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Breaking the Code on the Codes

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DO CPT CODES WORK? INDUSTRY HAS NO VOICE IN THE PROCESS. THE PUBLIC HAS NO VOICE ... CHANGING DESCRIPTION OF A CODE. GENERIC/COMPOUNDING SUBSTITUTION. PRICING ' ... – PowerPoint PPT presentation

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Title: Breaking the Code on the Codes


1
Breaking the Code on the Codes
Grant P. Bagley, M.D., J.D.
March 27, 2007
2
2007
CMS WILL ADOPT A FAIR AND USEFUL CODING SYSTEM
3
THE WORLD OF CODES
CODES ARE NOT NEW CODES ARE SOMETIMES
MYSTERIOUS CODES ARE VITAL
4
WHICH ONE IS THE BIGGER MYSTERY?
Or IS IT Really?
HCPCS
5
OUR UNIVERSAL MESSAGE TO OTHERS IN SPACE
GOLD PLATE WITH A MESSAGE FOR OTHERS SENT
INTO SPACE BY NASA OUR UNIVERSAL CONCEPTS--WHAT
ARE THEY SAYING?
6
THE REAL QUESTION IN OUR WORLD
I WONDER IF OTHER CIVILIZATIONS CAN GET A HCPCS
CODE FROM THEIR WORK GROUP
NO IM SURE ITS JUST A LAW OF NATURE FOR
HCPCS TO REFUSE
7
THE WORLD OF CODES
  • DRGs
  • APCs
  • ICD9
  • CPT
  • HCPCS

8
THE MEDICARE VISION OF CODES
For Medicare and other health insurance programs
to ensure that these claims are processed in an
orderly and consistent manner, standardized
coding systems are essential.
9
CPT CODES IN PARTICULAR
Decisions regarding the addition, deletion, or
revision of CPT codes are made by the AMA.
10
WHAT IS THE ROLE FOR CMS IN CODE DEFINITION?
11
DO CPT CODES WORK?
  • INDUSTRY HAS NO VOICE IN THE PROCESS
  • THE PUBLIC HAS NO VOICE IN THE PROCESS
  • CONTROLLED BY THIRD PARTY PAYERS
  • IN SPITE OF HIPPA--NO UNIFORMITY
  • Medicare contractors and insurers change code
    definitions and applications at will
  • CMS exercises little or no oversight

12
HCPCS LEVEL II CODES
  • FOR DEVICES
  • FOR SUPPLIES
  • FOR UNIQUE MEDICARE PURPOSES
  • DRUGS/BIOLOGICS

13
THE HCPCS DECISION TREE
14
CRITERIA FOR A NEW CODE
  • EVIDENCE OF IMPROVED OUTCOMES
  • PEER REVIEWED LITERATURE
  • COMPARATIVE STUDIES
  • NOT CLEARLY DEFINED

15
A DIFFERENT APPROACH FOR THE SAME SERVICE
REQUIRES LITTLE EVIDENCE BUT THE SAME CODE
16
DO I NEED MORE EVIDENCE OR A LOWER COST TO GET A
CODE?
E V I D E N C E
COST TO THE PROGRAM
17
ITEMS THAT PERFORM THE SAME FUNCTION MUST USE THE
SAME CODE UNLESS THEY HAVE PROOF OF IMPROVED
OUTCOMES
18
The MEDICARE Policy Dilemma
WHO WILL PROTECT THE TRUST FUND?
CODING
PAYMENT
COVERAGE
19
POLICIES IN CODE CLOTHING
  • SHARING OF A CODE (REFERENCE PRICING)
  • DENIAL OF A CODE
  • CHANGING DESCRIPTION OF A CODE
  • GENERIC/COMPOUNDING SUBSTITUTION
  • PRICING
  • EXPERIMENTAL/INVESTIGATIONAL DETERMINATION

20
WHO WILL PROTECT THE TRUST FUND FROM THE WOLF?
21
EVIDENCE BASED MEDICINE
WHAT DOES IT PROMISE US?
22
FORMULATE THE QUESTION
23
THE ANSWER FROM MEDICARE PERSPECTIVE---
24
THE MEDICARE TRUST FUND UNDER ATTACK
25
THE FIRST CMS GROUP SAID WE WILL PROTECT THE
TRUST FUND WITH COVERAGE POLICIES.
AND THE WOLF DID STUDIES, HAD THEM PUBLISHED
AND APPLIED FOR AN NCD.
26
THE SECOND CMS GROUP SAID, WE WILL PROTECT THE
TRUST FUND WITH A FEE SCHEDULE.
AND THE WOLF DEVELOPED COMMENTS TO THE
PROPOSED FEE SCHEDULE AND THE FINAL RULE WAS OK.
27
BUT THE CLEVER THIRD GROUP SAID WE WILL PROTECT
THE TRUST FUND WITH A HOUSE MADE OF CODES
WE WILL MAKE THIS HOUSE FROM STRONG CODES-- HCPCS
CODES, CPT CODES, ICD9 CODES, J CODES K
CODES, C CODES, XYZ CODES AND SO THEY DID.
28
AND THE WOLF CAME TO THE CODE HOUSE
AND THERE WAS NOTHING THE WOLF COULD DO
BECAUSE THERE WAS NO APPEAL PROCESS OR WAY THAT
HE COULD PARTICIPATE IN CODES.
29
(No Transcript)
30
THE CODE STRUCTURE CREATED BY CMS IS OUTMODED,
AND SHOULD BE CHANGED.
31
THE FACT THAT IT CAN GET DOWN THE ROAD IS NOT A
GOOD REASON TO KEEP IT.
32
THE EXISTING HCPCS CODE SET
  • IS POORLY MANAGED AND MAINTAINED
  • SERVES TO HIDE OTHER POLICY AGENDAS
  • IS HOSTILE TO NEW TECHNOLOGY
  • LACKS ADEQUATE COORDINATION
  • FAILS TO SERVE THE NEEDS OF PUBLIC HEALTH
  • FAILS TO MEET THE NEEDS OF OTHER AGENCIES
  • FAILS TO SERVE THE NEEDS OF HOMELAND SECURITY
  • FAILS TO MEET THE NEEDS OF MEDICA RESEARCH
  • IS UNRESPONSIVE TO QUALITY IMPROVEMENT
  • CONTROLLED BY PAYERS ONLY

33
Dclawap
34
WHAT NEEDS TO BE DONE
  • USE MODERN TECHNOLOGY
  • MAKE CODING AS SPECIFIC AS POSSIBLE
  • PROVIDE A BASIS FOR INFORMATION ABOUT OUTCOMES
  • INVOLVE ALL STAKEHOLDERS
  • Public
  • Industry
  • Providers
  • Payers
  • Government
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