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Wednesday, September 17, 2014

Time to get feedback on 2013 PQRS and possible Medicare penalties

The Centers for Medicare & Medicaid Services (CMS) has just released feedback reports from the 2013 Physician Quality Reporting System (PQRS). The reports permit physicians to see how they did on PQRS in 2013, a factor in determining whether or not the physicians will be subject to a 1.5 percent Medicare payment adjustment (cut) in 2015.

To find your own feedback report, follow the instructions beginning on page 25 of the PQRS user guide

The feedback reports themselves will not say whether a physician is subject to the 2015 payment adjustment. CMS will do that with notices sent to physicians in late October or early November. CMS staff did note, however, that physicians could avoid the penalty if they successfully reported just one measure for one patient in 2013, and that should be apparent on the feedback reports.

Physicians in large groups will have added interest in the feedback reports. Next year is the first year the CMS will implement the value-based payment modifier, which the agency is initially applying only to groups of 100 or more eligible professionals.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Monday, September 15, 2014

Medicare gives update on claim denials for incarcerated beneficiaries

Last year, the Centers for Medicare & Medicaid Services (CMS) refused to reimburse or ordered repayments from medical practices that had provided health services to beneficiaries the agency’s records showed were in prison on the date of service.

CMS officials later discovered that the information it used to determine whether patients were “in custody” or “incarcerated” was faulty, and the agency began making refunds.

Most of the refunds were made before the end of 2013. CMS sent to providers affected by the problem spreadsheets listing each claim for which a refund was paid.

Of course, not all of the repayment demands were determined to be invalid. Physicians who received repayment requests they believe were sent in error can ask their Medicare Administrative Contractor (MAC) to reopen the claim. Also, if a physician’s MAC provided a remittance advice (RA) indicating a temporary allowance (TA) but no other information, the physician can ask for an explanation from the MAC.

For more information on coverage and claims denials for services furnished to incarcerated Medicare beneficiaries, read this article and fact sheet from CMS.

Wednesday, September 3, 2014

HHS makes EHR Meaningful Use deadline changes final

The Department of Health and Human Services on Friday published the final version of rules that give physicians, hospitals, and other health care providers additional flexibility in how they comply with the Meaningful Use program in 2014.

The final rule largely mirrors the proposal released in May. Specifically, physicians this year can use certified electronic health record technology (CEHRT) that meets the 2011 criteria or a combination of the 2011 and 2014 criteria to attest to the Medicare and Medicaid EHR Incentive Programs. All physicians will be required to use the 2014 CEHRT criteria to attest in 2015.

The change was made after it was determined that technology meeting the updated criteria was not going to be widely available to users this year.

The final rule also gave providers who began Meaningful Use in 2011 or 2012 until 2017 to begin Stage 3 instead of the beginning of 2016.

Of course, although these delays are welcome, practices shouldn't become complacent or slow down their efforts to achieve compliance.

For more information on Meaningful Use and EHRs in general, see FPM's Electronic Health Records topic collection.

Friday, August 29, 2014

CMS providing Meaningful Use exemption for slow Internet

Physicians working to comply with stage 2 of the Centers for Medicare & Medicaid Services' (CMS) Meaningful Use program know that not all of the requirements are under their control.

Specifically, more than 5 percent of patients must send a secure message to their physician that is received using the electronic messaging function of the electronic health record (EHR), and more than 5 percent must view, download, or transmit their health information to a third party.

But both of those require the patient having access to broadband Internet service.

Enough physicians in Internet-poor locales have asked CMS how they can be required to meet those guidelines that the agency has finalized an exemption.

Under the rule, an eligible professional will not have to meet either of the above Meaningful Use measures if at least 50 percent of his or her patient encounters are in a county where more than 50 percent of the housing units lack access to broadband download speeds of at least 3 megabits per second (Mbps), as measured by the Federal Communications Commission (FCC) on the first day of the EHR reporting period.

Physicians can check the broadband download speed in their county through the FCC's National Broadband Map. Click "Analyze the data" and then "Rank your geography." Under step one, pick "Rank within a State," click "County," and then select your state. Under step two, click "Speed" (which defaults to a download speed of > 3Mbps). On the next screen select "Manage metrics" and then click "% housing units." As an example, here's the breakdown for FPM's home state of Kansas.

It must be noted, however, that the FCC map is based on advertised broadband speeds not typical ones, so the vast majority of counties in the United States are considered to have access to broadband speeds of 3 Mbps or more.

That means unless you practice in some truly remote areas of the country, slow broadband may not be an adequate defense against Meaningful Use stage 2.

Wednesday, August 27, 2014

Medicare plans new coding modifiers for 2015

The Centers for Medicare & Medicaid Services (CMS) recently announced that it is creating four new Healthcare Common Procedure Coding System (HCPCS) modifiers that will further refine the popular -59 modifier.

Adding a modifier -59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. Family physicians and others often use it to override edits found in Medicare’s National Correct Coding Initiative (NCCI). In fact, according to CMS, -59 is the most widely used modifier in the HCPCS.

That popularity is partly because, as currently defined, the -59 modifier can be used in a wide variety of circumstances, such as identifying different encounters, different anatomic sites, or distinct services. But physicians aren't always clear on why they're using the modifier, and, from CMS’s perspective, that usage is not always correct. CMS believes it can reduce the incorrect use of modifier -59 – and the subsequent Medicare overpayments – with a combination of more precise coding options, increased education, and selective editing.

As noted in the latest Medicare Learning Network Matters article, CMS on Jan. 1, 2015, will establish four new HCPCS modifiers to define specific subsets of the -59 modifier. They are referred to collectively as -X{EPSU} modifiers:

•    XE - Separate Encounter, a service that is distinct because it occurred during a separate encounter,
•    XS - Separate Structure, a service that is distinct because it was performed on a separate organ/structure,
•    XP - Separate Practitioner, a service that is distinct because it was performed by a different practitioner, and
•    XU - Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.

For the time being, CMS will continue to accept the -59 modifier. But don't expect that to last indefinitely as the agency notes that, under CPT, physicians should not use the -59 modifier when a more descriptive modifier is available. That means CMS may decide to require a more specific - X{EPSU} modifier for billing certain codes it believes are more likely to generate billing errors. For example, CMS may designate a particular NCCI code pair as payable only with the –XE (Separate Encounter) modifier and not the -59 or other -X{EPSU} modifiers. So be prepared to be more selective in your use of modifiers with Medicare in the near future.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday, August 20, 2014

How much is care management worth?

The Centers for Medicare & Medicaid Services' (CMS) proposal to begin paying for chronic care management in 2015 has led some to ask how much care management is worth. The CMS's proposal values it at approximately $42 for 30 days.

However, CMS’s Comprehensive Primary Care Initiative says it is reportedly worth between $8 and $40 per beneficiary per month (PBPM), averaging $20 PBPM during the first two years and $15 PBPM during the third and fourth years. Meanwhile, a Robert Graham Center presentation found that care management fees across public and private programs varied greatly, ranging from 60 cents to $444 per member per month (PMPM).

The fees are highly variable partly because no two fees are covering the same group of services. It is a matter of comparing not only apples and oranges but also pineapples and bananas.

One way to try to make sense of this fruit salad is to attempt to define what a care management fee should include. The AAFP recently took a stab at this by creating a policy on "Care Management Fees." The new policy lists seven elements it considers are core activities covered by a PMPM care management fee within the context of a patient-centered medical home:

1.    Nonphysician staff time dedicated to care management
2.    Patient education
3.    Use of advanced technology to support care management
4.    Physician time dedicated to care management
5.    Medication management
6.    Population risk stratification and management
7.    Integrated, coordinated care across the health care system

The policy does not address how much the AAFP thinks these activities are worth, either individually or as a group. However, it does provide a starting place for trying to value care management in a systematic way.

So, how much do you think care management is worth?

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, August 15, 2014

Open Payments program reopens after two-week glitch

The online database for a new federal program designed to track financial relationships between physicians and medical suppliers has reopened after a technical glitch forced officials to close it down almost two weeks ago.

Physicians will also have more time to check the database for errors.

The Centers for Medicare & Medicaid Services (CMS) announced Friday that physicians and teaching hospitals were again allowed to access the Open Payments system (formerly called the Sunshine Act). The initiative will eventually disclose financial payments or other transfers of value that pharmaceutical or medical device manufacturers and group purchasing organizations have made to individual physicians.

CMS shut down the system on Aug. 3 after discovering that some manufacturers and group purchasing organizations had mixed up records for physicians who have similar names, which allowed the physicians to see information that was not their own. The agency said it has worked to fix the problem, including making sure that all payment records are connected to a single physician and that the erroneous information is not published.

Despite the delay, and lingering concerns from some medical societies about releasing the data, CMS said it will still release the financial information to the public as scheduled on Sept. 30.

However, CMS has extended the 45-day period during which physicians who have registered with CMS can review and dispute data attributed to them. Originally scheduled to end on Aug. 27, the review and dispute period will now end on Sept. 8.

CMS asked physicians to make sure the National Plan and Provider Enumeration System (NPPES) and the Provider Enrollment, Chain, and Ownership System (PECOS) have their correct first name, last name, National Provider Identifier (NPI), and license information. CMS uses these programs to verify payments. The agency also said physicians should provide complete and accurate information when registering for Open Payments so that CMS can accurately match records reported about them by manufacturers and group purchasing organizations.

Thursday, August 14, 2014

Medicare offers ICD-10 testing opportunities

Now that the Centers for Medicare & Medicaid Services (CMS) has declared Oct. 1, 2015, as the new compliance date for switching to the ICD-10 coding system, the agency can again turn its eyes toward making sure Medicare providers are ready. The CMS has announced its approach to preparing the Medicare fee-for-service (FFS) community, focusing on four areas:

• CMS internal testing of its claims processing systems
• CMS Beta testing tools available for download
• Acknowledgement testing
• End-to-end testing

The first two areas are largely in CMS's control. But as for acknowledgement testing, physicians are welcome to submit acknowledgement test claims anytime up to Oct. 1, 2015. In addition, CMS is planning special week-long acknowledgement tests in November 2014, March 2015, and June 2015 to give submitters access to real-time help desk support and allow CMS to analyze testing data. Registration is not required for these virtual events, and physicians should contact their Medicare Administrative Contractor (MAC) for more information about acknowledgment testing.

CMS plans to offer Medicare claims submitters the opportunity to participate in end-to-end testing with MACs and the Common Electronic Data Interchange contractor in January, April, and July 2015. As planned, approximately 2,550 volunteer submitters can participate over the course of the three testing periods. CMS says that additional details about end-to-end testing will be available soon.

In the meantime, for more information, see Medicare Learning Network Matters Special Edition Article #SE1409 , “Medicare FFS ICD-10 Testing Approach.”

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, August 8, 2014

More physicians using EHR, but little information flowing between them

A new survey shows that physicians, particularly those in primary care, are continuing to adopt electronic health record systems at a rapid pace.

In fact, almost 80 percent of office-based physicians reported using some form of an electronic health record (EHR) in 2013, according to the study performed by the Centers for Disease Control and Prevention's National Center for Health Statistics and released this week in Health Affairs. Forty-eight percent of all physicians said their EHR systems could perform a series of "basic" EHR functions, such as recording medication and allergy lists, saving clinical notes, prescribing medication electronically, or viewing lab and imaging reports. That was double the adoption rate in 2009 and up 22 percent from 2012.

Primary care physicians' rate of adoption was highest with 53 percent saying they had a basic system, compared with 43 percent of physicians in other specialties.

But the survey also found that relatively few physicians are using or are capable of using their EHR systems to exchange patient care information with their fellow physicians, hospitals, or health systems, or even the patients themselves. Only 39 percent of office-based physicians said they had performed health information exchange with other providers or hospitals last year. Providers in larger practices or those owned by a hospital or academic medical center were far more likely to exchange information than small and solo practices.

Patient engagement with the EHR was also lagging as only 41 percent of physicians said they had the ability to let patients view, download, or transmit their health information online. Of those, about half said they actually used it. And while close to half of all physicians said they could exchange secure messages with patients through their EHR, two-thirds said they didn't in 2013.

Those results will continue to create concerns ahead of the deadline for complying with Stage 2 Meaningful Use requirements, which particularly stress interconnectivity and patient outreach.

A separate study that focused on EHR adoption and use by hospitals found that almost 60 percent of hospitals had adopted at least a basic EHR, but less than 6 percent were considered ready for Stage 2 Meaningful Use.

For information on how your practice can meet Stage 2 Meaningful Use requirements, see "Making Sense of Meaningful Use Stage 2: Second Wave or Tsunami?" in the January/February 2014 issue of FPM.

Tuesday, August 5, 2014

It's official: You have another year to prepare for ICD-10

Last week, the secretary of Health and Human Services (HHS) issued a final rule designating Oct. 1, 2015, as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10.

That means that you and your practice have another year to prepare, and the Centers for Medicare & Medicaid Services (CMS) seems committed to doing what it can to help. CMS has implemented a comprehensive testing approach, including end-to-end testing in 2015, to help ensure providers are ready. Also, CMS has an extensive array of ICD-10 resources on its web site, including the Road to 10, a free online tool that enables small provider practices to create an ICD-10 action plan and jumpstart their transition. The AAFP also has ICD-10 resources on its web site, including a timeline to assist physicians in preparing the transition to ICD-10 and a tool to calculate how much it will cost to implement ICD-10 in your practice.

Not to be outdone, Family Practice Management has amassed a collection of articles on the topic.

Whether you seek resources from CMS, AAFP, FPM, or someone else, it is not too late and certainly not too early to get started in the transition process.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, July 22, 2014

Improve the chances of your Medicare claims for obesity counseling

The most recent issue of the Medicare Quarterly Provider Compliance Newsletter said that documentation for obesity counseling has led to numerous instances of overpayment and other errors. Here’s what you need to know to ensure your documentation passes muster in an audit.

First, Medicare covers and pays for behavioral counseling for beneficiaries with obesity, measured as a body mass index (BMI) of 30 kg/m2 or greater. Specifically, obese Medicare beneficiaries are eligible for:

•    One face-to-face visit every week for the first month;
•    One face-to-face visit every other week for months 2-6; and
•    One face-to-face visit every month for months 7-12, if the beneficiary achieves the required weight loss.

Per Medicare, beneficiaries must be competent and alert at the time that they receive counseling, and the counseling must be furnished by a qualified primary care physician or other primary care practitioner in a primary care setting. Additionally, at the six-month visit, the beneficiary should receive a reassessment of obesity and a determination of the amount of weight loss. To be eligible for additional face-to-face visits occurring once a month for during months 7-12, beneficiaries must achieve documented weight loss of at least three kilograms (6.6 lbs.) during the first six months of intensive therapy.

Obesity counseling is reported with Healthcare Common Procedure Coding System (HCPCS) code G0447, “Face-to-face behavioral counseling for obesity, 15 minutes.” Medicare reviewers conducted a special study of HCPCS code G0447. Upon review, they determined that insufficient documentation caused approximately 92 percent of the improper payments. Examples of “insufficient documentation” included:

•    No physician’s signature on the encounter note
•    No documentation of the patient’s clinical condition
•    No documentation that the beneficiary has a BMI greater than or equal to 30kg/m2
•    No documentation that after six months the beneficiary lost 6.6 pounds or 3kg
•    No documentation that obesity counseling and dietary assessment actually occurred

So, to help improve the chances that your claims for obesity counseling will stand up to Medicare scrutiny, you need to document the patient’s clinical condition and qualifying BMI. You also need to document how much weight the patient has lost at the six-month mark and the counseling and dietary assessment that occurred at each visit. Finally, don’t forget to sign the encounter note when you’re done.

Medicare covers intensive behavioral therapy for obesity per National Coverage Determination 210.12. You can learn more about this benefit and the associated rules by reading section 200 of chapter 18 in the Medicare Claims Processing Manual as well as the Medicare Learning Network Matters article on obesity counseling.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Wednesday, July 16, 2014

CMS looks to add new code to track care provided off hospital grounds

If you're in a family medicine practice owned by a hospital or other health system, the recently proposed 2015 Medicare physician fee schedule offers some new reporting requirements.

The Centers for Medicare & Medicaid Services (CMS) wants to require hospitals and physicians to report a coding modifier for those services furnished in an off-campus, provider-based department.  

The modifier would be reported on both the claim form for physicians’ services and on hospital outpatient claims. CMS defines a hospital campus to be the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis by the CMS regional office. The new rule would apply to everything outside of that.

CMS said the information collected will help it improve its practice expense data and methodology under the physician fee schedule and more appropriately account for the different resource costs among traditional office, facility, and off-campus, provider-based settings.

The AAFP has prepared a summary of these and other changes proposed by CMS. You can access the full proposed rule  through the CMS web site.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, July 11, 2014

Medicare proposes paying for chronic care management

The Centers for Medicare & Medicaid Services (CMS) wants to begin reimbursing physicians for some of the unpaid care management services they provide patients with several chronic conditions.

Contained in CMS's proposed 2015 Medicare physician fee schedule, the provision would pay approximately $42 for the chronic care management (CCM) code no more than once per month per qualified patient. The payment is intended to compensate physician practices for non-face-to-face CCM services for Medicare beneficiaries who have two or more significant chronic conditions.

Under the proposal, CCM services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management. Other requirements to bill Medicare for CCM services include:

• Access to care management services 24 hours a day, seven days a week, which means providing beneficiaries with a way to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week.

• Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.

• Care management for chronic conditions, including systematic assessment of patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.

• Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.

• Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after a beneficiary visit to an emergency department; and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities.

CMS proposes that practices use an electronic health record (EHR) or other health information technology or information exchange platform to furnish the CCM services. It also says that technology solution should include an electronic care plan that is accessible to all providers within the practice, regardless of the hour of day, as well as being accessible to care team members outside of the practice. Physicians and other qualified health care professionals furnishing CCM services beginning in 2015 would be required to use an EHR certified to at least 2014 Edition certification criteria.

The AAFP has prepared a summary of this and other changes proposed by CMS.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Tuesday, July 8, 2014

CMS looks to tweak Open Payments reporting for CME events

The Centers for Medicare & Medicaid Services (CMS) Open Payment initiative hasn't truly gone into effect yet and its framers already want to change it.

The Open Payment program, which tracks and discloses financial relationships between physicians and drug and device manufacturers, will begin releasing that information by the end of September. Physicians will be able later this month to review the information reported about them and report any errors.

But in the 2015 Physician Fee Schedule proposed rule announced on July 3, CMS proposed some changes to the program based on feedback from stakeholders since the original rules were introduced last year.

Chief among those changes is a proposal requiring that applicable manufacturers disclose any payments or other transfers of value made to speakers at continuing education programs.

These types of payments had been excluded under the current rules, assuming they met three criteria:

• The speaker is appearing at a program accredited or certified by the ACCME, AAFP, ADA, AMA, or AOA,
• The manufacturer does not pay the speaker directly,
• The manufacturer does not choose the speaker or provide the third-party organizer with a list of preferred speakers.

CMS said commenters have argued that limiting the exemption to speakers at events tied to just those five organizations made the reporting requirements inconsistent and appeared to give continuing education events held by those five organizations CMS's "endorsement or support."

The agency said this was an "unintended consequence" and proposed removing the exemption language in its entirety.

Open Payments already has a general exemption for indirect payments or transfers of value where the manufacturer does not know the identity of the recipient, so payments and transfers of value to speakers would remain exempt under that rule, provided the manufacturer doesn't directly pay the speaker or provide the third-party organizers with a list of preferred speakers.

Monday, June 30, 2014

Physician recruiter sees continued plunge in private practive

One of the largest physician recruiters in the country says the market for private practice, at least among its clients, is drying up quickly.

According to an annual review by physician search firm Merritt Hawkins, less than one in 10 of the company's 3,158 search assignments between April 1, 2013, and March 31, 2014, were for independent practice settings, such as partnerships, solo offices, or concierge/direct pay practices.

The vast majority of assignments were for employed positions, with 64 percent going to hospitals and the remainder serving large groups, community health centers, or academic facilities.

By comparison, independent practice situations made up more than 45 percent of Merritt Hawkins' search assignments in 2004.

Researchers said the mounting economic and regulatory pressures of the Affordable Care Act and other changes in the health care landscape continue to fuel the shift of physicians, who typically view employed positions as more financially stable and free of the burdens of running their own practices.

Overall, there were 714 searches for family medicine, making it the most requested recruiting assignment for the company for the eighth year in a row. The next most-popular search was for internal medicine, with 235 assignments.

The average base salary for family medicine assignments during the study period was $199,000, the highest average in the last five years. That average salary is a little higher than the $190,907 found in a recent study of AAFP members.

"Concierge" and other practice models where patients directly pay the physician a retainer or other regular fee for increased access has also grown. Merritt Hawkins said it completed 32 searches during the past year for these positions – only 1 percent of total searches but an increase from 10 searches two years ago. 

The ongoing shift of medical reimbursement from models based on volume to those based on quality and value has been difficult for health care organizations, and it shows in the incentives used to attract physicians. Researchers said only 24 percent of the company's recruiting assignments included production bonuses based at least partly on quality and value, a decrease from 39 percent of assignments during the previous year.

Production bonuses based on Relative Value Units (i.e., the work units performed by a physician) are still the most common. Fifty-nine percent of assignments included that type of bonus versus 57 percent last year.

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Disclaimer

The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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