AMERICAN OSTEOPATHIC ASSOCIATION - PowerPoint PPT Presentation


Title: AMERICAN OSTEOPATHIC ASSOCIATION


1
AMERICAN OSTEOPATHIC ASSOCIATION
  • 5010 Data Standard, ICD-10-CM/PSC, Osteopathic
    Manipulative Treatment and Medicare
  • December 3, 2011
  • DIVISION OF
  • SOCIOECONOMIC AFFAIRS

2
Socioeconomic Affairs Staff
  • Yolanda Doss, MJ, RHIA,
  • Director, Division of Socioeconomic Affairs
  • Sandra Peter, MHA
  • Assistant Director, Clinical Practice Outreach
  • Michele Campbell, CPC,
  • Coding Reimbursement Specialist
  • Kavin Williams, CPC, CCP
  • Health Reimbursement Policy Specialist

3
Yolanda Doss, MJ, RHIA
  • Responsibilities include
  • Helping to secure reimbursement for osteopathic
    services
  • Securing the acceptance of osteopathic
    credentials
  • Addressing Medicare issues
  • HIPAA compliance
  • Fraud and Abuse

4
Sandra Peters, MHA
  • Responsibilities include
  • Develop educational material on physician
    advocacy, manage care, quality and performance
    measures impacting osteopathic medicine
  • Design and manage a set of member services to
    enhance their manage care interactions and to
    promote their opportunities to participate in
    manage care
  • Provide update to the AOA leadership on health
    care trends particularly in the areas of pay for
    performance and physician profiling

5
Kavin T. Williams, CPC, CCP
  • Responsibilities include
  • Assists AOA members with reimbursement and health
    payment policies.
  • Oversees and assists AOA members with coding and
    payment disputes with carriers.
  • Oversees the AOA Coding and Reimbursement
    Advisory Panel.
  • Represents the AOA at national reimbursement
    policy meetings.

6
Are you ready for ICD 10 and the HIPAA 5010 Data
Standard?
  • Objectives
  • To educate physicians on the ICD 10 and HIPAA
    5010 implementation compliance dates
  • To educate physicians on the  impact the new
    coding sets will have on the current
    reimbursement and coding structure
  •  

7
The Transition to HIPAA 5010
  • Have you heard of the HIPAA 5010 Data Standard?
  • Have you begun testing?
  • Will you be ready for January 1, 2012?

8
Background of HIPAA 5010 Data Standard
  • The current version of the standards
    (4010/4010A1) are identified as lacking certain
    functionality for health care needs
  • Version 5010 will accommodate the ICD 10 codes

9
Mark Your Calendars
  • Important dates for 5010 Implementation
  • January 1, 2011-begin external testing of the
    5010 version for electronic claims
  • December 31, 2011-to be at level II compliance
    external testing of the 5010 for electronic
    claims must be completed
  • January 1, 2012 All electronic claims must use
    Version 5010. Version 4010 claims will no longer
    be accepted

10
Getting Started
  • Now is the time.
  • Testing should be conducted both internally and
    externally with current business partners
  • Internal testing of version 5010 should have been
    completed by December 31, 2010
  • External should be completed by December 31, 2011

11
Getting Started
  • Testing early will allow you to identify any
    potential issues, and address them in advance
  • As HIPAA covered entity, CMS has to ensure that
    its business processes, systems , policies and
    those of ist contractors, providers, health
    plans, etc. are compliant with HIPAA

12
Pitfalls
  • Lack of testing with your vendors, clearing
    houses, insurers to ensure that you can accept
    and send transactions is probably the top barrier
    to success
  • Cost
  • Timing (deadlines)

13
Summarize
  • Implementation date to be compliant for the 5010
    HIPAA Data transaction is January 1, 2012
  • If you have not begun testing the time is NOW!!
  • Contact your vendors to inquire/schedule your
    internal and external testing

14
Vendor Model Letter
  • Dear Vendor (Clearinghouse, EMR system, Medicare,
    private payers)
  •  
  • My (name of practice)________________ uses your
    ___________________ product/services, version
    ___________. As ICD-10-CM implementation
    approaches, we would like some information and
    clarification about your plans to upgrade your
    systems.
  •  
  • Specifically, we would like to know your plans
    for updating software to comply with HIPAA
    transactions.  Can you provide a timetable for
    the following.
  •  
  • When will you be installing upgrades and will
    there be a charge for this data?
  •  
  • Will my practice need additional hardware or
    support services to install the upgrade(s)?
  •  
  • Thank you in advance for complying with and your
    prompt attention to this request. 
  •  
  • Sincerely,
  •  

15
ICD-10-CM/PCS
16
History
  • The International Classification of Diseases,
    Tenth Revision, Clinical Modification (ICD-10-CM)
    is the United States' clinical modification to
    the World Health Organizations (WHO)
    International Classification of Diseases, Tenth
    Revision (ICD-10). ICD-10 was adopted by the
    World Health Assembly in 1990. Following the
    publication of ICD-10, a number of countries
    performed an analysis to determine if the WHO
    classification would meet their needs given the
    changes to the roles of ICD since the ninth
    revision.

17
History
  • The United States remains the only industrialized
    nation that has not yet implemented ICD-10 (or a
    clinical modification) for morbidity, meaning
    diseases or causes of illness typically coded in
    a healthcare facility. Since 1999, however, the
    US has used ICD-10 for mortality reporting the
    coding of death certificates (typically done by a
    vital statistics office, not the healthcare
    facility). Implementing ICD-10-CM will maintain
    data comparability internationally and between
    mortality and morbidity data in the U.S.

18
Development
  • In 1994 under the leadership of the National
    Center for Health Statistics (NCHS), the United
    States began their process of determining whether
    an ICD-10 modification should be developed. NCHS
    awarded a contract to the Center for Health
    Policy Studies to decide if a clinical
    modification was necessary. A Technical Advisory
    Panel (TAP) was formed and their recommendation
    was to create a clinical modification. In 1997,
    the entire draft of the Tabular List of ICD-10-CM
    and the preliminary crosswalk between ICD-9-CM
    and ICD-10-CM were made available on the NCHS
    website for public comments. The public comment
    period ran from December 1997 through February
    1998. Since that time revisions were based on
    further study and the comments submitted. Draft
    versions of ICD-10-CM were made available in
    2002, 2007, 2009, 2010, and 2011. Limited code
    updates will continue to occur to this draft
    prior to implementation of ICD-10-CM.

19
Development
  • While ICD-10 provides many more categories for
    diseases and other health-related conditions than
    previous revisions, the clinical modifications
    thus far to ICD-10 offer a higher level of
    specificity by including separate codes for
    laterality and additional character and
    extensions for expanded detail. In addition,
    other changes included combining etiology and
    manifestations, poisoning and external cause, or
    diagnosis and symptoms into a single code.
    ICD-10-CM also provides code titles and language
    that complement accepted clinical practice.
    ICD-10-CM codes have the potential to reveal more
    about quality of care, so that data can be used
    in a more meaningful way to better understand
    complications, better design clinically robust
    algorithms and better track the outcomes of care.
    ICD-10-CM incorporates greater specificity and
    clinical detail to provide information for
    clinical decision making and outcome research.

20
ICD 10
  • Implementation date is October 1, 2013
  • Benefits of ICD 10
  • Have you started preparation for ICD 10?
  • How do I get started?
  • How do I find the necessary resource information?

21
Benefits of ICD 10
  • The Benefits of ICD-10-CM
  • ICD-10-CM incorporates much greater clinical
    detail and specificity than ICD-9-CM. Terminology
    and disease classification have been updated to
    be consistent with current clinical practice. The
    modern classification system will provide much
    better data needed for
  • Measuring the quality, safety, and efficacy of
    care
  • Reducing the need for attachments to explain the
    patients condition
  • Designing payment systems and processing claims
    for reimbursement
  • Conducting research, epidemiological studies,
    and clinical trials

22
Benefits of ICD 10
  • Setting health policy
  • Operational and strategic planning
  • Designing health care delivery systems
  • Monitoring resource utilization
  • Improving clinical, financial, and
    administrative performance
  • Preventing and detecting health care fraud and
    abuse and
  • Tracking public health and risks.
  • Non-specific codes still exist for use when the
    medical record documentation does not support a
    more specific code

23
ICD 9 vs ICD 10
  • Here are some SIMILARITIES AND DIFFERENCES
    BETWEEN THE TWO CODING SYSTEMS
  • ICD-10-CM uses 37 alpha and numeric digits and
    full code titles, but the format is very much the
    same as ICD-9-CM (e.g., ICD-10-CM has the same
    hierarchical structure as ICD-9-CM).
  • The 7th character in ICD-10-CM is used in several
    chapters (e.g., the Obstetrics, Injury,
    Musculoskeletal, and External Cause chapters). It
    has a different meaning depending on the section
    where it is being used (e.g., in the Injury and
    External Cause sections, the 7th character
    classifies an initial encounter, subsequent
    encounter, or sequelae (late effect)).

24
Similarities Differences contd
  • Primarily, changes in ICD-10-CM are in its
    organization and structure, code composition and
    level of detail

25
ICD-9-CM
  • 35 digits
  • First digit is alpha (E or V) or numeric (alpha
    characters are not case sensitive)
  • Digits 25 are numeric and
  • Decimal is used after third character.
  • Examples
  • 496 Chronic airway obstruction, not elsewhere
    classified (NEC)
  • 511.9 Unspecified pleural effusion and
  • V02.61 Hepatitis B carrier.

26
ICD-10-CM
  • 37 digits
  • Digit 1 is alpha Digit 2 is numeric
  • Digits 37 are alpha or numeric (alpha
    characters are not case sensitive) and
  • Decimal is used after third character.
  • Examples
  • A78 Q fever
  • A69.21 Meningitis due to Lyme disease and
  • S52.131A Displaced fracture of neck of right
    radius, initial encounter for closed fracture.

27
What will change?
  • Coding
  • Code set will increase from 17,000 to 140,000
    therefore the code books and styles will
    completely change ( both ICD 10-Cm and ICD
    10-PCS)
  • Clinical knowledge-Coders may need to be
    reeducated on anatomy and physiology
  • All staff who handle coding, from the front
    office staff to the practice manager

28
Additional Changes
  • Laterality ( left, right, bilateral)
  • For example
  • C50.511- Malignant neoplasm of lower-outer
    quadrant of right female breast
  • H16.013- Central corneal ulcer, bilateral
  • L89.012- Pressure ulcer of right elbow, stage II

29
Changes Contd
  • Combination codes for certain conditions and
    common associated symptoms and manifestations
  • Example
  • K57.21-Diverticulitis of large intestine with
    perforation and abscess with bleeding
  • E11.341- Type 2 diabetes mellitus with severe
    nonproliferative diabetic retinopathy with
    macular edema

30
Changes Contd
  • Combination codes for poisonings and their
    associated external cause
  • Example
  • T42.3x25-Poisoning by barbiturates, intentional
    self-harm, sequela. (The x character is used as
    a 5th character placeholder in certain 6
    character codes to allow for future expansion and
    to fill in other empty characters (e.g, character
    5 and/or 6) when a code that is less than 6
    characters in length requires a seventh character

31
Changes Contd
  • Example
  • T45.1x5A-Adverse effect of calcium-channel
    blockers, initial encounter
  • T15.02XD-Foreign body in cornea, left eye,
    subsequent encounter
  • Inclusion of clinical concepts that do not exist
    currently in ICD-9-CM (e.g., underdosing, blood
    type, blood type, blood alcohol level)

32
Changes contd
  • Example
  • T45.526D-Underdosing of antithrombotic drugs,
    subsequent encounter
  • Z67.40-Blood alcohol level of 120-199 mg/100mL
  • Expansion of codes
  • Example-E10.610-Type 1 diabetes mellitus with
    diabetic neuropathic arthropathy

33
Other changes in ICD 10
  • Injuries are grouped by anatomical site as
    opposed to type of injury
  • Category restructuring and code reorganization
    have occurred in a number of ICD-10-CM chapters
    resulting in the classification of certain
    diseases and disorders that are different from
    ICD -9-CM

34
Other changes contd
  • Certain diseases have been reclassified to
    different chapters or sections in order to
    reflect current medical knowledge
  • New code definitions
  • Example-Acute Myocardial Infarction is now 4
    weeks rather than 8 weeks
  • ICD-9-CM V codes (factors influencing health
    status and contact with health services) and E
    codes( External Causes of Injury and Poisoning)
    are incorporated in the main classification as
    opposed to being separated into supplementary
    classifications as they do currently in ICD-9-CM

35
Documentation Is the Center Piece for Successful
Reporting of ICD-10 Diagnosis Codes
36
Why get started now
  • Due to the potential significant financial and
    clinical impact ICD-10 and the changes required
    for transition to the information systems that
    are being mandated, physicians should be taking
    steps now to understand how to successfully
    prepare for ICD-10

37
ICD-10
  • Coding and billing systems will need to be
    updated to support the new code set
  • Currently the code set has 3-5 digits and ICD-10
    will increase to 5-7 digits
  • Documentation will be impacted severely which
    will cause a domino effect from productivity to
    increased claims delays

38
Steps to take to get started
  • 2. Understand the potential impact this will
    have on physicians practice
  • Financial How much will this transition cost a
    practice (training, software, etc)
  • Productivity How significant will this be for a
    practices bottom line and for how long?
  • Education-what is needed and for whom is it
    needed (coders, billers, front office staff, lab
    personnel, etc)

39
Quiz
  • True or false? V and E codes are supplemental
    classifications in ICD-10-CM.
  • True or false? In ICD-10-CM, injuries are
    grouped by anatomical site rather than injury
    category.
  • What is the maximum number of characters in
    ICD-10-CM?
  • How many chapters does ICD-10-CM contain?
  • True or false? The first modification to ICD-10
    was published in 2001
  • True or false? The final rule, published in the
    Federal Register naming ICD-10-CM as a new
    medical code set standard to replace the ICD-9-CM
    diagnosis codes, sets October 1, 2013 as the
    implementation for ICD-10.
  • True or false? ICD-10-CM uses extensions in some
    sections to identify an initial encounter,
    subsequent encounter or sequelae.
  • Which letter of the alphabet is not utilized in
    ICD-10-CM?
  • The first character of an ICD-10-CM code is
    always an alphabetic letter.

40
Osteopathic Manipulative Treatment (OMT)
  • Reporting of OMT Services
  • E/M
  • Modifier-25
  • Documentation
  • Compensatory Changes
  • OMT Survey

41
Osteopathic Manipulative Treatment (OMT)1-2 Body
Regions Involved
42
Vignette
  • A 25 yr. old female presents with right lower
    neck pain of two weeks duration. Somatic
    dysfunction of cervical and thoracic regions are
    identified on exam.

43
Description of Pre-Service Work
  • The physician determines which osteopathic
    techniques (eg, HVLA, Muscle energy,
    Counterstrain, articulatory, etc) would be most
    appropriate for this patient, in what order the
    affected body regions need to be treated and
    whether those body regions should be treated with
    specific segmental or general technique
    approaches. The physician explains the intended
    procedure to the patient, answers any preliminary
    questions, and obtains verbal consent for the
    OMT. The patient is placed in the appropriate
    potion on the treatment table for the initial
    technique and region(s) to be treated.

44
Description of Intra-Service Work
  • Patient is initially in the supine position on
    the treatment table. Motion restrictions of C6
    and C7 are isolated through palpation and treated
    using muscle energy technique. Dysfunctions of T1
    and T2 are treated using passive thrust (HVLA)
    technique. Patient position is changed as
    necessary for treatment of the individual somatic
    dysfunctions. Patient feedback and palpatory
    changes guide further technique application as
    appropriate.

45
Description of Post-Service Work
  • Post-care instructions related to the procedure
    are given, including side effects, treatment
    reactions, self-care, and follow-up. The
    procedure is documented in the medical record

46
Osteopathic manipulative treatment (OMT) 9-10
body regions involved
47
Vignette
  • A 40 year old male presents with sub-occipital
    headache, and pain in the neck, upper and lower
    back, left shoulder and chest, and right ankle.
    He was involved in a rear-end MVA two weeks ago.
    X-rays in the ED were negative. He has been
    taking prescribed analgesic and muscle relaxant
    medications with minimal improvement. On
    examination, somatic dysfunction is identified at
    the occipitoatlantal, left glenohumeral and right
    tibiotalar joints, as well as the cervical,
    thoracic, costal, lumbar, sacral and pelvic
    regions.

48
Description of Pre-Service Work
  • The physician determines which osteopathic
    techniques (eg, HVLA, Muscle energy,
    Counterstrain, articulatory, etc) would be most
    appropriate for this patient, in what order the
    affected body regions need to be treated and
    whether those body regions should be treated with
    specific segmental or general technique
    approaches. The physician explains the intended
    procedure to the patient, answers any preliminary
    questions, and obtains verbal consent for the
    OMT. The patient is placed in the appropriate
    position on the treatment table for the initial
    technique and region(s) to be treated.

49
Description of Intra-Service Work
  • Patient is initially in the supine position on
    the treatment table. Motion restrictions of
    identified joints are isolated through palpation
    and treated using a variety of techniques as
    follows occipitoatlantal joint and sacrum are
    treated using muscle energy and counterstain
    techniques right glenohumeral joint and pelvis
    are treated with articulatory technique lumbar,
    thoracic, cervical and right ankle are treated
    with passive thrust (HVLA) technique costal
    dysfunctions are treated using muscle energy
    technique. Patient position is changed as
    necessary for treatment of the individual somatic
    dysfunctions. Patient feedback and palpatory
    changes guide selection of further technique
    application as appropriate.

50
Description of Post-Service Work
  • Post-care instructions related to the procedure
    are given, including side effects, treatment
    reactions, self-care, and follow-up. The
    procedure is documented in the medical record

51
OMT RVUs
  • 2011
  • 2012
  • 98925 0.45
  • 98926 0.65
  • 98927 0.87
  • 98928 1.03
  • 98929 1.19
  • Conversion Factor 33.9764
  • 98925 0.46
  • 98926 0.71
  • 98927 0.96
  • 98928 1.21
  • 98929 1.46
  • Conversion Factor 24.6712

52
Medicare
53
The Objective is to Provide Informationon the
Following Topics
  • Medicare 2012 Updates
  • Evaluation Management
  • Medicare Audits
  • Recovery Audit Contractors (RAC)
  • Incident To Services

54
Medicare 2012 Updates
  • Physician Fee Schedule is facing a 27.4 percent
    reduction
  • Physician Quality Reporting Initiative (PQRI)
    Bonus Payment 2
  • E-Prescribing Bonus Payment 2
  • OMT Survey

55
Physician Documentation
  • This is critical to your reimbursement
  • If it was not documented it did not happen
  • Clear and Legible, words to document by
  • Chief complaint (this is the driver to most
    insurance auditors)
  • Familiarize yourself with your documentation
    style- is it 1995 guidelines that you follow or
    1997?

56
Documentation Guidelines
  • The medical record should be complete and
    legible.
  • The documentation of each patient encounter
    should include
  • reason for the encounter and relevant history,
    physical examination findings and prior
    diagnostic test results
  • assessment, clinical impression or diagnosis
  • plan for care

57
Documentation Guidelines Cont.
  • The patients progress, response to and changes
    in treatment, and revisions of diagnosis should
    be documented.
  • The CPT and ICD-9-CM codes reported on the health
    insurance claim form or billing statement should
    be supported by the documentation in the medical
    record.
  • Hospital visits should be included in the
    patients chart

58
Evaluation Management (E/M) Coding
  • Coding for office visits
  • Modifier usage when billing an E/M with a
    procedure (OMT)
  • Time Based Coding

59
Chief Complaint (CC)
  • The chief complaint is a concise statement
    describing the symptom, problem, condition,
    diagnosis, physician recommended return, or other
    factors that is the reason for the encounter,
    usually stated in the patients own words.
  • Documentation Guidelines states that the medical
    record should clearly reflect the chief complaint

60
Medical Necessity
  • This area is not black/white
  • There are numerous definitions of medical
    necessity
  • Linking the appropriate diagnosis to the
    appropriate procedure to support the necessity of
    the procedure performed is critical.
  • Medicare defines medical necessity as services or
    items reasonable and necessary for the diagnosis
    or treatment of illness or injury to improve the
    functioning of a malformed body member.

61
Coding For Time
  • When is it appropriate to code for time?
  • What is the auditor looking for when they review
    a chart that was billed as time being the
    controlling factor?

62
Tips For Verbiage When Billing For Time
  • Example of correct documentation of time
  • In your note it should read I spent 45 minutes
    with the patient and over 50 of that time was
    spent discussing
  • Example of incorrect documentation of time
  • I spent 45 minutes with the patient, discussed
    surgical options versus medical management.

63
How Would Code This Date of Service
64
What Is An Audit?
  • An effective tool used by Medicare and other
    payors to recover monies lost to fraud and
    erroneous billings.

65
Why Audits Are Initiated?
  • Suspicion (Billing Pattern)
  • Outlier Physicians
  • The Senior Patrol
  • Whistleblowers
  • Procedure Codes

66
Who Are The Auditors?
  • The Office of the Inspector General (OIG)
  • Medicare
  • The Department of Justice (DOJ)
  • The Federal Bureau of Investigation (FBI)
  • Carriers

67
Types of Audits
  • Prepayment Audits
  • Post-Payment Audits
  • Statistical Sampling Method

68
What Auditors Look For?
  • Billing for services or supplies that were not
    provided.
  • Billing for non-allowable or non-covered
    services.
  • Altering claim forms to receive a higher payment
    amount.
  • Unbundling claims.

69
How To Respond To A Request For Documentation
  • Reply to the audit notice in a timely fashion.
  • Gather and submit Only the requested
    documentation.
  • Be cooperative.
  • You may want to conduct an internal audit.

70
How to Respond to the Audit Findings
  • If the findings are not favorable
  • Attempt to discuss the findings with the
    reviewer.
  • If necessary request redetermination.
  • If necessary request a level one appeal.

71
Medicare Recovery AuditContractors (RACs)
71
72
RAC Legislation
  • The RAC program was created by the Medicare
    Prescription Drug, Improvement, and Modernization
    Act of 2003 which pays incentive fees to
    third-party auditors that identify and correct
    improper payments paid to healthcare providers in
    fee-for-service Medicare.
  • The Medicare Prescription Drug, Improvement, and
    Modernization Act of 2003 also requires permanent
    and nationwide RAC program by no later than 2010

72
73
The RAC Demonstration Project
  • The RAC demonstration project took place of New
    York, Florida, and California.
  • By 2010 the RAC covered all 50 states.

74
RAC Program Mission
  • To detect and correct past improper payments,
  • To implement actions that will prevent future
    improper payments.
  • Providers can avoid submitting claims that dont
    comply with Medicare rules
  • CMS can lower its error rate
  • Taxpayers future Medicare beneficiaries are
    protected

74
75
The New RACs Are
  • Diversified Collection Services, Inc. of
    Livermore, California, in Region A, initially
    working in Maine, New Hampshire, Vermont,
    Massachusetts, Rhode Island and New York.
  • CGI Technologies and Solutions, Inc. of Fairfax,
    Virginia, in Region B, initially working in
    Michigan, Indiana and Minnesota.
  • Connolly Consulting Associates, Inc. of Wilton,
    Connecticut, in Region C, initially working in
    South Carolina, Florida, Colorado and New Mexico.
  • HealthDataInsights, Inc. of Las Vegas, Nevada, in
    Region D, initially working in Montana, Wyoming,
    North Dakota, South Dakota, Utah and Arizona.
  • Additional states will be added to each
    RAC region in 2009

76
Minimize Provider Burden
  • Limit the RAC look back period to three years
  • Maximum look back date is October 1, 2007
  • RACs will accept imaged medical records on CD/DVD
  • Limit the number of medical record requests

76
77
Medical Record Limit Example
  • Outpatient Hospital
  • 360,000 Medicare paid services in 2007
  • Divided by 12 average 30,000 Medicare paid
    services per month
  • x .01 300
  • Limit 200 records/45 days (hit the max)

77
78
Summary of Medical Record Limits (for FY 2009)
  • Inpatient Hospital, IRF, SNF, Hospice
  • 10 of the average monthly Medicare claims (max
    200) per 45 days per NPI
  • Other Part A Billers (HH)
  • 1 of the average monthly Medicare episodes of
    care (max 200) per 45 days per NPI

78
79
Summary of Medical Record Limits (for FY 2009)
Continued
  • Physicians (including podiatrists, chiropractors)
  • Sole Practitioner 10 medical records per 45 days
    per NPI
  • Partnership 2-5 individuals 20 medical records
    per 45 days per NPI
  • Group 6-15 individuals 30 medical records per 45
    days per NPI
  • Large Group 16 individuals 50 medical records
    per 45 days per NPI
  • Other Part B Billers (DME, Lab, Outpatient
    hospitals)
  • 1 of the average monthly Medicare services (max
    200) per NPI per 45 days

79
80
RAC Validation Contractor (RVC)
  • CMS has contracted with Provider Resources, Inc.
    of Erie, PA, to work as the Recovery Audit
    Contractor (RAC) Validation Contractor.
  • The RAC Validation Contractor (RVC) will work
    with CMS and the RAC to approve new issues the
    RACs want to pursue for improper payments, as
    well as perform accuracy reviews on a sample of
    randomly selected claims on which the RACs have
    already collected overpayment.
  • The RVC is another tool CMS will use to provide
    additional oversight and ensure that the RACs are
    making accurate claim determinations in the
    permanent program.

81
For Additional Information on RAC
  • http//www.cms.hhs.gov/MLNMattersArticles/download
    s/MM6125.pdf
  • http//www.cms.hhs.gov/RAC/Downloads/RAC20Evaluat
    ion20Report.pdf
  • http//www.cms.hhs.gov/rac/

82
Medicare Incident to Physician Services
  • The OIG reviews Medicare services that are
    incident to physicians services to determine
    the qualifications and appropriateness of the
    staff who performed them.

83
Physician Defined
  • The physician refers to physician or other
    practitioner (listed below), who are authorized
    to receive payment for services incident to his
    or her own services.
  • physician assistants
  • nurse practitioners
  • clinical nurse specialist
  • nurse midwife, and
  • clinical psychologist

84
Professional Service
  • A direct, personal, professional service which is
    rendered by the physician
  • To meet the incident to guidelines, the
    physician must initiate the course of treatment,
    and
  • Conduct subsequent physician services to show
    ongoing involvement

85
Coverage Requirements
  • To be covered, service and supplies must be
  • An integral, though incidental, part of the
    physicians or on-physician practitioners
    professional services
  • Commonly furnished in a physicians office or
    clinic
  • Furnished by the practitioner or auxiliary
    personnel under the physicians direct supervision

86
Supervision Requirements
  • Direct physician supervision of auxiliary
    personnel is required.
  • Auxiliary personnel
  • any individual (employee, leased employee, or
    independent contractor) who is acting under the
    supervision of a physician
  • Auxiliary personnel include nurses, medical
    assistants, technicians, etc.

87
Direct Supervision in the Office
  • Physician must be present in the office suite
  • Physician must be immediately available to assist
    if needed
  • Does not require that the physician be in the
    same room

88
Direct Supervision in the Office Continued
  • Scenarios that do not meet the direct supervision
    requirement
  • Availability of a physician by telephone
  • Physician presence somewhere in an institution

89
Documentation
  • To support the use of the incident to provision,
    the documentation should clearly indicate
  • Who performed the Incident to service
  • The physicians presence in the office suite
    during
  • the service/procedure

90
Division Website
  • Go to www.do-online.org and sign onto DO-Online.
  • First time users will need their AOA member
    number to sign up.
  • On DO-Online, click on Practice Management for
    the division website.
  • There is also a Division email address
    practicemanagement_at_osteopathic.org.

91
What the DO-Online Practice Management Website
has for You
  • Billing and Coding
  • E/M documentation
  • ICD-9-CM code updates
  • OMT information
  • Legal
  • Litigation fund
  • Updates on class action suits
  • CMS/Medicare
  • Links to local carrier information
  • Information on each CPT code
  • Enrollment information
  • CMS Medlearn
  • CCI link
  • Fee schedules, new and prior

92
What the DO-Online Practice Management Website
has for You
  • Preventive health services
  • Demonstration projects
  • CERT- fraud and abuse information
  • HIPPA
  • Managed care
  • Osteopathic Advocacy Resources

93
Division CME Seminars
  • Conducted in conjunction with state associations
    and specialty colleges.
  • Seminars available include Medicare Compliance,
    HIPAA Privacy Compliance, and Documentation
    Guidelines and Coding Reimbursement.
  • Call Yolanda Doss, MJ, RHIA at 800-621-1773 ext.
    8187 or ydoss_at_osteopathic.org for info.

94
Contact Information
  • Yolanda Doss 1-312-202-8187
  • ydoss_at_osteopathic.org
  • Sandra Peters 1-312-202-8088
  • speters_at_osteopathic.org
  • Kavin T. Williams, -312-202-8194
  • kwilliams_at_osteopathic.org
View by Category
About This Presentation
Title:

AMERICAN OSTEOPATHIC ASSOCIATION

Description:

AMERICAN OSTEOPATHIC ASSOCIATION 5010 Data Standard, ICD-10-CM/PSC, Osteopathic Manipulative Treatment and Medicare December 3, 2011 DIVISION OF – PowerPoint PPT presentation

Number of Views:259
Avg rating:3.0/5.0
Slides: 95
Provided by: jobr60
Learn more at: http://www.inosteo.org
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: AMERICAN OSTEOPATHIC ASSOCIATION


1
AMERICAN OSTEOPATHIC ASSOCIATION
  • 5010 Data Standard, ICD-10-CM/PSC, Osteopathic
    Manipulative Treatment and Medicare
  • December 3, 2011
  • DIVISION OF
  • SOCIOECONOMIC AFFAIRS

2
Socioeconomic Affairs Staff
  • Yolanda Doss, MJ, RHIA,
  • Director, Division of Socioeconomic Affairs
  • Sandra Peter, MHA
  • Assistant Director, Clinical Practice Outreach
  • Michele Campbell, CPC,
  • Coding Reimbursement Specialist
  • Kavin Williams, CPC, CCP
  • Health Reimbursement Policy Specialist

3
Yolanda Doss, MJ, RHIA
  • Responsibilities include
  • Helping to secure reimbursement for osteopathic
    services
  • Securing the acceptance of osteopathic
    credentials
  • Addressing Medicare issues
  • HIPAA compliance
  • Fraud and Abuse

4
Sandra Peters, MHA
  • Responsibilities include
  • Develop educational material on physician
    advocacy, manage care, quality and performance
    measures impacting osteopathic medicine
  • Design and manage a set of member services to
    enhance their manage care interactions and to
    promote their opportunities to participate in
    manage care
  • Provide update to the AOA leadership on health
    care trends particularly in the areas of pay for
    performance and physician profiling

5
Kavin T. Williams, CPC, CCP
  • Responsibilities include
  • Assists AOA members with reimbursement and health
    payment policies.
  • Oversees and assists AOA members with coding and
    payment disputes with carriers.
  • Oversees the AOA Coding and Reimbursement
    Advisory Panel.
  • Represents the AOA at national reimbursement
    policy meetings.

6
Are you ready for ICD 10 and the HIPAA 5010 Data
Standard?
  • Objectives
  • To educate physicians on the ICD 10 and HIPAA
    5010 implementation compliance dates
  • To educate physicians on the  impact the new
    coding sets will have on the current
    reimbursement and coding structure
  •  

7
The Transition to HIPAA 5010
  • Have you heard of the HIPAA 5010 Data Standard?
  • Have you begun testing?
  • Will you be ready for January 1, 2012?

8
Background of HIPAA 5010 Data Standard
  • The current version of the standards
    (4010/4010A1) are identified as lacking certain
    functionality for health care needs
  • Version 5010 will accommodate the ICD 10 codes

9
Mark Your Calendars
  • Important dates for 5010 Implementation
  • January 1, 2011-begin external testing of the
    5010 version for electronic claims
  • December 31, 2011-to be at level II compliance
    external testing of the 5010 for electronic
    claims must be completed
  • January 1, 2012 All electronic claims must use
    Version 5010. Version 4010 claims will no longer
    be accepted

10
Getting Started
  • Now is the time.
  • Testing should be conducted both internally and
    externally with current business partners
  • Internal testing of version 5010 should have been
    completed by December 31, 2010
  • External should be completed by December 31, 2011

11
Getting Started
  • Testing early will allow you to identify any
    potential issues, and address them in advance
  • As HIPAA covered entity, CMS has to ensure that
    its business processes, systems , policies and
    those of ist contractors, providers, health
    plans, etc. are compliant with HIPAA

12
Pitfalls
  • Lack of testing with your vendors, clearing
    houses, insurers to ensure that you can accept
    and send transactions is probably the top barrier
    to success
  • Cost
  • Timing (deadlines)

13
Summarize
  • Implementation date to be compliant for the 5010
    HIPAA Data transaction is January 1, 2012
  • If you have not begun testing the time is NOW!!
  • Contact your vendors to inquire/schedule your
    internal and external testing

14
Vendor Model Letter
  • Dear Vendor (Clearinghouse, EMR system, Medicare,
    private payers)
  •  
  • My (name of practice)________________ uses your
    ___________________ product/services, version
    ___________. As ICD-10-CM implementation
    approaches, we would like some information and
    clarification about your plans to upgrade your
    systems.
  •  
  • Specifically, we would like to know your plans
    for updating software to comply with HIPAA
    transactions.  Can you provide a timetable for
    the following.
  •  
  • When will you be installing upgrades and will
    there be a charge for this data?
  •  
  • Will my practice need additional hardware or
    support services to install the upgrade(s)?
  •  
  • Thank you in advance for complying with and your
    prompt attention to this request. 
  •  
  • Sincerely,
  •  

15
ICD-10-CM/PCS
16
History
  • The International Classification of Diseases,
    Tenth Revision, Clinical Modification (ICD-10-CM)
    is the United States' clinical modification to
    the World Health Organizations (WHO)
    International Classification of Diseases, Tenth
    Revision (ICD-10). ICD-10 was adopted by the
    World Health Assembly in 1990. Following the
    publication of ICD-10, a number of countries
    performed an analysis to determine if the WHO
    classification would meet their needs given the
    changes to the roles of ICD since the ninth
    revision.

17
History
  • The United States remains the only industrialized
    nation that has not yet implemented ICD-10 (or a
    clinical modification) for morbidity, meaning
    diseases or causes of illness typically coded in
    a healthcare facility. Since 1999, however, the
    US has used ICD-10 for mortality reporting the
    coding of death certificates (typically done by a
    vital statistics office, not the healthcare
    facility). Implementing ICD-10-CM will maintain
    data comparability internationally and between
    mortality and morbidity data in the U.S.

18
Development
  • In 1994 under the leadership of the National
    Center for Health Statistics (NCHS), the United
    States began their process of determining whether
    an ICD-10 modification should be developed. NCHS
    awarded a contract to the Center for Health
    Policy Studies to decide if a clinical
    modification was necessary. A Technical Advisory
    Panel (TAP) was formed and their recommendation
    was to create a clinical modification. In 1997,
    the entire draft of the Tabular List of ICD-10-CM
    and the preliminary crosswalk between ICD-9-CM
    and ICD-10-CM were made available on the NCHS
    website for public comments. The public comment
    period ran from December 1997 through February
    1998. Since that time revisions were based on
    further study and the comments submitted. Draft
    versions of ICD-10-CM were made available in
    2002, 2007, 2009, 2010, and 2011. Limited code
    updates will continue to occur to this draft
    prior to implementation of ICD-10-CM.

19
Development
  • While ICD-10 provides many more categories for
    diseases and other health-related conditions than
    previous revisions, the clinical modifications
    thus far to ICD-10 offer a higher level of
    specificity by including separate codes for
    laterality and additional character and
    extensions for expanded detail. In addition,
    other changes included combining etiology and
    manifestations, poisoning and external cause, or
    diagnosis and symptoms into a single code.
    ICD-10-CM also provides code titles and language
    that complement accepted clinical practice.
    ICD-10-CM codes have the potential to reveal more
    about quality of care, so that data can be used
    in a more meaningful way to better understand
    complications, better design clinically robust
    algorithms and better track the outcomes of care.
    ICD-10-CM incorporates greater specificity and
    clinical detail to provide information for
    clinical decision making and outcome research.

20
ICD 10
  • Implementation date is October 1, 2013
  • Benefits of ICD 10
  • Have you started preparation for ICD 10?
  • How do I get started?
  • How do I find the necessary resource information?

21
Benefits of ICD 10
  • The Benefits of ICD-10-CM
  • ICD-10-CM incorporates much greater clinical
    detail and specificity than ICD-9-CM. Terminology
    and disease classification have been updated to
    be consistent with current clinical practice. The
    modern classification system will provide much
    better data needed for
  • Measuring the quality, safety, and efficacy of
    care
  • Reducing the need for attachments to explain the
    patients condition
  • Designing payment systems and processing claims
    for reimbursement
  • Conducting research, epidemiological studies,
    and clinical trials

22
Benefits of ICD 10
  • Setting health policy
  • Operational and strategic planning
  • Designing health care delivery systems
  • Monitoring resource utilization
  • Improving clinical, financial, and
    administrative performance
  • Preventing and detecting health care fraud and
    abuse and
  • Tracking public health and risks.
  • Non-specific codes still exist for use when the
    medical record documentation does not support a
    more specific code

23
ICD 9 vs ICD 10
  • Here are some SIMILARITIES AND DIFFERENCES
    BETWEEN THE TWO CODING SYSTEMS
  • ICD-10-CM uses 37 alpha and numeric digits and
    full code titles, but the format is very much the
    same as ICD-9-CM (e.g., ICD-10-CM has the same
    hierarchical structure as ICD-9-CM).
  • The 7th character in ICD-10-CM is used in several
    chapters (e.g., the Obstetrics, Injury,
    Musculoskeletal, and External Cause chapters). It
    has a different meaning depending on the section
    where it is being used (e.g., in the Injury and
    External Cause sections, the 7th character
    classifies an initial encounter, subsequent
    encounter, or sequelae (late effect)).

24
Similarities Differences contd
  • Primarily, changes in ICD-10-CM are in its
    organization and structure, code composition and
    level of detail

25
ICD-9-CM
  • 35 digits
  • First digit is alpha (E or V) or numeric (alpha
    characters are not case sensitive)
  • Digits 25 are numeric and
  • Decimal is used after third character.
  • Examples
  • 496 Chronic airway obstruction, not elsewhere
    classified (NEC)
  • 511.9 Unspecified pleural effusion and
  • V02.61 Hepatitis B carrier.

26
ICD-10-CM
  • 37 digits
  • Digit 1 is alpha Digit 2 is numeric
  • Digits 37 are alpha or numeric (alpha
    characters are not case sensitive) and
  • Decimal is used after third character.
  • Examples
  • A78 Q fever
  • A69.21 Meningitis due to Lyme disease and
  • S52.131A Displaced fracture of neck of right
    radius, initial encounter for closed fracture.

27
What will change?
  • Coding
  • Code set will increase from 17,000 to 140,000
    therefore the code books and styles will
    completely change ( both ICD 10-Cm and ICD
    10-PCS)
  • Clinical knowledge-Coders may need to be
    reeducated on anatomy and physiology
  • All staff who handle coding, from the front
    office staff to the practice manager

28
Additional Changes
  • Laterality ( left, right, bilateral)
  • For example
  • C50.511- Malignant neoplasm of lower-outer
    quadrant of right female breast
  • H16.013- Central corneal ulcer, bilateral
  • L89.012- Pressure ulcer of right elbow, stage II

29
Changes Contd
  • Combination codes for certain conditions and
    common associated symptoms and manifestations
  • Example
  • K57.21-Diverticulitis of large intestine with
    perforation and abscess with bleeding
  • E11.341- Type 2 diabetes mellitus with severe
    nonproliferative diabetic retinopathy with
    macular edema

30
Changes Contd
  • Combination codes for poisonings and their
    associated external cause
  • Example
  • T42.3x25-Poisoning by barbiturates, intentional
    self-harm, sequela. (The x character is used as
    a 5th character placeholder in certain 6
    character codes to allow for future expansion and
    to fill in other empty characters (e.g, character
    5 and/or 6) when a code that is less than 6
    characters in length requires a seventh character

31
Changes Contd
  • Example
  • T45.1x5A-Adverse effect of calcium-channel
    blockers, initial encounter
  • T15.02XD-Foreign body in cornea, left eye,
    subsequent encounter
  • Inclusion of clinical concepts that do not exist
    currently in ICD-9-CM (e.g., underdosing, blood
    type, blood type, blood alcohol level)

32
Changes contd
  • Example
  • T45.526D-Underdosing of antithrombotic drugs,
    subsequent encounter
  • Z67.40-Blood alcohol level of 120-199 mg/100mL
  • Expansion of codes
  • Example-E10.610-Type 1 diabetes mellitus with
    diabetic neuropathic arthropathy

33
Other changes in ICD 10
  • Injuries are grouped by anatomical site as
    opposed to type of injury
  • Category restructuring and code reorganization
    have occurred in a number of ICD-10-CM chapters
    resulting in the classification of certain
    diseases and disorders that are different from
    ICD -9-CM

34
Other changes contd
  • Certain diseases have been reclassified to
    different chapters or sections in order to
    reflect current medical knowledge
  • New code definitions
  • Example-Acute Myocardial Infarction is now 4
    weeks rather than 8 weeks
  • ICD-9-CM V codes (factors influencing health
    status and contact with health services) and E
    codes( External Causes of Injury and Poisoning)
    are incorporated in the main classification as
    opposed to being separated into supplementary
    classifications as they do currently in ICD-9-CM

35
Documentation Is the Center Piece for Successful
Reporting of ICD-10 Diagnosis Codes
36
Why get started now
  • Due to the potential significant financial and
    clinical impact ICD-10 and the changes required
    for transition to the information systems that
    are being mandated, physicians should be taking
    steps now to understand how to successfully
    prepare for ICD-10

37
ICD-10
  • Coding and billing systems will need to be
    updated to support the new code set
  • Currently the code set has 3-5 digits and ICD-10
    will increase to 5-7 digits
  • Documentation will be impacted severely which
    will cause a domino effect from productivity to
    increased claims delays

38
Steps to take to get started
  • 2. Understand the potential impact this will
    have on physicians practice
  • Financial How much will this transition cost a
    practice (training, software, etc)
  • Productivity How significant will this be for a
    practices bottom line and for how long?
  • Education-what is needed and for whom is it
    needed (coders, billers, front office staff, lab
    personnel, etc)

39
Quiz
  • True or false? V and E codes are supplemental
    classifications in ICD-10-CM.
  • True or false? In ICD-10-CM, injuries are
    grouped by anatomical site rather than injury
    category.
  • What is the maximum number of characters in
    ICD-10-CM?
  • How many chapters does ICD-10-CM contain?
  • True or false? The first modification to ICD-10
    was published in 2001
  • True or false? The final rule, published in the
    Federal Register naming ICD-10-CM as a new
    medical code set standard to replace the ICD-9-CM
    diagnosis codes, sets October 1, 2013 as the
    implementation for ICD-10.
  • True or false? ICD-10-CM uses extensions in some
    sections to identify an initial encounter,
    subsequent encounter or sequelae.
  • Which letter of the alphabet is not utilized in
    ICD-10-CM?
  • The first character of an ICD-10-CM code is
    always an alphabetic letter.

40
Osteopathic Manipulative Treatment (OMT)
  • Reporting of OMT Services
  • E/M
  • Modifier-25
  • Documentation
  • Compensatory Changes
  • OMT Survey

41
Osteopathic Manipulative Treatment (OMT)1-2 Body
Regions Involved
42
Vignette
  • A 25 yr. old female presents with right lower
    neck pain of two weeks duration. Somatic
    dysfunction of cervical and thoracic regions are
    identified on exam.

43
Description of Pre-Service Work
  • The physician determines which osteopathic
    techniques (eg, HVLA, Muscle energy,
    Counterstrain, articulatory, etc) would be most
    appropriate for this patient, in what order the
    affected body regions need to be treated and
    whether those body regions should be treated with
    specific segmental or general technique
    approaches. The physician explains the intended
    procedure to the patient, answers any preliminary
    questions, and obtains verbal consent for the
    OMT. The patient is placed in the appropriate
    potion on the treatment table for the initial
    technique and region(s) to be treated.

44
Description of Intra-Service Work
  • Patient is initially in the supine position on
    the treatment table. Motion restrictions of C6
    and C7 are isolated through palpation and treated
    using muscle energy technique. Dysfunctions of T1
    and T2 are treated using passive thrust (HVLA)
    technique. Patient position is changed as
    necessary for treatment of the individual somatic
    dysfunctions. Patient feedback and palpatory
    changes guide further technique application as
    appropriate.

45
Description of Post-Service Work
  • Post-care instructions related to the procedure
    are given, including side effects, treatment
    reactions, self-care, and follow-up. The
    procedure is documented in the medical record

46
Osteopathic manipulative treatment (OMT) 9-10
body regions involved
47
Vignette
  • A 40 year old male presents with sub-occipital
    headache, and pain in the neck, upper and lower
    back, left shoulder and chest, and right ankle.
    He was involved in a rear-end MVA two weeks ago.
    X-rays in the ED were negative. He has been
    taking prescribed analgesic and muscle relaxant
    medications with minimal improvement. On
    examination, somatic dysfunction is identified at
    the occipitoatlantal, left glenohumeral and right
    tibiotalar joints, as well as the cervical,
    thoracic, costal, lumbar, sacral and pelvic
    regions.

48
Description of Pre-Service Work
  • The physician determines which osteopathic
    techniques (eg, HVLA, Muscle energy,
    Counterstrain, articulatory, etc) would be most
    appropriate for this patient, in what order the
    affected body regions need to be treated and
    whether those body regions should be treated with
    specific segmental or general technique
    approaches. The physician explains the intended
    procedure to the patient, answers any preliminary
    questions, and obtains verbal consent for the
    OMT. The patient is placed in the appropriate
    position on the treatment table for the initial
    technique and region(s) to be treated.

49
Description of Intra-Service Work
  • Patient is initially in the supine position on
    the treatment table. Motion restrictions of
    identified joints are isolated through palpation
    and treated using a variety of techniques as
    follows occipitoatlantal joint and sacrum are
    treated using muscle energy and counterstain
    techniques right glenohumeral joint and pelvis
    are treated with articulatory technique lumbar,
    thoracic, cervical and right ankle are treated
    with passive thrust (HVLA) technique costal
    dysfunctions are treated using muscle energy
    technique. Patient position is changed as
    necessary for treatment of the individual somatic
    dysfunctions. Patient feedback and palpatory
    changes guide selection of further technique
    application as appropriate.

50
Description of Post-Service Work
  • Post-care instructions related to the procedure
    are given, including side effects, treatment
    reactions, self-care, and follow-up. The
    procedure is documented in the medical record

51
OMT RVUs
  • 2011
  • 2012
  • 98925 0.45
  • 98926 0.65
  • 98927 0.87
  • 98928 1.03
  • 98929 1.19
  • Conversion Factor 33.9764
  • 98925 0.46
  • 98926 0.71
  • 98927 0.96
  • 98928 1.21
  • 98929 1.46
  • Conversion Factor 24.6712

52
Medicare
53
The Objective is to Provide Informationon the
Following Topics
  • Medicare 2012 Updates
  • Evaluation Management
  • Medicare Audits
  • Recovery Audit Contractors (RAC)
  • Incident To Services

54
Medicare 2012 Updates
  • Physician Fee Schedule is facing a 27.4 percent
    reduction
  • Physician Quality Reporting Initiative (PQRI)
    Bonus Payment 2
  • E-Prescribing Bonus Payment 2
  • OMT Survey

55
Physician Documentation
  • This is critical to your reimbursement
  • If it was not documented it did not happen
  • Clear and Legible, words to document by
  • Chief complaint (this is the driver to most
    insurance auditors)
  • Familiarize yourself with your documentation
    style- is it 1995 guidelines that you follow or
    1997?

56
Documentation Guidelines
  • The medical record should be complete and
    legible.
  • The documentation of each patient encounter
    should include
  • reason for the encounter and relevant history,
    physical examination findings and prior
    diagnostic test results
  • assessment, clinical impression or diagnosis
  • plan for care

57
Documentation Guidelines Cont.
  • The patients progress, response to and changes
    in treatment, and revisions of diagnosis should
    be documented.
  • The CPT and ICD-9-CM codes reported on the health
    insurance claim form or billing statement should
    be supported by the documentation in the medical
    record.
  • Hospital visits should be included in the
    patients chart

58
Evaluation Management (E/M) Coding
  • Coding for office visits
  • Modifier usage when billing an E/M with a
    procedure (OMT)
  • Time Based Coding

59
Chief Complaint (CC)
  • The chief complaint is a concise statement
    describing the symptom, problem, condition,
    diagnosis, physician recommended return, or other
    factors that is the reason for the encounter,
    usually stated in the patients own words.
  • Documentation Guidelines states that the medical
    record should clearly reflect the chief complaint

60
Medical Necessity
  • This area is not black/white
  • There are numerous definitions of medical
    necessity
  • Linking the appropriate diagnosis to the
    appropriate procedure to support the necessity of
    the procedure performed is critical.
  • Medicare defines medical necessity as services or
    items reasonable and necessary for the diagnosis
    or treatment of illness or injury to improve the
    functioning of a malformed body member.

61
Coding For Time
  • When is it appropriate to code for time?
  • What is the auditor looking for when they review
    a chart that was billed as time being the
    controlling factor?

62
Tips For Verbiage When Billing For Time
  • Example of correct documentation of time
  • In your note it should read I spent 45 minutes
    with the patient and over 50 of that time was
    spent discussing
  • Example of incorrect documentation of time
  • I spent 45 minutes with the patient, discussed
    surgical options versus medical management.

63
How Would Code This Date of Service
64
What Is An Audit?
  • An effective tool used by Medicare and other
    payors to recover monies lost to fraud and
    erroneous billings.

65
Why Audits Are Initiated?
  • Suspicion (Billing Pattern)
  • Outlier Physicians
  • The Senior Patrol
  • Whistleblowers
  • Procedure Codes

66
Who Are The Auditors?
  • The Office of the Inspector General (OIG)
  • Medicare
  • The Department of Justice (DOJ)
  • The Federal Bureau of Investigation (FBI)
  • Carriers

67
Types of Audits
  • Prepayment Audits
  • Post-Payment Audits
  • Statistical Sampling Method

68
What Auditors Look For?
  • Billing for services or supplies that were not
    provided.
  • Billing for non-allowable or non-covered
    services.
  • Altering claim forms to receive a higher payment
    amount.
  • Unbundling claims.

69
How To Respond To A Request For Documentation
  • Reply to the audit notice in a timely fashion.
  • Gather and submit Only the requested
    documentation.
  • Be cooperative.
  • You may want to conduct an internal audit.

70
How to Respond to the Audit Findings
  • If the findings are not favorable
  • Attempt to discuss the findings with the
    reviewer.
  • If necessary request redetermination.
  • If necessary request a level one appeal.

71
Medicare Recovery AuditContractors (RACs)
71
72
RAC Legislation
  • The RAC program was created by the Medicare
    Prescription Drug, Improvement, and Modernization
    Act of 2003 which pays incentive fees to
    third-party auditors that identify and correct
    improper payments paid to healthcare providers in
    fee-for-service Medicare.
  • The Medicare Prescription Drug, Improvement, and
    Modernization Act of 2003 also requires permanent
    and nationwide RAC program by no later than 2010

72
73
The RAC Demonstration Project
  • The RAC demonstration project took place of New
    York, Florida, and California.
  • By 2010 the RAC covered all 50 states.

74
RAC Program Mission
  • To detect and correct past improper payments,
  • To implement actions that will prevent future
    improper payments.
  • Providers can avoid submitting claims that dont
    comply with Medicare rules
  • CMS can lower its error rate
  • Taxpayers future Medicare beneficiaries are
    protected

74
75
The New RACs Are
  • Diversified Collection Services, Inc. of
    Livermore, California, in Region A, initially
    working in Maine, New Hampshire, Vermont,
    Massachusetts, Rhode Island and New York.
  • CGI Technologies and Solutions, Inc. of Fairfax,
    Virginia, in Region B, initially working in
    Michigan, Indiana and Minnesota.
  • Connolly Consulting Associates, Inc. of Wilton,
    Connecticut, in Region C, initially working in
    South Carolina, Florida, Colorado and New Mexico.
  • HealthDataInsights, Inc. of Las Vegas, Nevada, in
    Region D, initially working in Montana, Wyoming,
    North Dakota, South Dakota, Utah and Arizona.
  • Additional states will be added to each
    RAC region in 2009

76
Minimize Provider Burden
  • Limit the RAC look back period to three years
  • Maximum look back date is October 1, 2007
  • RACs will accept imaged medical records on CD/DVD
  • Limit the number of medical record requests

76
77
Medical Record Limit Example
  • Outpatient Hospital
  • 360,000 Medicare paid services in 2007
  • Divided by 12 average 30,000 Medicare paid
    services per month
  • x .01 300
  • Limit 200 records/45 days (hit the max)

77
78
Summary of Medical Record Limits (for FY 2009)
  • Inpatient Hospital, IRF, SNF, Hospice
  • 10 of the average monthly Medicare claims (max
    200) per 45 days per NPI
  • Other Part A Billers (HH)
  • 1 of the average monthly Medicare episodes of
    care (max 200) per 45 days per NPI

78
79
Summary of Medical Record Limits (for FY 2009)
Continued
  • Physicians (including podiatrists, chiropractors)
  • Sole Practitioner 10 medical records per 45 days
    per NPI
  • Partnership 2-5 individuals 20 medical records
    per 45 days per NPI
  • Group 6-15 individuals 30 medical records per 45
    days per NPI
  • Large Group 16 individuals 50 medical records
    per 45 days per NPI
  • Other Part B Billers (DME, Lab, Outpatient
    hospitals)
  • 1 of the average monthly Medicare services (max
    200) per NPI per 45 days

79
80
RAC Validation Contractor (RVC)
  • CMS has contracted with Provider Resources, Inc.
    of Erie, PA, to work as the Recovery Audit
    Contractor (RAC) Validation Contractor.
  • The RAC Validation Contractor (RVC) will work
    with CMS and the RAC to approve new issues the
    RACs want to pursue for improper payments, as
    well as perform accuracy reviews on a sample of
    randomly selected claims on which the RACs have
    already collected overpayment.
  • The RVC is another tool CMS will use to provide
    additional oversight and ensure that the RACs are
    making accurate claim determinations in the
    permanent program.

81
For Additional Information on RAC
  • http//www.cms.hhs.gov/MLNMattersArticles/download
    s/MM6125.pdf
  • http//www.cms.hhs.gov/RAC/Downloads/RAC20Evaluat
    ion20Report.pdf
  • http//www.cms.hhs.gov/rac/

82
Medicare Incident to Physician Services
  • The OIG reviews Medicare services that are
    incident to physicians services to determine
    the qualifications and appropriateness of the
    staff who performed them.

83
Physician Defined
  • The physician refers to physician or other
    practitioner (listed below), who are authorized
    to receive payment for services incident to his
    or her own services.
  • physician assistants
  • nurse practitioners
  • clinical nurse specialist
  • nurse midwife, and
  • clinical psychologist

84
Professional Service
  • A direct, personal, professional service which is
    rendered by the physician
  • To meet the incident to guidelines, the
    physician must initiate the course of treatment,
    and
  • Conduct subsequent physician services to show
    ongoing involvement

85
Coverage Requirements
  • To be covered, service and supplies must be
  • An integral, though incidental, part of the
    physicians or on-physician practitioners
    professional services
  • Commonly furnished in a physicians office or
    clinic
  • Furnished by the practitioner or auxiliary
    personnel under the physicians direct supervision

86
Supervision Requirements
  • Direct physician supervision of auxiliary
    personnel is required.
  • Auxiliary personnel
  • any individual (employee, leased employee, or
    independent contractor) who is acting under the
    supervision of a physician
  • Auxiliary personnel include nurses, medical
    assistants, technicians, etc.

87
Direct Supervision in the Office
  • Physician must be present in the office suite
  • Physician must be immediately available to assist
    if needed
  • Does not require that the physician be in the
    same room

88
Direct Supervision in the Office Continued
  • Scenarios that do not meet the direct supervision
    requirement
  • Availability of a physician by telephone
  • Physician presence somewhere in an institution

89
Documentation
  • To support the use of the incident to provision,
    the documentation should clearly indicate
  • Who performed the Incident to service
  • The physicians presence in the office suite
    during
  • the service/procedure

90
Division Website
  • Go to www.do-online.org and sign onto DO-Online.
  • First time users will need their AOA member
    number to sign up.
  • On DO-Online, click on Practice Management for
    the division website.
  • There is also a Division email address
    practicemanagement_at_osteopathic.org.

91
What the DO-Online Practice Management Website
has for You
  • Billing and Coding
  • E/M documentation
  • ICD-9-CM code updates
  • OMT information
  • Legal
  • Litigation fund
  • Updates on class action suits
  • CMS/Medicare
  • Links to local carrier information
  • Information on each CPT code
  • Enrollment information
  • CMS Medlearn
  • CCI link
  • Fee schedules, new and prior

92
What the DO-Online Practice Management Website
has for You
  • Preventive health services
  • Demonstration projects
  • CERT- fraud and abuse information
  • HIPPA
  • Managed care
  • Osteopathic Advocacy Resources

93
Division CME Seminars
  • Conducted in conjunction with state associations
    and specialty colleges.
  • Seminars available include Medicare Compliance,
    HIPAA Privacy Compliance, and Documentation
    Guidelines and Coding Reimbursement.
  • Call Yolanda Doss, MJ, RHIA at 800-621-1773 ext.
    8187 or ydoss_at_osteopathic.org for info.

94
Contact Information
  • Yolanda Doss 1-312-202-8187
  • ydoss_at_osteopathic.org
  • Sandra Peters 1-312-202-8088
  • speters_at_osteopathic.org
  • Kavin T. Williams, -312-202-8194
  • kwilliams_at_osteopathic.org
About PowerShow.com