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AES 2010 Practice Management Course December 7, 2010

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Title: AES 2010 Practice Management Course December 7, 2010 Author: Gregory L. Barkley Last modified by: Cheryl-Ann Tubby Created Date: 12/5/2009 4:15:53 PM – PowerPoint PPT presentation

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Title: AES 2010 Practice Management Course December 7, 2010


1
AES 2010 Practice Management Course December 7,
2010
Gregory L. Barkley, M.D. Comprehensive Epilepsy
Program Henry Ford Hospital Detroit,
MI Associate Professor of Neurology Wayne State
University
2
Outline
  • Consultation Codes
  • 2011 Medicare Conversion Factor and SGR
  • October 2010 ICD-9 coding changes of interest
  • 2011 CPT Codes
  • PQRI update
  • Gearing up for ICD-10 on October 1, 2013
  • Miscellaneous Please note, I have removed the
    cell slice images from this set to keep the file
    size smaller. Images are at http//www.nytimes.c
    om/slideshow/2010/11/29/science/20101130-brain-1.h
    tml

3
  • Deadline extended until Dec 10. We specifically
    need members from
  • Alaska, Arizona, Arkansas
  • Colorado, Connecticut
  • Delaware, Kansas
  • Kentucky, Maine
  • Mississippi, Nebraska
  • Nevada, North Dakota
  • Rhode Island, South Carolina
  • South Dakota, West Virginia
  • Melissa Larson
  • Manager, Advocacy Development
  • AAN Professional Association
  • Ph 651.695.2748
  • FAX 651.361.4848
  • mlarson_at_aan.com
  • www.aan.com\advocacy

4
Consultation Codes Are Gone Forever
  • CMS stopped paying for consultations, 9924x and
    9925x
  • In 2007, gt 28 million claims
  • Money from Consultation codes redistributed to
    other physician codes to maintain budget
    neutrality
  • Other payers stopped paying for consults during
    2010
  • An attempt this year by AAN and other societies
    to get reconsideration of consult codes was
    rejected
  • CMS commented "in most cases there is no
    substantial difference in physician work between
    E/M visits and services that would otherwise be
    reported with CPT consultation codes."

5
Coding an outpatient New Patient visit (3/3 or
Hx, PE, and MDM)
History Exam elements Decision making Time (minutes) Code
HPI 1-3 facts 1-5 Straight- forward 10 99201
HPI 1-3 facts ROS 1 fact 6 Straight- forward 20 99202
HPI 4 facts ROS 2, PSFH 1 12 low 30 99203
HPI 4 facts, ROS 10, PSFH 3 25 moderate 45 99204
HPI 4 facts, ROS 10, PSFH 3 25 high 60 99205
6
Coding an outpatient Established Patient visit
(2/3 MDM Hx or PE)
History Exam elements Decision making Time (minutes) Code
- - Minimal or none 5 99211
HPI 1-3 facts 1-5 Straight- forward 10 99212
HPI 1-3 facts ROS 1 6 low 15 99213
HPI 4 facts, ROS 2, PSFH 1 12 moderate 25 99214
HPI 4 facts, ROS 10, PSFH 3 25 high 40 99215
7
9922x Coding an inpatient Initial Care Day (3/3)
History (CC always needed) Exam elements Decision making Time (minutes) Code (wRVU)
HPI 4 facts, 1 PFSH, 2-9 ROS 12 Neuro SSE or 5-7 systems Straight-forward or low 30 99221 (1.89)
HPI 4 facts, 3 PFSH, 10 ROS Full Neuro SSE (25) or 8 Systems Moderate (2 Chronic with 1 exacerbation) 50 99222 (2.57)
HPI 4 facts, 3 PFSH, 10 ROS Full Neuro SSE (25) or 8 Systems High Threatening, acute or chronic, illness or injury 70 99223 (3.79)
8
9923x Coding an inpatient Subsequent Day Care
(2/3)
History Exam elements Decision making Time (minutes) Code (wRVU)
HPI 1-3 facts 1-5 straight-forward or low 15 99231 (0.76)
HPI 1-3 facts ROS 1 fact 6 moderate 25 99232 (1.39)
HPI 4 facts ROS 2 facts 12 high 35 99233 (2.00)
9
Counseling and Coordination of Care
  • Counseling is a discussion with patient or family
    about diagnoses, test results, recommended tests,
    prognosis, treatment alternatives, compliance,
    risk factor reduction, and patient and family
    education.
  • Coordination of care is arranging for care with
    other health care providers. This includes any
    type of such activity.

10
Counseling and Coordination of Care
  • This can be used in place of the above HX-PE-MDM.
  • It uses time to set LOS
  • The documentation should state
  • Minutes spent face-to-face
  • That more than 50 of time was counseling and/or
    coordinating care,
  • Give some general idea of what counsel/coord.
    care.
  • Time is
  • Face-to-face with patient (outpatient)
  • At bedside and on unit/floor (inpatient).
  • No history or exam elements are needed except, of
    course, for real patient care purposes!

11
Emergency Room Care
  • Most ER services provided by neurologists and
    neurosurgeons are as consultants
  • Use Established Patient (99211-99215) codes for
    Medicare patients seen by anyone in your group in
    the past three years
  • Otherwise use Outpatient New Patient
    (99201-99205) codes
  • If the patient is admitted to the hospital, then
    use the initial hospital day codes (99221-99223)
  • Critical Care services provided in ER, e.g. tPA
    or status epilepticus management
  • Use Critical Care codes 99291 - 99292

12
Critical Care
  • 99291 first hour of critical care (31-74
    minutes)
  • 99292 each additional 30 minutes
  • Coded by time for bedside and unit physician work
    for an unstable, critically ill patient
  • Not for consultant's time
  • Need not be continuous in any location
  • Generally cannot bill other E/M on same day.
  • Exceptions are if an E M is performed at one
    time, then a crisis occurs and critical services
    are performed.
  • Make sure you document times carefully so you do
    not appear to be combining times of routine care
    with critical care times or procedure times.
  • Not every day in the ICU is critical care!!!
  • Patients awaiting transfer to GPU are not
    critically ill
  • Critical care can be provided anywhere including
    in the clinic
  • You must document time spent and what you did in
    your note

13
A Very Short Primer on American Health Care
Financing
  • 2.5 trillion spent on health care in 2009.
    Private insurance covered
  • 59 of Americans. Government programs paid for
    53 of direct health care costs and 62 if tax
    exemptions counted. More than 50 million
    Americans without health care coverage.
  • Medicare Trust Fund
  • - Elderly and those qualifying for Medicare
    disability
  • For outpatient care, covers 80 of professional
    fee schedule for visits and procedures APC for
    technical charges
  • In 2006 outpatient medications were covered
  • - For inpatient care, covers 80 of fee schedule
    for professional costs DRG for technical costs
  • - Covers 55 of psychiatric care charges (Chapter
    5 of ICD-9)

Private insurance policies - Largely paid for by
employers - Usually small, but increasing,
out-of-pocket costs borne by individuals -
Thousands of companies offering tens of thousands
of individual policies - Range minimal coverage
for catastrophic illness to full coverage
14
In 2007, U.S per capita health care spending was
7,290, 2.5 times the OECD average and 16 of GDP
  • U.S. government alone already pays more than
    total costs in nearly all other countries

15
(No Transcript)
16
Health Care Spending is 16 of GDP
17
To Control US Debt
  • Only options are to
  • Cut Medicare spending
  • 2010 Accountable Care Act reduces Medicare
    spending by 350 Billion over 10 years
  • Cut Defense spending
  • Cut Social Security spending
  • Raise taxes
  • Reality is that all of the above are necessary

18
Social Security P. Krugman, NYTimes 12/06/2010
19
2011 Medicare Proposed Conversion Rate issued
11/02/2010, 2023 pages
  • In the final rule, the Medicare Conversion Factor
    will be 25.5217 starting 01/01/2011
  • 30 drop compared to 2010 to meet SGR law
  • Comment period is open until January 3, 2011
  • Conversion factor law override from 06/01/2010
    until 11/30/2010 was 36.8729
  • A 2.2 increase from 2009 and averted a 21.5 cut
  • Legislation proposals in Congress to override
    remain contentious at this time
  • On 11/18/2010, Senate passed a one month
    extension of current pay scale
  • House passed same bill on 11/30/2010
  • Rescaling of RVU weights (-8.2) and (0.5)
    budget neutrality change due to RVU changes
    mandated by law, so CF likely to be 34.00 if
    Congress overrides

20
2011 Medicare Conversion Rate
  • 12/06/2010, 817 PM
  • To mem_at_lyris.aan.com
  • From mamery_at_aan.com
  • Re SGR Agreement
  • Dear MEM Members
  • The Senate Finance committee just announced a one
    year delay of the SGR cuts. The deal will be
    fully paid for. Details to come.
  • Michael J. Amery, Esq.
  • Legislative Counsel
  • American Academy of Neurology
  • 202-506-7468

21
SGR Annual Override..
  • Does not fixed flawed formula and increases the
    decrease needed the next year, currently 210-279
    B

210-279 B
AMA
22
2011 ICD-9 Code Changes
  • On October 1 of each year, the ICD-9 code changes
    occur
  • There are new codes as well as new index terms.
  • Index terms can be used by coders to map to a
    specific code
  • New index terms for epilepsy I presented at the
    ICD Coding and Maintenance Committee Meeting on
    9/25/2008, my presentation is at
    http//www.cdc.gov/nchs/icd/icd9cm_maintenance.htm
  • Epilepsy, epileptic (idiopathic) 345.9
  • Note use the following fifth-digit
    subclassifications with categories 345.0, 345.1,
    345.4-345.9 0 without mention of intractable
    epilepsy 1 with intractable epilepsy pharmac
    oresistant (pharmacologically resistant) poorl
    y controlled refractory (medically) treatm
    ent resistant

23
2011 ICD-9 Code Changes
  • 345 Epilepsy and recurrent seizures
  • Delete Excludes progressive myoclonic epilepsy
    (333.2)
  • 780 General symptoms
  • 780.3 Convulsions
  • New code 780.33 Post traumatic seizures
  • Excludes post traumatic epilepsy (345.00-345.91)

24
2011 ICD-9 Code Changes
  • 225 Benign neoplasm of brain and other parts of
    nervous system
  • Revise Excludes neurofibromatosis
    (237.70-237.79)
  • 237 Neoplasm of uncertain behavior of endocrine
    glands and nervous
  • system
  • 237.7 Neurofibromatosis
  • Delete von Recklinghausen's disease
  • New code 237.73 Schwannomatosis
  • New code 237.79 Other neurofibromatosis

25
2011 ICD-9 Code Changes Codes in Red are in
Chapter 5, reimbursed at 55 vs. 80
  • 278.0 Overweight and obesity
  • New code 278.03 Obesity hypoventilation syndrome
  • Pickwickian syndrome
  • 307 Special symptoms or syndromes, not elsewhere
    classified
  • Revise 307.0 Stuttering Adult onset fluency
    disorder
  • Add Excludes childhood onset fluency disorder
    (315.35)
  • Revise stuttering (fluency disorder) due to late
    effect of cerebrovascular accident (438.14)
  • Add fluency disorder in conditions classified
    elsewhere (784.52)

26
2011 ICD-9 Code Changes Codes in Red are in
Chapter 5, reimbursed at 55 vs. 80
  • 315 Specific delays in development
  • 315.3 Developmental speech or language disorder
  • New code 315.35 Childhood onset fluency disorder
  • Cluttering NOS
  • Stuttering NOS
  • Excludes adult onset fluency disorder (307.0)
  • fluency disorder due to late effect of
    cerebrovascular accident (438.14)
  • fluency disorder in conditions classified
    elsewhere (784.52)
  • 315.39 Other
  • Delete Excludes stammering and stuttering
    (307.0)

27
2011 ICD-9 Code Changes
  • 337 Disorders of the autonomic nervous system
  • 337.3 Autonomic dysreflexia
  • Revise Use additional code to identify the cause,
    such as fecal impaction (560.32)
  • 488 Influenza due to certain identified influenza
    viruses
  • 488.0 Influenza due to identified avian influenza
    virus
  • New code 488.09 Influenza due to identified avian
    influenza virus with other manifestations
  • Avian influenza with involvement of
    gastrointestinal tract
  • Encephalopathy due to identified avian influenza
  • Excludes "intestinal flu" viral
    gastroenteritis (008.8)

28
2011 ICD-9 Code Changes
  • 488.1 Influenza due to identified novel H1N1
    influenza virus
  • New code 488.19 Influenza due to identified novel
    H1N1 influenza virus with other manifestations
  • Novel H1N1 influenza with involvement of
    gastrointestinal tract
  • Encephalopathy due to identified novel H1N1
    influenza
  • Excludes "intestinal flu" viral
    gastroenteritis (008.8)
  • 721 Spondylosis and allied disorders
  • 721.4 Thoracic or lumbar spondylosis with
    myelopathy
  • 721.42 Lumbar region
  • Delete Spondylogenic compression of lumbar spinal
    cord

29
2011 ICD-9 Code Changes
  • 724 Other and unspecified disorders of back
  • 724.0 Spinal stenosis, other than cervical
  • Revise 724.02 Lumbar region, without neurogenic
    claudication
  • Add Lumbar region NOS
  • New code 724.03 Lumbar region, with neurogenic
    claudication
  • 742 Other congenital anomalies of nervous system
  • 742.8 Other specified anomalies of nervous system
  • Revise Excludes neurofibromatosis (237.70-237.79)

30
2011 ICD-9 Code Changes
  • 781 Symptoms involving nervous and
    musculoskeletal systems
  • Revise 781.8 Neurologic neglect syndrome
  • Add Excludes visuospatial deficit (799.53)
  • New code V13.63 Personal history of (corrected)
    congenital malformations of nervous system
  • V49 Other conditions influencing health status
  • V49.8 Other specified conditions influencing
    health status
  • New code V49.86 Do not resuscitate status

31
2011 ICD-9 Code Changes
  • 784 Symptoms involving head and neck
  • 784.5 Other speech disturbance
  • Revise Excludes stammering and stuttering
    (315.35)
  • Delete that of nonorganic origin (307.0, 307.9)
  • New code 784.52 Fluency disorder in conditions
    classified elsewhere
  • Stuttering in conditions classified elsewhere
  • Code first underlying disease or condition, such
    as
  • Parkinsons disease (332.0)
  • Excludes adult onset fluency disorder (307.0)
  • childhood onset fluency disorder (315.35)
  • fluency disorder due to late effect of
    cerebrovascular accident (438.14)

32
2011 ICD-9 Code Changes
  • 799 Other ill-defined and unknown causes of
    morbidity and mortality
  • New Subcategory 799.5 Signs and symptoms
    involving cognition
  • Excludes amnesia (780.93)
  • amnestic syndrome (294.0)
  • attention deficit disorder (314.00-314.01)
  • late effects of cerebrovascular disease (438)
  • memory loss (780.93)
  • mild cognitive impairment, so stated (331.83)
  • specific problems in developmental delay
    (315.00-315.9)
  • transient global amnesia (437.7)
  • visuospatial neglect 781.8

33
2011 ICD-9 Code Changes
  • 799 Other ill-defined and unknown causes of
    morbidity and mortality
  • New code 799.51 Attention or concentration
    deficit
  • New code 799.52 Cognitive communication deficit
  • New code 799.53 Visuospatial deficit
  • New code 799.54 Psychomotor deficit
  • New code 799.55 Frontal lobe and executive
    function deficit
  • New code 799.59 Other signs and symptoms
    involving cognition

34
2011 ICD-9 Code Changes
  • 992 Effects of heat and light
  • 992.0 Heat stroke and sunstroke
  • Add Use additional code(s) to identify any
    associated complication of heat stroke, such as
  • Add alterations of consciousness (780.01-780.09)
  • Add systemic inflammatory response syndrome
    (995.93-995.94)

35
2011 Practice Expense (PE) Changes
  • Second year of 4 year transition on PE
    methodology
  • CMS is using results of 2009 AMA Physician
    Practice Information Survey
  • www.ama-assn.org/go/ppisurvey
  • Neurology 73 PE/hr, 127.21Total PE/hr Overall
    increase 3
  • Neurosurgery 81 PE/hr, 132.52 Total PE/hr
    Overall increase 2
  • Assume that imaging equipment such as CT and MRI
    are used 90 of the time instead of current 50
  • Other equipment remains at 50 usage for now
  • Work defined as 150,000 minutes/year (48 hour
    work week)

36
2011 MFS for Neurology Services RVUs, excluding
the conversion factor
  • 95812, EEG 41-60 minutes
  • Total RVUs 9.31, 28
  • Practice Expense 8.16, 33
  • Professional 1.60, 8
  • Physician Work (wRVU) 1.08, No change
  • 95813, EEG gt 1 hour
  • Total RVUs 10.48, 21
  • Practice Expense 8.64, 26
  • Professional 2.54, 7
  • Physician Work (wRVU) 1.73, No change

37
2011 MFS for Neurology Services RVUs, excluding
the conversion factor
  • 95816, Awake EEG
  • Total RVUs 8.39, 26
  • Practice Expense 7.22, 31
  • Professional 1.60, 8
  • Physician Work (wRVU) 1.08, No change
  • 95819, Awake and Asleep EEG
  • Total RVUs 9.62, 32
  • Practice Expense 8.47, 38
  • Professional 2.54, 7
  • Physician Work (wRVU) 1.73, No change

38
2011 MFS for Neurology Services RVUs, excluding
the conversion factor
  • 95822, Sleep EEG
  • Total RVUs 7.84, 33
  • Practice Expense 7.22, 31
  • Professional 1.60, 8
  • Physician Work (wRVU) 1.08, No change
  • 95824, EEG for Brain Death
  • Total RVUs 0.00, No change
  • Practice Expense 0.00, N/A
  • Professional 1.12, 8
  • Physician Work (wRVU) 0.74, No change

39
2011 MFS for Neurology Services RVUs, excluding
the conversion factor
  • 95827, Overnight EEG
  • Total RVUs 16.52, 33
  • Practice Expense 15.31, 36
  • Professional 1.60, 8
  • Physician Work (wRVU) 1.08, No change
  • 95829, Surgery Electrocorticogram
  • Total RVUs 44.12 20
  • Practice Expense 37.71, 29
  • Professional 9.11, 8
  • Physician Work (wRVU) 6.20, No change

40
2011 MFS for Neurology Services RVUs, excluding
the conversion factor
  • 95950, Ambulatory Cassette EEG
  • Total RVUs 7.99, 18
  • Practice Expense 6.38, 22
  • Professional 2.25, 9
  • Physician Work (wRVU) 1.51, No change
  • 95951, 24 Hour Video EEG
  • Total RVUs 0.00, Carrier-defined technical
    expense
  • Practice Expense Carrier-defined technical
    expense
  • Professional 9.14, 8
  • Physician Work (wRVU) 5.99, No change

41
2011 MFS for Neurology Services RVUs, excluding
the conversion factor Codes presented at RUC
04/2010 by M. Spanaki
  • 95953, 24 hour computerized digital EEG,
    unattended
  • Total RVUs 12.19, 6
  • Practice Expense 7.56, 8.78
  • Professional 4.63, 1.76
  • Physician Work (wRVU) 3.08
  • 95956, 24 Hour attended EEG without video
  • Total RVUs 29.82, 49.92
  • Practice Expense 24.6, 57.19
  • Professional 5.22, 23.11
  • Physician Work (wRVU) 3.61

42
2011 MFS for Neurology Services RVUs, excluding
the conversion factor
  • 95954, EEG with administration of drugs
  • Total RVUs 9.15, 26.56
  • Practice Expense 5.8 RVUs, 41.12
  • Professional 3.35 RVUs, 7.37
  • Physician Work (wRVU) 2.45
  • 95955, EEG during surgery
  • Total RVUs 4.96, 25.89
  • Practice Expense 3.48, 35.41
  • Professional 1.48, 8.03
  • Physician Work (wRVU) 1.01

43
2011 MFS for Neurology Services RVUs, excluding
the conversion factor
  • 95957, EEG Digital Analysis
  • Total RVUs 10.01, 27.68
  • Practice Expense 7.05 RVUs, 41.12
  • Professional 2.96 RVUs, 8.03
  • Physician Work (wRVU) 1.98
  • 95958, EEG monitoring, functional mapping (Wada
    Test)
  • Total RVUs 13.39, 20.20
  • Practice Expense 7.08, 34.35
  • Professional 1.48, 8.03
  • Physician Work (wRVU) 4.24

44
2011 MFS for Neurology Services RVUs, excluding
the conversion factor
  • 95961, Electrode stimulation, brain, first hour
  • Total RVUs 7.41, 16.88
  • Practice Expense 2.93 RVUs, 33.79
  • Professional 4.48 RVUs, 7.95
  • Physician Work (wRVU) 2.97
  • 95962, Electrode stimulation, brain, each
    additional hour
  • Total RVUs 6.67, 14.21
  • Practice Expense 1.8, 33.33
  • Professional 4.79, 8.13
  • Physician Work (wRVU) 3.21

45
2011 MFS for Neurology Services RVUs, excluding
the conversion factor
  • 95970, Analyze neurostimulator, no programming
  • Physician Work (wRVU) 0.45
  • 95975, Cranial neurostimulation, complex analysis
    and programming
  • Physician Work (wRVU) 1.70

46
2009 AAN MEG Payment Policy
  • In 2008, AAN MEM Payment Policy Subcommittee
    decided to develop a model payment policy for MEG
    due to difficulties in getting MEG payments by
    insurers
  • Saty Satya-Murti, William Sutherling, and Gregory
    L. Barkley wrote the policy
  • Joel Kaufman, M.D. Katie Kuechenmeister lead
    AAN efforts
  • Passed by AAN Board of Directors on May 8, 2009
  • Sent by AAN MEM to major insurance companies
  • http//www.aan.com/globals/axon/assets/5641.pdf
  • ACMEGS developed a similar policy in 2009
  • Anto Bagic, Michael Funke, John Ebersole wrote
    the policy
  • JClinNeurophys 26 (4) p290-293, 2009
  • Model payment policy, letters, meetings changed
    insurance coverage by major providers

47
Secrets to success in dealing with insurance
companies
  • Data, data, data, especially evidence-based
  • The AAN ACMEGS statements are referenced in the
    MEG policy review.
  • I am certain that the AAN MEG policy review was a
    crucial piece of information in this change in
    policy
  • Several of the points in the AAN payment policy
    statement are restated in the AETNA review
  • Personal Contacts and establishing relationships
    with the decision-makers were also key factors

48
CIGNA MEG Payment Policy 0248
  • For 12/15/2009 to 12/15/2010, CIGNA does not
    cover magnetoencephalography (MEG) or magnetic
    source imaging (MSI) for any condition because
    they are considered experimental, investigational
    or unproven.
  • The AAN MEM Payment Policy Subcommittee (PPS) met
    with CIGNA representatives in September 2010
  • CIGNA requested a letter regarding their policies
  • AAN Response letter sent November 12, 2010 by
    Joel Kaufman, Chair of AAN PPS
  • CIGNA has not yet posted MEG policy for 2011

49
2011 Medicare MEG Medicare Fee Schedule
  • 95965 Spontaneous MEG for epileptic spike mapping
  • 2011 Professional 12.34 Total RVUs (7.99 wRVUs)
  • 2010 11.83 Total RVUs (8.0) Payment ?
  • 2011 Technical (APC 067) 3408.69 (-4.6 )
  • 95966 Evoked magnetic fields
  • 2011 Professional 6.16 Total RVUs (3.99 wRVUs)
  • 2010 5.72 Total RVUs (8,0 ) Payment ?
  • Technical (APC 066) 977.12
  • 2010 962.61 (1.5 )
  • 95967 Each additional evoked magnetic field
    procedure
  • 2011 Professional 5.34 Total RVUs (3.49 wRVUs)
  • 2010 4.92 Total RVUs (9.0 ) Payment ?
  • Technical (APC 066) 977.12
  • 2010 962.61 (1.5 )
  • When one procedure is performed with another,
    payment would be reduced by 50
  • Charges to private insurance are set by each
    laboratory and cannot be compared due to US
    antitrust (price-fixing) laws

50
MEG Practice Expense Payment Rate
  • The Affordable Care Act (ACA) requires that CMS
    establish the equipment utilization rate for CT,
    MR and PET at 75 percent. CMS had previously set
    the equipment utilization rate for this equipment
    at 90 percent, phasing in reduced payments over
    four years. This may result in changes to payment
    rates for CT and MR services.
  • May affect MEG technical pricing since MEG
    grouped in imaging APCs

51
2010 e-Prescribing
  • PQRI revision for e-Rx
  • For 2011, only have to report at least 25 uses of
    e-Rx to qualify for PQRI payment
  • Failure to register for e-Rx in first half of
    2011 and do not qualify for an exemption will
    face penalties in 2012.
  • AAN has signed on to a letter of protest
  • Physicians who participate in 2011 EHR cannot
    participate in e-Rx incentive program

52
PQRI (Physician Quality Reporting
Initiative) http//www.cms.hhs.gov/apps/media/pres
s/factsheet.asp?
  • AAN has developed 8 epilepsy measures lead by N.
    Fountain and P Van Ness
  • Approved by AMA Physician's Consortium for
    Performance Improvement
  • Currently under review by National Quality Forum
    (NQF)
  • If NQF approves, then will be submitted to CMS
    for possible inclusion in the PQRI
  • Being developed by AAN for Maintenance of
    Certification program as a module

53
CPT Medicare Payment Relative to Site of Services
Professional Component Technical Component
Inpatient Use -26 modifier Paid to physician Single DRG payment made to hospital to cover all technical expenses for that admission (IPPS)
Outpatient medical center (includes EDs) Use -26 modifier Paid to physician APC payment made to medical center (HOPPS)
Outpatient, private office Global bill Submitted for professional and technical components Paid to physician Global bill Submitted for professional and technical components Paid to physician
54
Mapping of Seizure/Epilepsy DRG
Documentation Principle Diagnosis Secondary Diagnosis MS DRG v25
Seizure, psychogenic nonepileptic seizure, spells 780.39 (other convulsions) 101 Sz w MCC 100 Sz w/o MCC
Recurrent seizures, Epilepsy, Seizure disorder Specific epilepsies 345.8y (other recurrent seizures) 345.xy 101 Sz w MCC 100 Sz w/o MCC
Psychogenic conversion disorder 300.11 (Conversion disorder) 780.39 880 Acute Adjustment Reaction
55
2011 Hospital Outpatient Prospective Payment
System (HOPPS)
  • Published 11/24/2010
  • 782 pages in the Federal Register
  • http//edocket.access.gpo.gov/2010/pdf/2010-27926.
    pdf
  • Payment for the technical portion of CPT codes
    done on Medicare Outpatients
  • Some outpatient procedures with HOPPS values have
    no payment assigned in MFS for doctors billing
    global
  • 95951 24 hour video EEG is carrier priced
  • 95965 MEG is carrier priced
  • Payment for technical portion of Medicare
    inpatients is bundled into a single DRG payment
  • Payment for technical fees in outpatients in
    private offices is in the Medicare Physician Fee
    Schedule
  • Billing global in private offices

56
2011 HOPPS APC 0213
  • APC 0213 Level 1 Sleep, EEG, and CV studies
  • 95812 EEG 41-60 min
  • 95812 EEG gt 1 hour
  • 95816 EEG awake and drowsy
  • 95819 EEG awake and asleep
  • 96822 EEG sleep and/or coma
  • 95827 EEG all night recording
  • 95958 EEG monitoring/function test
  • 2010 APC rate is 162.06
  • 2011 APC rate will be 166.64
  • Increase of 4.62 or 2.83

57
2011 HOPPS APC 0209
  • APC 0209 Level II sleep, EEG, CV
  • 95950 ambulatory cassette EEG
  • 95951 24 hour video EEG
  • 95953 ambulatory digital EEG
  • 95956 24 hour EEG without video
  • MSLP and polysomnograms
  • 2010 APC Rate is 770.55
  • 2011 APC Rate will be 780.77
  • Increase of 10.22 or 1.33

58
2011 HOPPS APC 218
  • APC 218 Level II Nerve and Muscle Tests
  • 95970 Neurostimulation, analysis with no
    programming
  • 95954 EEG monitoring with drug administration
  • 2010 payment is 80.65
  • 2011 payment will be 80.78
  • Increase of 0.13 or 0.16

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2011 HOPPS APC 216
  • APC 216 Level III Nerve and Muscle Tests
  • 95961 Cortical Stimulation, 1st hour
  • 95962 Cortical Stimulation, each additional hour
  • 2010 payment is 180.86
  • 2011 payment will be 186.17
  • Increase of 5.31 or 2.94

60
2011 HOPPS APC 0692
  • APC 0692 Level III Electronic Analysis of Devices
  • 95971 Analyze neurostim, simple
  • 95972 Analyze neurostim, complex
  • 95973 Analyze neurostim, complex
  • 95974 Cranial neurostim, complex
  • 95974 Cranial neurostim, complex
  • 95978 Analyze neurostim brain, 1st hour
  • 95979 Analyze neurostim brain, each 1 hour
  • 95982 Low gain neurostim subseq w/ reprogram
  • 2010 payment is 107.85
  • 2011 payment will be 110.95
  • Increase of 3.10 or 2.87

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2011 MEG HOPPs
  • Technical payments for MEG studies in
    hospital-based outpatient care facilities
  • Does not apply to free standing MEG sites
  • Carrier priced
  • Does not apply to MEG studies done on inpatients
  • Technical fees bundled to DRG

62
2010 HOPPS APC 0067
  • APC 0065 Level III Stereotactic Radiosurgery,
    MRgFUS, and MEG
  • 95965 MEG, spontaneous
  • 2010 payment is 3571.78
  • 2011 payment is 3408.69
  • Decrease of 163.09 or 4.57
  • Caught by the change in assumption of work hours
    for equipment costing more than 1 M. Decrease
    of 394.54 in past two years.
  • New MEG cost reporting may help
  • MEG and EEG were combined on Line 54 of the
    Medicare Cost Report
  • Now MEG is moved to a new line, 54.01

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2011 HOPPs APC 0065
  • Level I Stereotactic radiosurgery, MrgGUS, and
    MEG
  • 95966 MEG Evoked Response
  • 95967 Additional MEG Evoked Response
  • 2010 payment is 962.61
  • 2011 payment will be 977.12
  • Increase of 14.51 or 1.5

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Update on HFHS Transition to ICD-10 Coding
System Kickoff December 9, 2010
  • Nov 18th , 2010

65
ICD-10-CM/PCS (Clinical Modification/Procedure
Coding System)
Final Rule HHS published on Jan 2009
Compliance Date October 1st, 2013
  • ICD-10-CM/PCS will enhance accurate payment for
    services rendered and facilitate evaluation of
    medical processes and outcomes.
  • ICD-10-CM The diagnosis classification system
    developed by the Centers for Disease Control and
    Prevention for use in all (inpatient and
    outpatient) U.S. health care treatment settings.
    Diagnosis coding under this system uses 37 alpha
    and numeric digits and full code titles, but the
    format is very much the same as ICD-9-CM
  • ICD-10-PCS The procedure classification system
    developed by the Centers for Medicare Medicaid
    Services (CMS) for use in the U.S. for inpatient
    hospital settings ONLY. The new procedure coding
    system uses 7 alpha or numeric digits while the
    ICD-9-CM coding system uses 3 or 4 numeric
    digits.
  • A number of other countries have already moved to
    ICD-10, including
  • United Kingdom (1995)
  • France (1997)
  • Australia (1998)
  • Germany (2000) and
  • Canada (2001).

66
HIPAA X12 5010 Electronic Transaction Changes
  • All HIPAA X12 Electronic Transactions with payors
    (e.g., eligibility verification, claims,
    remittance advise) have to be upgraded from
    current 4010 version to newer 5010 version
  • This will enable payors to request more
    information in the future electronic transactions
  • (adding extra lanes to electronic freeway system
    to carry more information)
  • This change has to be operational by Jan 1 2012
    and it is a pre-requisite for ICD 10 CM/PCS
    changes

67
ICD-9-CM - Shortcomings
  • Shortcomings of ICD-9 include
  • ICD-9 is outdated, with only a limited ability to
    accommodate new procedures and diagnoses
  • ICD-9 lacks the precision needed for a number of
    emerging uses such as pay-for-performance and
    biosurveillance.  Biosurveillance is the
    automated monitoring of information sources that
    may help in detecting an emerging epidemic,
    whether naturally occurring or as the result of
    bioterrorism
  • ICD-9 limits the precision of diagnosis-related
    groups (DRGs) as a result of very different
    procedures being grouped together in one code
  • ICD-9 lacks specificity and detail, uses
    terminology inconsistently, cannot capture new
    technology, and lacks codes for preventive
    services and
  • ICD-9 will eventually run out of space,
    particularly for procedure codes.

68
Expected Benefits from usage of ICD 10 codes
  • Adoption of the ICD-10 code sets is expected to
  • Support value-based purchasing and Medicares
    anti-fraud and abuse activities by accurately
    defining services and providing specific
    diagnosis and treatment information
  • Support comprehensive reporting of quality data
  • Ensure more accurate payments for new procedures,
    fewer rejected claims, improved disease
    management, and harmonization of disease
    monitoring and reporting worldwide and
  • Allow the United States to compare its data with
    international data to track the incidence and
    spread of disease and treatment outcomes because
    the United States is one of the few developed
    countries not using ICD-10.

69
Next Generation of Coding
Structural Changes
S. No. ICD-9-CM ICD-10-CM / PCS
1. Minimum of 3 digits, maximum of 5 digits, decimal point after the third digit Minimum of 3 digits, maximum of 7 digits, decimal point after the third digit
2. Numeric, except for supplementary codes V codes and E codes Alphanumeric, with all codes using alphabetic lead character V and E codes have been eliminated and incorporated into the main code set
3. Structure of injuries designated by wound type Structure of injuries designated by body part (location)
4. Diagnosis 13,000 Codes IP Procedure 4,000 Codes 67,000 ICD-10-CM Codes 87,000 ICD-10-PCS Codes
Mapping ICD-9 To ICD-10
One to One One old code to one new code . 3,458 codes or 24.52 of all ICD-9 DX codes
Single Entry One old code to one of many new code. 9,600 codes or 68.07 of all ICD-9 DX codes
Combination Entry One old code is split into multiple new code. 629 codes or 4.46 of all ICD-9 DX codes
No Match All new codes. 416 codes or 2.95 of all ICD-9 DX codes
70
Difference between ICD-9 and ICD-10
ICD-9-CM Mechanical complication of other
vascular device, implant and graft 1 code (996.1)
ICD-9-CM Angioplasty 1 code (39.50)
ICD-10-CM Mechanical complication of other
vascular grafts 156 codes, including T82.310
Breakdown (mechanical) of aortic (bifurcation)
graft (replacement) T82.311 Breakdown
(mechanical) of carotid arterial graft
(bypass) T82.312 Breakdown (mechanical) of
femoral arterial graft (bypass) T82.318
Breakdown (mechanical) of other vascular
grafts T82.319 Breakdown (mechanical) of
unspecified vascular grafts T82.320
Displacement of aortic (bifurcation) graft
(replacement) T82.321 Displacement of carotid
arterial graft (bypass) T82.322 Displacement
of femoral arterial graft (bypass) T82.328
Displacement of other vascular grafts
ICD-10-PCS Angioplasty codes 854 codes Specifying
body part, approach, and device,
including 047K04Z Dilation of right femoral
artery with drug-eluting intraluminal device,
open approach 047K0DZ Dilation of right
femoral artery with intraluminal device, open
approach 047K0ZZ Dilation of right femoral
artery, open approach 047K34Z Dilation of
right femoral artery with drug-eluting
intraluminal device, percutaneous
approach 047K3DZ Dilation of right femoral
artery with intraluminal device, percutaneous
Approach
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ICD-10 Example
  • Fracture of wrist
  • Patient fractures left wrist
  • A month later, fractures right wrist
  • ICD-9-CM does not identify left versus right
  • (requires additional documentation to clarify
    during claim
  • adjudication)
  • ICD-10-CM describes left versus right, Initial
    encounter, subsequent
  • encounter, routine healing, delayed healing,
    nonunion, or malunion

72
Potential Risks of Transition to ICD10
  • Training and Education ICD10 codes are based on
    human anatomy and physiology will require
    significant mind set change for coders to get
    used to new system
  • Business Process Potential significant shift in
    roles and responsibilities between clinicians and
    coders to handle the complexity of ICD 10s
  • Information Technology Significant risk in
    modifications to several systems to accommodate
    new code sets
  • Financial/Reimbursement Transition from ICD 9
    to ICD 10 can result into temporary delays in
    cash flow from payors due to technology
    implementation glitches

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ICD 10 Potential Impacts to HFMG Operations
  • Significant process changes in the areas of
    documentation, coding and charge capture
  • May result in extensive training for Physicians,
    Coders and other care-givers
  • MediPac revenue cycle systems will be modified to
    address transition to ICD 10
  • OMR and TCAP systems have to be replaced with
    newer technology to handle the complexity and
    explosion of ICD 10 codes

75
OMR Considerations
  • HFMG Clinic Coding model Physician Model
    enabled by branching technology logic (CAC) vs.
    Centralized Coder model
  • Handheld devices with future integration with
    CarePlus(NG)/CPOE solution

76
Phase 1 Impact Assessment Planning
HFHS ICD-10 Project Phasing
  • Develop project management structure
  • Engage Steering Committee and Business Unit
    Operational Teams
  • Assess Process Implications
  • Assess IT Systems impact
  • Create Multi-Year Capital and Expense budget to
    address the change

Phase 2 Process Redesign and IT System Changes
  • Process Redesign-Current and Future State
  • Detailed analysis, design and build of IT changes
  • Create testing plans to validate process redesign
    and IT system changes

77
Phase 3 Testing and Implementation Planning
HFHS ICD-10 Project Phasing
  • Internal Testing and Training
  • External Testing (Payors, Regulatory Reporting)
  • Operational Readiness and Implementation Planning

Phase 4 End User Training and Go-Live
  • Finalize IT system changes and certify testing
  • Finalize process changes and certify operational
    readiness
  • Complete intensive coding professional education

Phase 5 Post Go-Live Support
  • Monitor coding accuracy for reimbursement, coding
    productivity and continue with appropriate coding
    professional training

78
HFHS Project Phasing and Tentative Timeline
79
Key components of level of service
History Chief complaint (CC) History of present illness (HPI) Past medical, family, social history (PFSH) Review of systems (ROS)
Examination Neurological single system exam or general multi-system exam
Medical Decision Making Number of diagnoses or number of management options Complexity of data Risk of morbidity and mortality
80
You Get Credit for Trying...
  • Sometimes, you cannot do a full H P no matter
    what
  • Document your attempt and what happened
  • History
  • Patient aphasic, lethargic, in coma, won't
    answer, demented, etc.
  • PE
  • Patient aphasic, uncooperative, limb amputated,
    strict bedrest, etc.
  • Do not write unable to obtain
  • Forgetting one bullet point on a New Patient
    visit has major consequences in billing drops to
    a level 1 visit

81
Tips for documenting history
  • CC always required
  • ROS is very important
  • must document pertinent positives, may be in HPI
  • all other systems negative permitted
  • ROS deficiency a major reason for not meeting
    criteria for highest level of service
  • ROS and PFSH
  • staff may record, and physician note
  • may use previous ROS and PFSH, revise as needed
  • If history not obtainable, document why

82
History of Present Illness (HPI)
  • 1997 E M Guidelines allow for the option of
    documenting the status/acuity of chronic problems
    and/or inactive problems to complete the History
    of Present Illness.
  • IMPORTANT You must document the chronic or
    inactive problem that you are addressing during
    the visit and detail the current status/acuity of
    the problem

83
Documenting the neurological examination
  • CPT defines 25 individual elements (bullets)
    of the neuro exam, in 4 main groups
  • constitutional, eyes, cardiovascular
  • higher integrative functions or mental status
  • cranial nerves
  • musculoskeletal, motor, and sensory
  • CPT specifies the numbers of elements that must
    be documented for each level of service
  • You must comment on these elements (WNL not
    acceptable)

84
Medical Decision Making (MDM)
  • Documentation Tips
  • Document the test(s) that you have reviewed
    (summarize what you have reviewed) and ordered
  • Document discussing test(s) with the physician
    who performed the test. For example discussing
    with the cardiologist the interpretation of an
    echocardiogram
  • Document the review of old records. Remember you
    must summarize what you have reviewed.
  • For Example Patient was admitted a month ago
    for __________. Course of treatment included
    ____and patient was discharged with home health
    care and continue with _________.
  • IF IT IS NOT DOCUMENTED IT IS NOT DONE

85
Medical Decision Making (MDM)
  • Medical decision making refers to the complexity
    of establishing a diagnosis and/or selecting a
    management option. It can be broken down into
    three components.
  • Number of diagnoses or management options
  • Amount and complexity of data to review (Previous
    documentation tips support this component)
  • Risk of complication and/or morbidity or mortality

86
2002 CMS Regulations on Supervision of Residents
and Students
  • Effective date November, 22, 2002
  • Resident means an individual who participates in
    an approved graduate medical education (GME)
    program
  • Receiving a staff or faculty appointment or
    participating in a fellowship does not by itself
    alter the status of resident.
  • A student is never considered to be an intern or
    a resident. Medicare does not pay for any
    clinical service furnished by a student.
    (Medicare pays hospitals and medical schools
    large sums of money in other ways.)

87
Medicare Teaching Definitions
  • Critical or key portion means that part (or
    parts) of a service that the teaching physician
    determines is (are) a critical or key portion(s).
  • Documentation may be dictated and typed,
    hand-written or computer-generated, and typed or
    handwritten.
  • Documentation must be dated and include a legible
    signature or identity.

88
Payment Definitions
  • For purposes of payment, E/M services billed by
    teaching physicians require that they personally
    document at least the following
  • a. That they performed the service or were
    physically present during the key or critical
    portions of the service when performed by the
    resident and
  • b. The participation of the teaching physician in
    the management of the patient.
  • When assigning codes to services billed by
    teaching physicians, reviewers will combine the
    documentation of both the resident and the
    teaching physician.
  • Documentation for the service must support the
    medical necessity of the service.

89
Examples of Acceptable Notes
  • I was present with resident during the history
    and exam. I discussed the case with the resident
    and agree with the findings and plan as
    documented in the residents note.
  • I saw the patient with the resident and agree
    with the residents findings and plan.
  • See residents note for details. I saw and
    evaluated the patient and agree with the
    residents finding and plans as written.
  • I saw and evaluated the patient. Agree with
    residents note but lower extremities are weaker,
    now 3/5 MRI of L/S Spine today.

90
Examples of Unacceptable Notes
  • Agree with above.
  • Rounded, Reviewed, Agree
  • Discussed with resident. Agree.
  • Seen and agree.
  • Patient seen and evaluated
  • A legible countersignature or identity alone.

91
E/M Service Documentation Provided By Students.
  • Any contribution and participation of a student
    to the performance of a billable service (other
    than the review of systems and/or past
    family/social history which are not separately
    billable, but are taken as part of an E/M
    service) must be performed in the physical
    presence of a teaching physician or physical
    presence of a resident in a service meeting the
    requirements set forth in this section for
    teaching physician billing.

92
E/M Service Documentation Provided By Students.
  • Students may document services in the medical
    record.
  • Documentation by a student that may be referred
    to by the teaching physician is limited to the
    review of systems and/or past family/social
    history.
  • The teaching physician may not refer to a
    students documentation of physical exam findings
    or medical decision making in his or her personal
    note.
  • The teaching physician must verify and redocument
    the history of present illness as well as perform
    and redocument the physical exam and medical
    decision making activities of the service.

93
DISCHARGE DAY
  • On the day of discharge, code as follows
  • 99238 for a total staff time of 30 minutes or
    less
  • 99239 for a total staff time of more than 30
    minutes
  • You must document the time spent in your note
  • Time does not need to be continuous
  • Time does not need to be spent with the patient
    and includes
  • Writing Rx
  • Doing discharge summary
  • Making follow up arrangements
  • Contacting other providers
  • Resident time does not count
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