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Monday, October 25, 2010

Medicare participation: Why, indeed?

As I write this entry, the "SGR Countdown" on the Family Practice Management (FPM) home page has dropped to less than 40 days. And it reminds me of a question that a family physician asked awhile back: "Why would any physician in his [or her] right mind want to participate in a system such as this [Medicare]?"

Why, indeed? I doubt it's for the money. I understand that Medicare is the best payer in some parts of the country (a scary thought as we head into Halloween!).  However, the fact is that the current Medicare physician fee schedule conversion factor ($36.8729) is less than it was in 2004. 

I also doubt that it's because of the simplicity and ease of interaction with Medicare. As documented in this blog and elsewhere, just getting enrolled in Medicare can be a nightmare, and once you're in, there are the myriad of other rules and regulations with which physicians must comply.

So, why do family physicians participate in Medicare? The most common answer that I've heard is that they do it for their Medicare patients. There is a relationship and obligation there that family physicians are reluctant to break. 

What confuses me about this answer is that the law allows physicians to privately contract with those patients and continue to treat them without being bound by Medicare's rules or low payments. Both FPM and the AAFP web site explain what this option involves and provide sample forms for pursuing the option. It does not seem difficult, and yet, the last that I heard, only about 10,000 of the more than 850,000 physicians in the U.S. had elected to pursue this option. 

In the end, I do not have a good answer to the question, although I still think it's a good question. What do you think?

Friday, October 8, 2010

Accountable care organizations and the future of physician payment

This week, the Federal Trade Commission (FTC), the Centers for Medicare and Medicaid Services, and the Office of the Inspector General in the U.S. Department of Health and Human Services (HHS) discussed legal issues related to accountable care organizations (ACOs) during a public workshop in Baltimore.

As promised in the meeting agenda, an FTC panel debated circumstances under which independent health care providers participating in an ACO could engage in price point negotiations with private payers without running afoul of federal antitrust laws that prohibit price-fixing. Also, panel participants explored different ways in which the HHS secretary could exercise waiver authority or create new exceptions and safe harbors related to the physician self-referral law, the federal anti-kickback statute, and the civil monetary penalty law, for the purpose of encouraging the creation and development of ACOs. The AAFP submitted comments that were included in the meeting record, and the Academy will continue to track the progress of the issues discussed.
As I listened to the workshop and as I have thought about it since, my thoughts had less to do with how ACOs might be facilitated and more to do with what they might mean for coding by and payment of family physicians.  Regarding coding, I am inclined to think that ACOs will de-emphasize the importance of procedure and service coding while heightening the importance of diagnosis coding. My reason for thinking so is that I expect ACOs will be paid on something other than a fee-for-service basis and, in turn, will pay physicians accordingly. When payment is made, for example, on an episode-treatment or global capitation basis, coding of each individual service becomes much less important than it is under fee-for-service. At the same time, appropriate risk adjustment of global capitation or delineation of episodes of care will depend, at least initially, on correct and complete coding of each patient's condition(s), which is all about diagnosis coding.
Regarding the payments themselves, I am optimistic that family physicians can do well in an ACO model of health care delivery. Family medicine has long touted its value, essentially arguing that nobody can do it better for less. ACOs, according to proponents, are all about cost-effectiveness, which suggests that they will depend on family physicians to succeed. That dependency should create leverage for family physicians to be paid at a level that is commensurate with the value that they bring to the ACO. Of course, this assumes family physicians exercise this leverage and choose to play a key role in the formation and ongoing governance of ACOs. 
Admittedly, this is all a bit of crystal ball gazing on my part, and as my 401(k) results will attest, crystal ball gazing is not my strong suit. As in most matters, only time will tell, but I'd like to hear your predictions. What do you think?

Thursday, October 7, 2010

New tobacco-use cessation counseling benefits: Three billing scenarios

The Centers for Medicare & Medicaid Services released guidance this week on payment for expanded smoking and tobacco-use cessation counseling. This service is now covered for patients who use tobacco but do not have symptoms of related conditions, and the coverage is retroactive to Aug. 25, 2010. The counseling must be provided by a physician or other qualified health care professional (e.g., physician assistant).

Now for the not-so-good news. Allowing different benefits for the same service based on whether it is preventive or problem-oriented creates coding and payment guidelines that are, well, problem-oriented. Here's what I mean:

While asymptomatic patients became eligible for the counseling benefit on Aug. 25, 2010, the full benefit of the preventive service coverage does not begin until Jan. 1, 2011. For services delivered from Aug. 25, 2010, to Dec. 31, 2010, charges will be subject to any unmet deductible and to the patient's co-insurance. For dates of service Jan. 1, 2011, and after, the same services will not be subject to deductible and co-insurance (i.e., there will be no out-of-pocket expense for the patient who receives the service). This may require some patient education.

Here's what else you need to know to code and bill for these services now and in the future:

• For counseling provided to patients who use tobacco and have a condition that is adversely affected by tobacco use and/or are undergoing a treatment that is adversely affected by tobacco use, continue reporting CPT codes 99406 and 99407. The benefits for these patients have not changed. (If you're not familiar with these services, see the FPM article An Update on Tobacco Cessation Reimbursement.)

• For counseling provided to patients who do not have symptoms of conditions related to tobacco use and are not undergoing a treatment that is adversely affected by tobacco use, report unlisted CPT code 99199, "Unlisted special service, procedure, or report" for dates of service Aug. 25, 2010, through Dec. 31, 2010.  Submit ICD-9 codes 305.1, "Non-dependent tobacco-use disorder," or V15.82, "History of  tobacco use," as well. Be sure to inform patients that unless there is a secondary insurance that pays the balance after Medicare, they may be responsible for an unmet deductible and for co-insurance amounts.

• For counseling provided to asymptomatic patients beginning on Jan. 1, 2011, you should bill using the new Medicare G codes: G0436, "Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes," or G0437, "Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes." The same diagnosis codes, 305.1 or V15.82, will be required. Again, patients will not have an out-of-pocket expense for these services when they are delivered on Jan. 1, 2011, or after.

When reporting any significant and separately identifiable evaluation and management service on the same date as tobacco-use cessation counseling, append modifier 25 to the evaluation and management code.

These are some of the first changes for preventive services in response to requirements of the Affordable Care Act. There will no doubt be other guidance coming from CMS and private payers on coverage, coding, and payment for preventive services. Stay tuned, and we will deliver information as promptly as possible after its publication.

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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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