MANAGING%20MEDICARE

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MANAGING MEDICARE
California Society of Pathologists
San Francisco,
California
December 4, 2009

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WE WILL DISCUSS

• National and Local Lab Policies
• Requesting Reconsiderations
• Referral Rules
• Enrollment PECOS
• Revalidation
• Reporting any Changes
• HIGLASSDecember Payment Changes
• On-Line Viewing of Claimssoon a reality
• Signature Rules
• Coverage for New Lab Tests
• National Versus Local Coverage
• Meet with CMDs Others
• Thoughts on Pricing Coding
• Time Factors for Decisions
• Some 2010 Reimbursement Changes
• Questions and answers

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NATIONAL COVERAGE DECISIONS

• National NCDs come from CMS
• Based on scientific studies data collected
• Presented often at MCAC-open meetings
• Notice and comment welcome
• Reconsiderations always possible
• NCDs cover entire country
• May specify services always covered
• May specify services never covered
• Published in CMS Coverage Manual
• May change as science changes, new studies
  emerge, or as laws change.

• Reconsiderations always possible

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NATIONAL COVERAGE DECISIONS

• Examples of NCDs (over 300 currently)
• Alpha-fetoprotein
• Collagen crosslinks, any method
• Cytogenic studies
• Digoxin therapeutic drug assay
• Fecal occult blood testing
• Genetic testing for warfarin
• HIV testing
• Prostate cancer screening tests
• Sweat test
• National Laboratory Coverage Determinations
  (23 currently)

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LOCAL COVERAGE DECISIONS

• Local LCDs from 1 or more states/areas
• Written by local CMDs about situations that are
  data based need control or instruction
• Presented at state CACs open to medical and
  specialty societies representatives
• Notice and comment always welcome
• Reconsiderations always possible
• LCDs cover a Medicare Jurisdiction (e.g., J-1)
• Discuss and describe medical necessity
• Usually give codes conditions for payment
• May state frequency of service and diagnoses and
  always published locally and nationally

• Reconsiderations always possible

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LOCAL COVERAGE DECISIONS

• Example of J-1 LCDs (Currently 80 B LCDs)
• Category III codes temporary or tracking
• Cytogenic studies
• Free PSA
• Mammaprint
• Oncologic in-vitro chemoresponse assays
• Oncotype DX
• Flow cytometry and immunohistochemistry (article)
  soon to be policy
• Some Part A LCDs may also apply
• Local articles may also specify lab use or
  instruct in billing/coding

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FINDING LCDs NCDs

• www.cms.hhs.gov/MCD/overview.asp
• Click indexes from left box
• Click national or local coverage
• For local coverage, click LCDs by contractor (We
  are MACsPart A or Part B---Palmetto)
• For articles, we are MACs---Part A or Part
  B---Palmetto

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REQUESTING LCD RECONSIDERATIONS

• Send in writing to local Contractor
• Specific address for reconsiderations on our web
  site
• Specific address of CMDs
• Add supporting scientific evidence
• Literature in peer reviewed journals
• Expert opinion from credible sources
• Guidelines/statements from specialty societies
• Results of medium or long term studies
• Be specific in requests
• CPT, ICD-9, organ systems or special
  circumstances
• Be conscious of vested interests
• Contractor must respond in 30 days to valid
  reconsideration requests

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ORDERING-REFERRING DOCS

• MD Clin. Nurse Specialist
• DO Clin. Psychologist
• Dental Surgery Nurse Midwife
• Dental Medicine Clin. Social Worker
• Podiartist Nurse Practitioner
• Optometrist Chiropractor
• Physician Assistant

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ORDERING PHYSICIANS

• Claims ordered / referred must
• NPI of ordering provider
• Name in PECOS or MAC system
• Specialty as listed
• Grace Period
• Phase 1 10/5/09 to 3/31/10 warning message on
  remittance
• Phase2 4/01/10 and after claim rejected if
  referring individual not in Pecos or MAC list

4/01/10 and after
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OTHER ENROLLMENT

• Revalidation of older physicians not in PECOS
• Revalidation of some labs
• Need to update any changes within 30 days
• Address, phone, suite
• New members in group
• Other changes
• If no claims to Medicare in one yearphysician is
  disenrolled in Medicare

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HIGLASS-FINANCIAL CHANGE

• Healthcare Integrated General Ledger Accounting
  System (HIGLASS)
• Change CMS accounting system
• More accurate, timely, consistent payments
• More CMS direct oversight
• Dec. 9th Payment floor to 0
• All claims approved are paid
• Dec. 14 Payment floor returns
• 14 days for electronic claims
• 28 days for paper claims

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CHANGE IN
CHANGE IN PAYMENT FLOOR
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ON-LINE CLAIMS MANAGEMENT

• On-line provider service
• Claims status
• Eligibility status
• Remittance Status
• Financial Status
• In real time, updated daily
• Must have EDI enrollment agreement signed with
  Palmetto

Available Soon
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ON-LINE CLAIMS MANAGEMENT

• Register on OPS home page

• Get user ID and Password
• Answer security question

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ON-LINE CLAIMS MANAGEMENT

• Log in

• Claim status claim status, claim lines
• Remits online list of remits, e-remits
• Eligibility Inquiry, deductibles, caps, MSP,
  more
• Financial Tools payment floor, cash flow, more
• Administration control who can use tool

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SIGNATURES

•  
• Handwritten signatures or initials
• Must be legible
• Electronic signatures 
• Digitized- an electronic image of an individuals
  handwritten signature reproduced in its identical
  form using a pen tablet
• Electronic signatures usually contain date
  timestamps and include printed statements, e.g.,
  'electronically signed by,' or 'verified/
  reviewed by,' followed by physicians name
  preferably a professional designation.  Note The
  responsibility and authorship related to the
  signature should be clearly defined in the record
  
• Digital signature - an electronic method of a
  written signature typically generated by
  encrypted software that allows for sole usage

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SIGNATURES

• Chart 'Accepted By' with providers name
• 'Electronically signed by' with providers name
• 'Verified by' with providers name
• 'Reviewed by' with providers name
• 'Released by' with providers name
• 'Signed by' with providers name
• 'Signed before import by' with providers name
• 'Signed John Smith, M.D.' with providers name
  
• Digitalized signature Handwritten scanned into
  the compute.
• 'This is an electronically verified report by
  John Smith, M.D.'
• 'Authenticated by John Smith, M.D.'
• 'Authorized by John Smith, M.D.'
• 'Digital Signature John Smith, M.D.'
• 'Confirmed by' with providers name
• 'Closed by' with providers name
• 'Finalized by' with providers name
• 'Electronically approved by' with providers name

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Unacceptable Signatures

• See unacceptable signature examples
• 'Signing physician' when provider's name is
  typedExample Signing physician
  ______________________                           
                            John Smith, M.D.
• 'Confirmed by' when a provider's name is
  typedExample Confirmed by _____________________
  _                                                
      John Smith, M.D.
• 'Signed by' provider's name typed and the signing
  line above, but done as part as the
  transcription.
• 'This document has been electronically signed in
  the surgery department' with no provider name.
• 'Dictated by' when provider's name is
  typedExample Dictated by  _____________________
  _                                              Jo
  hn Smith, M.D.
• Signature stamp
• 'Signature On File'

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SIGNATURES WHAT WE FIND

• Illegible, unrecognizable handwritten signatures
  or initials
• Unsigned typewritten progress notes with a
  typed name only
• Unverified or unauthorized electronic signatures
• No indication of the rendering physician/practitio
  ner
• Required for all labs, progress notes, orders and
  the like

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IF SIGNATURE IS AN ILLEGIBLE SCRAWL

• Have an official signature page with name and
  signature OR
• Send an attestation statement certifying that
  physician saw patient and wrote note on that date

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MAC OVERVIEW-15 AREAS

• 15 MACs, 4 DMACs, 4RHHIs
• Companies may have gt 1MAC
• MAC may have gt1 CMD
• CMDs work together
• Within MACs
• Within Companies
• Across MACs
• Within CMS Committees, Workgroups
• Many MAC Contracts in Dispute

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NATIONAL VS LOCAL LAB COVERAGE

• Advantages
• Policies, coverage, coding and pricing same
  everywhere
• More publicity, fewer local hassles
• More likely private insurance accepts
• Disadvantages of National
• Requires more evidence, studies
• Longer time frame for acceptance
• Usually requires FDA clearance
• Increased marketing costs required
• Access across all states/territories when lab not
  large enough for tests

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NATIONAL VS LOCAL COVERAGE

• Advantages of Local
• Home brew possible, without FDA approval needed
• Quicker, less intensive reviews
• Easier to convince CMDs
• Can select areas for introduction
• Can use 1-2 MACs to influence others
• Disadvantages of Local
• Less uniform coding, coverage, pricing
• Variation in payment, acceptance
• Private insurance may not go along
• Have to repeat work with each MAC

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MEETING WITH LOCAL CMD

• CMDs are very busy
• Policies, articles, coverage
• Med Review and chart adjudication
• Education, outreach to societies / groups
• Contact with CMS other organizations
• Most CMDs will find time for meeting
• In Person office, hotel, other location
• Telephone, Web, etc. may be more efficient
• Time is always a consideration
• Send info, data, literature in advance
• Allows CMDs to be prepared, shortens meeting,
  allows quicker resolution
• Must fit between CMDs travel, outreach,
  teleconferences with CMS and home office

• Send info, data, literature in advance

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MEETING WITH LOCAL CMD

• Show us the data
• Published peer reviewed data
• Statistically significant differences
• Demonstrate effect on patient diagnosis or
  patient therapy
• Bottom Line
• Does it work affect patient care
• Sensitivity, specificity related
• Outcomes for patients
• Cost (and more important pricing)

- Demonstrate effect on patient diagnosis or
patient therapy
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HELP US WITH PRICING

• Show us the pricing
• Prefer single pricing vs code stacking
• Reality versus imagination
• What is included in pricing
• What should not be included
• Can it be cross walked to existing CPT codes
• Easier to determine prices
• May use NOC codes at first to describe its use
• Remember least costly alternative situations

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SELECTING CPT CODES

• Stacking codes problematic
• Dont define test to us
• May give inaccurate prices--- too high or too low
• Use NOC code (e.g. 84999)
• Use with name of test (e.g. WonderTest)
• We can assign specific price
• We can follow use of test for policy
• Less confusing for ordering MD
• We can consider development costs or small
  quantity costs

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LONGER TERM CODING

• Real CPT Code Helps Define Test
• Can take years
• Usually associated with national coverage and
  national pricing
• Consider HCPCS or Category III
• HCPCS comes from CMS
• Category III easy to obtain
• Allows national tracking of data
• Can allow for payment also
• Category III can progress to regular CPT
• Consider Coverage With Evidence Development
• Obtained from CMS

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GENETIC TESTING

• Consider the science
• Same proof science as other tests
• Same clinical validity
• Same peer reviewed data
• Consider the ethics
• Who gets tested
• Under what circumstances
• When tests done
• Consider the costs
• Once per lifetime?

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GENETIC TESTING

• Consider if the test is screening- not covered
• Each screening test requires new law from
  Congress
• When is screening not screening but disease
  management gray area
• Future CMS legal issues dealing with genetic
  testing

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OTHER ASPECTS OF NEW TESTS

• Coverage for a new test (service) may be
  positively influenced by
• Requests from physicians in practice
• Clinical society white papers or guidelines
• Technical Advisory Committees
• Other Medicare MACs or insurers
• Coverage for a new test (service) may be
  negatively influenced by
• Over-marketing by manufacturer
• Inadequate data with spin by consultants
• Ridiculous pricing demands
• Use of stacking codes when other coding more
  appropriate

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TIME FACTORS FOR DECISIONS

• Review (re-review) literature
• Discuss with staff
• Review other Contractors for like policies
• Add as article 3-6 weeks
• Includes code decision, price decision
• Claims personnel education
• Formal Policy due to restrictions of use or
  diagnoses 3-6 months
• Write review policy
• Draft on web for public review
• CAC and open meetings required
• Open for comments from anyone
• Notice of final policy before effect date

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Welcome to The ACP Advocate

• Our second story, as promised, is an analysis of
  the Medicare Fee Schedule for next year. ACPs
  Advocacy Web Site also has answers to your
  frequently asked questions about the new rule.
  While the new schedule is considered final, we
  still expect that Congress will step in to stop
  the 21 percent overall fee cut that is supposed
  to start Jan. 1.  On Thursday afternoon, the
  House passed H.R. 3961, a bill that would fix the
  problems in Medicare payments caused by the
  sustainable growth rate formula. If they manage
  to work with the Senate to pass similar
  legislation, this would provide a fix for not
  only the 21 percent cut it would pave the way
  for the long-term fix weve been waiting for.

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MAJOR PRICING CHANGES 2010

• PPIS (AMA Physician Practice Information Survey)
  data
• Change in utilization rate
• ???Medicare Consultations eliminated some other
  CPT changes
• 5 year review of malpractice RVUs
• Implementation of MIPPA provisions
• Not many changes for routine lab

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PPIS SURVEY FOR PRACTICE EXPENSE INFORMATION

• PPIS is multispecialty survey of physicians and
  NPPs
• Used consistent survey instrument
• 3,656 across 51 specialties and professional
  groups
• New survey conducted by AMA
• Expanded to include NPPs
• CMS purchased updated specialty specific PE / hr
  data for PE RVUs
• Most consistent source of practice expense survey
  information to date

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PPIS SURVEY FOR PE

• PPIS data has effects of redistribution with
  negative aspects to some groups
• Cardiology
• Radiology
• Oncology
• Urology
• Positive aspects for primary care
• PPIS data transitioned over 4 years
• Supplemental survey data also used
• Clinical labs
• IDTFs
• Oncology and Drug Administration

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WINNERS AND LOSERS
CHANGES FOR 2010
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From Federal Register
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(No Transcript)
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(No Transcript)
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CMS ACTION (not final) from AMA Meeting

• Eliminated use of all consultation codes (except
  for telehealth consult G-codes).
• Increased work RVUs for new established office
  visits
• Increased work RVUs for initial hospital and
  initial nursing facility visits
• Incorporated the increased use of these visits
  into PE and malpractice RVU calculations.
• Increased incremental work RVUs for EM codes
  built into the 10-day and 90-day global surgical
  codes.

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CONSULTATION Decision not Final

• Per AMA-CPT Meeting Consultations no longer
  reimbursed for Medicare
• Effective 1-1-10 unless rules change
• Regular initial EM codes for initial inpatient
  hospital nursing facilities
• Regular follow up codes for hosp / SNF-NF
• Regular office initial follow up codes
• Principal physician of record uses a modifier to
  be listed
• CPT still lists consult codes for non-Medicare
  patients

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QUESTIONS