Xact%20Medicare%20Services

1
(No Transcript)
2

• MAC Jurisdiction-12 Contractor Advisory
  Committee (CAC) Meetings
• February 11-13, 2009

3
AGENDA

• Welcome and Introductions
• J-12 Contractor Update
• Medical Affairs Review
• Contractor Advisory Committee
• Roles, Composition, Survey, Schedule
• Discussion of Draft LCDs
• Old Business / New Business
• Q A

4

Contact Information

• Andrew Bloschichak, MD, MBA
• VP Clinical Affairs
• 717-302-4198 (office)
• 717-302-4165 (fax)andrew.bloschichak_at_
• highmarkmedicareservices.com

5

Contact Information

• Paula Bonino, MD, MPE
• Contractor Medical Director
• 412-544-1931 (office)
• 412-544-1971 (fax)
• paula.bonino_at_
• highmarkmedicareservices.com

6

Contact Information

• Eileen M. Moynihan, M.D., FACR, FACP
• Contractor Medical Director
• 856-857-5257 (office)
• 717-302-4165 (fax)
• eileen.moynihan_at_
• highmarkmedicareservices.com

7

• Highmark Medicare Services
• J-12
• Contractor Update

8
Transition Update

• All transitions completed as of 12-12-08
• Largest Jurisdiction in country
• Approximately 4.2 M Medicare beneficiaries
• 137,350 physicians and healthcare professionals
• 433 Hospitals
• 131 Million claims per year (11 of Natl
  volume)
• 31.5 Billion/year in healthcare payments
• Current Operational Metrics

9
Claims Processing Part A
CMS Standard 95
CPT
10
Claims Processing Part B
CMS Standard 95
CPT
11
Provider Contact Center Part A
Call Completion Rate
of Completion
CMS Standard 80 Call Completion Rate
12
Provider Contact Center Part B
Call Completion Rate
of Completion
CMS Standard 80 Call Completion Rate
13
Provider Contact Center Part A
ASA
CMS Standard 60 seconds/call
Seconds/Call
14
Provider Contact Center Part B
ASA
CMS Standard 60 seconds/call
Seconds/Call
15
Redeterminations
within 60 days
16
Enrollment Part A (January 2009)
Timeliness
CMS Standard 80
17
Enrollment Part B (January 2009)
Timeliness
CMS Standard 80
18

• Highmark Medicare Services
• J-12
• Medical Affairs Update

19
Local Coverage Decisions

• Local Coverage Decisions implement the SSA
  1862(a)(1)(A) requirement of Reasonable and
  Necessary through
• Analysis of scientific evidence
• Refinement and input from a diverse body of
  clinicians (CAC)
• Use of Community Standard of Practice via
  clinicians and data
• Application to individual claim determinations

20
LCD Development Process

• LCDs will be developed, in keeping with CMS
  directives
• A validated widespread problem
• a significant risk to the Medicare trust fund
  (high dollar and/or high volume services)
• Assuring beneficiary access to care
• Frequent denials issued or anticipated
• Multi-state contractor creating uniform LCDs
  across its jurisdiction
• CERT findings

21
Local Coverage Decisions

• LCDs set coverage for ALL Medicare programs in
  the state
• PLUS Medicare used as template by many other
  payors
• All LCDs (and drafts) on contractor Web Site
• Can comment on web, via CAC, to CMDs directly, at
  Open session

22
Local Coverage Decisions (LCDs)

• Draft LCDs sent out to CAC and posted on website
  to allow 45 days for comment
• Interested parties can comment directly, through
  website, at Open Session.
• After final policy published, allow 45 days
  notification until implementation
• Draft policy comments and responses posted on
  website
• All then posted on CMS national LCD database
  (www.cms.hhs.gov/coverage)

23
C0ntractor Advisory Committee

• One CAC per state
• Meets 3-4 times per year, no more than 4 months
  apart
• Purpose
• Formal mechanism for participation in development
  of ALL LCDs in advisory capacity
• Mechanism to discuss administrative policies
• Forum for information exchange

24
C A C

• CAC is not a forum for peer review, discussion of
  individual cases, or individual providers
• Not a forum for specific billing issues or
  individual interests
• Reviews and comments on ALL drafts, but final
  implementation rests with CMD

25
MAC LCDs and CAC

• Local Coverage Determinations (Medical Policies)
• 57 Policies for MAC start
• Had full comment period prior to finalization
• LCDs, Comments Responses Posted on our Website
• Date of Service Sensitive by Segment Cutover Date
• In the absence of an NCD/LCD services must be
  RN per SSA
• National Coverage Determinations
• Coding Articles - PET Scans BMM Immunizations
• Jurisdiction Advisory Committee / Contractor
  Advisory Committee
• Statewide Membership A/B Combined 3/year
• Survey recently sent to members of record
• Updated rosters and contact information

26
CAC Surveys

• 231 Responses received !
• Prefer 3 meetings/year Feb June Oct cycle
  for all locales
• Maintain state specific membership and meetings
  (but almost 2/3 in favor of at least 1 CAC/yr as
  combined)
• Meeting times
• PA Weekday mornings
• NJ Weekday morning (afternoon close 2nd)
• Del Weekday evening
• MD Weekday evening
• DCMA Weekday morning (evening close 2nd)

27
CAC Surveys

• Prefer option to attend any CAC of choice if
  schedule demands
• In favor of CAC meetings via teleconference
• YES 58
• NO 41
• Many comments in favor of one teleconference/year,
  however not all CACs via teleconference as find
  face-to-face meetings important

28
Upcoming CAC Meetings

• Second Thursday of Feb-June-Oct as anchor
• Separate Meetings for each Locale Week of June
  10-12
• Planning for combined meeting for all J-12
  October 9/10

29

• COMPREHENSIVE ERROR RATE TESTING
• (CERT)
• PROGRAM

30
Comprehensive Error Rate Testing (CERT) Program

• GPRA established in mid 90s
• Managed by CMS with outside contractor, Advance
  Med
• Data obtained by specialty, procedures, locale
• Major driver of
• Medical Review
• LCD Development
• Physician/Provider Outreach and Education

31
Comprehensive Error Rate Testing (CERT) Program

• CERT Documentation Office requests records from
  billing provider of record
• AdvanceMed performs complex medical review using
  NCDs, CMS coding policies, each contractors LCDs
  and articles
• Contractors must recover overpayments and pay
  underpayments on claims with errors determined
  by AdvanceMed
• Physicians / providers can appeal such findings
• Contractors are tasked with implementing various
  interventions to reduce the Error rate
• Highmark Medicare Services and CMS website quite
  extensive in CERT information (www.cms.hhs.gov/cer
  t)

32
Table 3b National Error Rates by Year Table 3b National Error Rates by Year Table 3b National Error Rates by Year Table 3b National Error Rates by Year Table 3b National Error Rates by Year Table 3b National Error Rates by Year Table 3b National Error Rates by Year Table 3b National Error Rates by Year
Year Total Dollars Paid Overpayments Overpayments Underpayments Underpayments Overpayments Underpayments Overpayments Underpayments
Year Total Dollars Paid Payment Rate Payment Rate Improper Payments Rate
1996 168.1 B 23.5B 14.00 0.3 B 0.20 23.8 B 14.20
1997 177.9 B 20.6B 11.60 0.3 B 0.20 20.9 B 11.80
1998 177.0 B 13.8B 7.80 1.2 B 0.60 14.9 B 8.40
1999 168.9 B 14.0B 8.30 0.5 B 0.30 14.5 B 8.60
2000 174.6 B 14.1B 8.10 2.3 B 1.30 16.4 B 9.40
2001 191.3 B 14.4B 7.50 2.4 B 1.30 16.8 B 8.80
2002 212.8 B 15.2B 7.10 1.9 B 0.90 17.1 B 8.00
2003 199.1 B 20.5B 10.30 0.9 B 0.50 12.7 B 6.40
2004 213.5 B 20.8B 9.70 0.9 B 0.40 21.7 B 10.10
2005 234.1 B 11.2 B 4.80 0.9 B 0.40 12.1 B 5.20
2006 246.8 B 9.8 B 4.00 1.0 B 0.40 10.8 B 4.40
33
Error Rates by Specialty
  Error Rate Projected Improper Payment Amount
General Practice 22.20 212,369,460
Pulmonary Disease 19.30 291,337,094
Chiropractic 15.30 92,309,814
Geriatric Medicine 11.80 9,822,684
Emergency Medicine 10.70 180,887,379
Psychiatry 10.70 81,500,712
Physical Med and Rehab 8.90 53,141,230
Internal Medicine 7.60 601,424,011
Gastroenterology 7.30 98,157,283
General Surgery 6.60 115,182,292
Family Practice 6.40 253,401,309
Cardiology 5.10 325,652,570
All Specialties/providers 5.00 3,678,057,770
34
Error Rates by Specialty (cont.)
All Specialties/providers 5.00 3,678,057,770
Orthopedic Surgery 4.40 114,135,388
Vascular Surgery 4.40 19,939,498
Urology 4.20 72,463,458
Nurse Practitioner 4.00 20,061,954
Pain Management 3.80 5,493,295
Allergy/Immunology 2.80 4,726,848
Hematology/Oncology 2.40 92,340,993
Anesthesiology 2.10 27,066,376
Ophthalmology 1.80 65,405,586
Diagnostic Radiology 1.40 59,245,685
Radiation Oncology 0.70 7,834,567
Ambulatory Surgical Center 0.20 3,582,286
35
CMS May 07 CERT Report Part B
36
J-12 Part B CERT
37
J-12 Part A CERT
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
Part B CERT Drivers

• Our Informatics and CERT Team is able to
  determine CERT Drivers (within statistically
  significant groupings) for our Jurisdiction by
• County
• Specialty / Provider Type
• Procedure Codes and Betos Groups
• This information is utilized to focus our
  interventions and monitor effectiveness

48
Part B CERT Drivers

• Evaluation and Management Services
• Consultations (esp. inpatient Level IV/V)
• Subsequent Office Visits (esp. 99214)
• Hospital Visits , including Discharge (time
  separates 99238-99239)
• Therapies
• PT / OT
• Chiropractic Services
• Diagnostic Studies (-26) need Interpretation and
  Report
• New Issue - Date of Service and Physician
  Orders!

49
MEDICAL REVIEW

• Medical Review / Progressive Corrective Action
  (PCA) is DATA DRIVEN (but not data determined)
• Data includes CERT, Medicare utilization in many
  statistical analyses
• Notice of Medical Review
• Provider notified via ADR Additional
  Documentation Request
• If based on comparative data, data is provided
• Reviews can be provider-specific or
  service-specific (procedure code driven)
• Most common provider-specific reviews of recent
  years are Pre-pay Probes which consists of
  20-30 claim sample reviewed BEFORE payment made

50
MEDICAL REVIEW

• Documentation is not only required, but is
  essential for fair and accurate review
• Providers have 30 days to respond
• Service denied as not RN if no doc after 45
  days
• Unfortunately in many PCA efforts we do not
  receive any documentation 30 of the time!!
• Contractors have 60 days from receipt of records
  to complete review
• Depending on outcome of Probe and at risk, can
  lead to full Pre-Pay review

51
(No Transcript)
52
(No Transcript)
53
(No Transcript)
54
EMs

• Based on EM Documentation Guidelines per AMA and
  CMS (1995/1997)
• EM Scoresheet and dedicated webpage on web
• Computer-based modules with CME credit on
  website
• HMS POE staff very able and willing to conduct
  learning workshops

55
Consultations

• Effective January 1, 2006, per AMA CPT
• 99251 99255 Initial inpatient consultation for
  new or established patient
• 99241 99245 Office (or other Outpatient)
  consultation for new or established patient
• Can use TIME if documentation meets time
  requirements
• Need
• Request Reason - Report
• LCD requirements (Expertise and/or specific
  patient knowledge)
• Appropriate documentation for level of care
• Requires all 3 components of History, Exam, and
  Medical Decision Making

56
CONSULTATIONS

• Need History Exam AND Medical Decision-Making
  (or Time reporting requirements)
• NPPs may Request or Perform Consults ( within
  scope of practice, expertise)
• Split-Sharing of Consults is NOT allowed as of
  1-1-2006 per CMS instruction
• Standing consults are not covered by Medicare
• For ongoing management, report as subsequent
  visits

57
Prevention Gap
Covered Service Medicare Utilization
Pap Test and Pelvic Exam 36
Prostate Cancer Screening 54
Screening Mammograms 54
Pneumococcal Shot 65
Flu Shots 68
Cardiovascular screenings 82
58
(No Transcript)
59
Medicare Part B Preventative Services
60
Medicare Part B Preventative Services
61
Medicare Part B Preventative Services
62
Medicare Part B Preventative Services
63
(No Transcript)
64

• REVIEW OF DRAFT LCDs

65
Conflict of Interest

• The opportunity to influence a policy and/or
  decision, either directly or indirectly, through
  ones membership on the Committee, which allows
  for personal gain.

66
Conflict of Interest

• CAC acknowledges that members represent their
  specific specialties and clinical practice, and
  will be speaking on behalf of that
  specialty/practice. To that extent, any inherent
  benefit as such is not considered a conflict of
  interest.

67
Conflict of Interest

• CAC members are asked to divulge any
  significant financial interest, as defined as
  ownership interest of 5 or more in companies
  (other than their clinical practice), which stand
  to benefit from Medicare policy decisions, prior
  to providing comments regarding specific
  policies.

68
Draft Local Coverage Determinations (LCDs)

• DL 27499Intraoperative Neurophysiological
  Testing
• DL 27530Sleep Disorders Testing
• DL 29544Posterior Tibial Nerve Stimulation
• DL 29547EMG and Nerve Conduction Studies

69
DL 27530 Sleep Disorders Testing

• Updated LCD to address
• Repeat testing criteria for PSG
• Coverage criteria for Home Sleep Testing
• Clarify specific covered indications for PSG, HST
  for OSA and CPAP
• HST emerging with CMS mandate for coverage of
  CPAP based on Dx of OSA by HST

70
DL 27530 Sleep Disorders Testing

• LCD updated in keeping with
• CMS HST instructions
• DMERC CPAP coverage Guidelines
• American Academy of Sleep Medicine Clinical
  Guidelines for Use of Unattended Portable
  Monitors in Dx of OSA (specifically physician
  performing PC)
• Other contractor LCDs

71
DL 27530 Sleep Disorders Testing

• No change to documentation guidelines
• Significant updates to ICD-9 covered indications
  to include
• Expansion of coverage for 95807-95810
• Allowing limited coverage for 95806 and
  G0398-G0400
• CAC Comments..

72
LCD DL27499 IntraoperativeNeurophysiological
Testing

• Updated policy for emerging/expanding service
  initially distributed 04/01/08
• Data often showed monitoring of ten or more cases
  at a time
• Many diagnoses did not seem to support medical
  necessity
• Many inquiries about who could perform

73
LCD DL27499 IntraoperativeNeurophysiological
Testing

• Many inquiries and issues about location of the
  performing provider
• Many inquiries about type of equipment to be used
• Needed to add ICD 9 CM codes to match the
  narrative diagnoses for ease of processing
• CAC comments

74
LCD DL29547 Electromyography (EMG) and Nerve
Conduction Studies

• Components of testing in segregated policies in
  the past. Difficult to pull all components
  together in one policy without JAC comments
• Clarify what constitutes valid studies under the
  CPT codes of the policy.
• Specify guidance for performance and billing of
  nerve conduction studies due to previously high
  utilization

75
LCD DL29547 Electromyography (EMG) and Nerve
Conduction Studies

• Followed AAEM guidelines regarding number of
  studies
• CAC Comments.

76
DL29544 Posterior Tibial Nerve Stimulation (PTNS)

• This procedure involves percutaneous (or
  transcutaneous) peripheral stimulation of the
  posterior tibial nerve.
• It has been under study for the treatment of
  pelvic floor dysfunction manifesting in a variety
  of clinical problems such as urinary frequency,
  urgency, incontinence or retention bowel
  dysfunction and/or pelvic pain.
• This procedure came to our attention through a
  provider inquiry about proper coding and through
  CMS Contractor Medical Director Workgroup
  discussions.

77
Posterior Tibial Nerve Stimulation Procedure /
Methods

• While studies vary in the protocols used,
  generally a 34 gauge needle is placed
  percutaneously above the medial malleolus, into
  the tibial nerve, with a surface electrode on the
  foot. A stimulator delivers a low voltage
  electrical impulse.
• Most papers report sessions of 30 minutes of
  treatment weekly for 10 to 12 weeks.
  Continuation beyond the initial treatment is
  highly variable, and little published experience
  is available.
• What is available shows a rapid loss of
  improvement when treatment is stopped. Most use
  for the duration, every 3 to 4 weeks. One small
  study demonstrated about a 3 month window before
  loss of effect.

78
Posterior Tibial Nerve Stimulation Hypotheses

• The mechanism of action is not known, but some of
  the hypothetical bases are as follows
• The posterior tibial nerve is a mixed
  sensory-motor nerve whose fibers originate from
  spinal roots L4 through S3.
• PTNS inhibits bladder activity by depolarizing
  somatic sacral and lumbar afferent fibers.
  Afferent stimulation provides central inhibition
  of the preganglionic bladder motor neurons.
  Stimulation of the large somatic fibers could
  modulate / inhibit the thinner afferent A-delta
  or C fibres, decreasing the perception of
  urgency.
• Neurochemical changes and changes to blood flow
  have been hypothesized.

79
Posterior Tibial Nerve Stimulation Hypotheses

• Activation of endorphin pathways within the
  spinal cord could affect detrusor behavior
• Most of the discussion has focused on the role of
  neuromodulation of the sacral nervous outflow
  tract
• Neuromodulation helps restore the balance between
  inhibitory and excitatory impulses that govern
  bladder function
• The minimally invasive method for
  neuromodulation may address drawbacks of
  implantation of sacral neurostimulator, including
  the need for re-operation (up to 30) migration
  of neural leads, etc.

80
Posterior Tibial Nerve Stimulation Clinical
Considerations for Medicare Patients, Esp.
Elderly

• Urinary incontinence is a common and disabling
  problem associated with isolation, embarrassment,
  other illnesses (e.g., infection, decubiti), and
  loss of independent living need more and better
  prevention and treatment options
• Often multifactorial drugs, drug interactions
• Consider practical realities of treatment
  delivery
• Diabetes and other peripheral neuropathy
• Peripheral edema, CHF
• Cardiovascular disease patient on
  anticoagulation
• Visual impairment
• Arthritis hands, hips, etc. positioning and
  performing, mobility
• Cognitive impairment, dementia
• BPH, prostate CA

81
Posterior Tibial Nerve Stimulation Regulatory
Considerations

• Related NCDs
• 160.2 Treatment of Motor Function Disorders with
  Electric Nerve Stimulation Not covered, with
  some exceptions
• 160.7 Electrical Nerve Stimulators Peripheral
  and Central, for chronic intractable pain
  criteria for coverage discussed
• 160.7.1 Assessing Patients Suitability for
  Electrical Nerve Stimulation Therapy for pain
  TENS and PENS discussed
• 230.8 Non-Implantable Pelvic Floor Electrical
  Stimulator covered for stress and/or urge
  urinary incontinence with specific criteria
  (usually delivered by vaginal or anal probes,
  external pulse generator)

82
Posterior Tibial Nerve Stimulation Regulatory
Considerations, Data

• 230.15 Electrical Continence Aid Not covered
  (device placed in anal canal, portable generator
  stimulates anal musculature)
• 230.16 Bladder Stimulators (Pacemakers) Not
  covered (implanted electrodes, current causes
  contractions)
• 230.18 Sacral Nerve Stimulation for Urinary
  Incontinence Covered for urinary urge
  incontinence, urgency-frequency syndrome, and
  urinary retention. Test stimulation, then
  permanent implantation. Specific inclusion and
  exclusion criteria discussed.
• Data on next slide NOC code claims review
  showed almost all of the services were not PTNS,
  but rather neurosurgical services very little
  current use in J12 region per claims

83
(No Transcript)
84
Posterior Tibial Nerve StimulationPublished
Research Findings

• Small numbers various etiologies and problems
  mixed prior history of treatment and length /
  type of symptoms
• No control groups, unable to assess placebo
  effect methods vary in amount of current
  applied, frequency and length of treatments (not
  directly comparable)
• Almost all do not reflect the Medicare
  population, except perhaps the disabled
• No randomized controlled studies or studies of
  sufficient sample size and power
• Some investigators receive support from the study
  sponsor

85
Posterior Tibial Nerve StimulationPublished
Research Findings

• Misattributed effects of urodynamic testing
  itself as evidence of success of procedure
• Some report an intention-to-treat analysis,
  others do not evaluate dropouts.
• Definitions of success or improvement also vary
  not directly comparable
• Modest statistical findings clinical relevance?
  
• Other Medicare Contractors who have LCDs
  Non-coverage at this time

86
Posterior Tibial Nerve Stimulation

• Alternatives are available, all with pros and
  cons meds, surgical, behavioral, multiple
  interventions for multifactorial problem
• On the horizon implanted electrode in
  posterior tibial nerve, externally placed
  radiofrequency generator self-administered.
• Promising work, currently experimental /
  investigational for the Medicare population,
  therefore not reasonable and necessary
  (non-covered).
• Discussion

87
(No Transcript)
88
Upcoming CAC Meetings

• Second Thursday of Feb-June-Oct as anchor
• Separate Meetings for each Locale Week of June
  10-12
• Planning for combined meeting for all J-12
  October 9/10

89

• CAC DISCUSSION
• OLD BUSINESS
• NEW BUSINESS

90

• The Future Aint What It Used To Be
• Yogi

91
(No Transcript)