD-10 ICD-9-CM

Mechanical complication of other vascular device, implant and graft

1 code (996.1)

ICD-10-CMMechanical complication of other vascular grafts

156 codes, includingT82.310 – Breakdown (mechanical) of aortic (bifurcation) graft (replacement)

T82.311 – Breakdown (mechanical) of carotid arterial graft (bypass)

T82.312 – Breakdown (mechanical) of femoral arterial graft (bypass)

T82.318 – Breakdown (mechanical) of other vascular grafts

T82.319 – Breakdown (mechanical) of unspecified vascular grafts

T82.320 – Displacement of aortic (bifurcation) graft (replacement)

T82.321 – Displacement of carotid arterial graft (bypass)

T82.322 – Displacement of femoral arterial graft (bypass)

T82.328 – Displacement of other vascular grafts

ICD-9-CMAngioplasty

1 code (39.50)

ICD-10-PCSAngioplasty codes

854 codesSpecifying body part, approach, and device, including:

047K04Z – Dilation of right femoral artery withdrug-eluting intraluminal device, open approach

047K0DZ – Dilation of right femoral artery with intraluminal device, open approach

047K0ZZ – Dilation of right femoral artery, open approach

047K34Z – Dilation of right femoral artery with drug-eluting intraluminal device, percutaneous approach

047K3DZ – Dilation of right femoral artery with intraluminal device, percutaneous Approach

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ICD-10 Example

Fracture of wrist

• Patient fractures left wrist

• A month later, fractures right wrist

• ICD-9-CM does not identify left versus right (requires additional documentation to clarify during claim adjudication)

• ICD-10-CM describes left versus right, Initial encounter, subsequent encounter, routine healing, delayed healing, nonunion, or malunion

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Potential Risks of Transition to ICD10

• Training and Education – ICD10 codes are based on human anatomy and physiology will require significant mind set change for coders to get used to new system

• Business Process – Potential significant shift in roles and responsibilities between clinicians and coders to handle the complexity of ICD 10s

• Information Technology – Significant risk in modifications to several systems to accommodate new code sets

• Financial/Reimbursement – Transition from ICD 9 to ICD 10 can result into temporary delays in cash flow from payors due to technology implementation glitches

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ICD 10 Potential Impacts to HFMG Operations• Significant process changes in the areas of

documentation, coding and charge capture• May result in extensive training for Physicians,

Coders and other care-givers • MediPac revenue cycle systems will be modified to

address transition to ICD 10 • OMR and TCAP systems have to be replaced with

newer technology to handle the complexity and explosion of ICD 10 codes

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OMR Considerations

• HFMG Clinic Coding model: Physician Model enabled by branching technology logic (CAC) vs. Centralized Coder model

• Handheld devices with future integration with CarePlus(NG)/CPOE solution

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Phase 1 – Impact Assessment & Planning

• Develop project management structure• Engage Steering Committee and Business Unit Operational Teams• Assess Process Implications • Assess IT Systems impact • Create Multi-Year Capital and Expense budget to address the change

Phase 2 – Process Redesign and IT System Changes

• Process Redesign-Current and Future State• Detailed analysis, design and build of IT changes• Create testing plans to validate process redesign and IT system changes

HFHS ICD-10 Project Phasing

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Phase 3 – Testing and Implementation Planning• Internal Testing and Training• External Testing (Payors, Regulatory Reporting)• Operational Readiness and Implementation Planning

Phase 4 – End User Training and Go-Live

Phase 5 – Post Go-Live Support

• Finalize IT system changes and certify testing• Finalize process changes and certify operational readiness• Complete intensive coding professional education

• Monitor coding accuracy for reimbursement, coding productivity and continue with appropriate coding professional training

HFHS ICD-10 Project Phasing

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HFHS Project Phasing and Tentative Timeline

Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4Phase 1 - Impact Assessment & Planning

Phase 2 - Process Redesign and IT System Modifications

Phase 3- Testing and Implementation Planning

Phase 4- End User Training and Go-Live

Phase 5 - Post Go-Live Support

2011 2012 20132010

Jan 1, 2012 - Version 5010 EDI Transaction Compliance

Oct 1, 2013 ICD 10 Compliance

Key components of level of service

History

• Chief complaint (CC)• History of present illness (HPI)• Past medical, family, social history (PFSH)• Review of systems (ROS)

Examination • Neurological single system exam or general multi-system exam

MedicalDecisionMaking

• Number of diagnoses or number of management options• Complexity of data• Risk of morbidity and mortality

You Get Credit for Trying...

• Sometimes, you cannot do a full H & P no matter what

– Document your attempt and what happened

• History

– Patient aphasic, lethargic, in coma, won't answer, demented, etc.

• PE

– Patient aphasic, uncooperative, limb amputated, strict bedrest, etc.

• Do not write “unable to obtain”

• Forgetting one bullet point on a New Patient visit has major consequences in billing: drops to a level 1 visit

Tips for documenting history

• CC always required• ROS is very important

– must document pertinent positives, may be in HPI– “all other systems negative” permitted– ROS deficiency a major reason for not meeting criteria for

highest level of service

• ROS and PFSH – staff may record, and physician note– may use previous ROS and PFSH, revise

as needed

• If history not obtainable, document why

History of Present Illness (HPI)

1997 E &M Guidelines allow for the option of documenting the status/acuity of chronic problems and/or inactive problems to complete the History of Present Illness.

IMPORTANT: You must document the chronic or inactive problem that you are addressing during the visit and detail the current status/acuity of the problem

Documenting the neurological examination

• CPT™ defines 25 individual elements (“bullets”) of the neuro exam, in 4 main groups– constitutional, eyes, cardiovascular– higher integrative functions or mental status– cranial nerves– musculoskeletal, motor, and sensory

• CPT™ specifies the numbers of elements that must be documented for each level of service

• You must comment on these elements (“WNL” not acceptable)

Medical Decision Making (MDM)

Documentation Tips• Document the test(s) that you have reviewed (summarize what you

have reviewed) and ordered• Document discussing test(s) with the physician who performed the test.

For example discussing with the cardiologist the interpretation of an echocardiogram

• Document the review of old records. Remember you must summarize what you have reviewed.

• For Example: Patient was admitted a month ago for __________. Course of treatment included ____and patient was discharged with home health care and continue with _________.

IF IT IS NOT DOCUMENTED IT IS NOT DONE

Medical Decision Making (MDM)

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option. It can be broken down into three components. – Number of diagnoses or management options – Amount and complexity of data to review (Previous

documentation tips support this component)– Risk of complication and/or morbidity or mortality

2002 CMS Regulations on Supervision of Residents and Students

• Effective date November, 22, 2002• Resident means an individual who participates in an

approved graduate medical education (GME) program • Receiving a staff or faculty appointment or participating in a

fellowship does not by itself alter the status of “resident”. • A student is never considered to be an intern or a resident.

Medicare does not pay for any clinical service furnished by a student. (Medicare pays hospitals and medical schools large sums of money in other ways.)

Medicare Teaching Definitions

• Critical or key portion means that part (or parts) of a service that the teaching physician determines is (are) a critical or key portion(s).

• Documentation may be dictated and typed, hand-written or computer-generated, and typed or handwritten.

• Documentation must be dated and include a legible signature or identity.

Payment Definitions• For purposes of payment, E/M services billed by teaching

physicians require that they personally document at least the following:– a. That they performed the service or were physically present during

the key or critical portions of the service when performed by the resident; and

– b. The participation of the teaching physician in the management of the patient.

• When assigning codes to services billed by teaching physicians, reviewers will combine the documentation of both the resident and the teaching physician.

• Documentation for the service must support the medical necessity of the service.

Examples of Acceptable Notes

• “I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.”

• “I saw the patient with the resident and agree with the resident’s findings and plan.”

• “See resident’s note for details. I saw and evaluated the patient and agree with the resident’s finding and plans as written.”

• “I saw and evaluated the patient. Agree with resident’s note but lower extremities are weaker, now 3/5; MRI of L/S Spine today.”

Examples of Unacceptable Notes

• “Agree with above.”

• “Rounded, Reviewed, Agree”

• “Discussed with resident. Agree.”

• “Seen and agree.”

• “Patient seen and evaluated”

• A legible countersignature or identity alone.

E/M Service Documentation Provided By Students.

• Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing.

E/M Service Documentation Provided By Students.

• Students may document services in the medical record.• Documentation by a student that may be referred to by the

teaching physician is limited to the review of systems and/or past family/social history.

• The teaching physician may not refer to a student’s documentation of physical exam findings or medical decision making in his or her personal note.

• The teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.

DISCHARGE DAY

• On the day of discharge, code as follows:On the day of discharge, code as follows:– 99238 for a total staff time of 30 minutes or less99238 for a total staff time of 30 minutes or less

– 99239 for a total staff time of more than 30 minutes99239 for a total staff time of more than 30 minutes

• You must document the time spent in your noteYou must document the time spent in your note

– Time does not need to be continuousTime does not need to be continuous

– Time does not need to be spent with the patient Time does not need to be spent with the patient and includes:and includes:

• Writing RxWriting Rx

• Doing discharge summaryDoing discharge summary

• Making follow up arrangementsMaking follow up arrangements

• Contacting other providersContacting other providers

• Resident time does not countResident time does not count

AES 2010 Practice Management Course December 7, 2010 Gregory L. Barkley, M.D. Comprehensive Epilepsy...

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