Med Law Blog : Pennsylvania Health Care Lawyers & Attorneys : Tucker Arensberg Law Firm : Employee Benefits, HIPAA & HIT in Pittsburgh, PA

Medicare will cover intracranial percutaneous angioplasty (PTA) with stenting effective February 5, 2007. MLN Matters #MM5432 released on January 5, 2007 explains the changes in Medicare policy regarding reimbursement for PTA. Coverage will be effective as of November 6, 2006 for a PTA and stenting of intracranial arteries for the treatment of cerebral artery stenosis greater than equal to 50% in patients with intracranial atherosclerotic disease when furnished in accordance with FDA-approved protocols. The key points announced in the MLN Matters article are as follows:

§      Providers billing FIs and A/B MACs should note this coverage applies to claims with:

·        A discharge date on or after November 6, 2006;

·        ICD-9-CM procedure codes of 00.62 and 00.65 both being present;

·        ICD-9-CM diagnosis code 437.0 present; and

·        The IDE number present on a 0624 revenue code line.

§      Non-institutional providers billing Medicare carriers or A/B MACs should note this coverage applies to claims with:

·        CPT code 37799 (Unlisted procedure, Vascular surgery);

·        A QA modifier to denote Category B IDE clinical trial; and

·        The appropriate IDE number.

For full information on the transmittals can be obtained from the CMS website at the following two link:

http://www.cms.hhs.gov/Transmittals/downloads/R1147CP.pdf

http://www.cms.hhs.gov/Transmittals/downloads/R64NCD.pdf.

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Coincidentally, just a few days after the Office of Inspector General announced the $3 million settlement of the credit balance case with the Tennessee cardiology practice, Highmark Medicare Services issued a bulletin reminding providers of their obligation to file the Medicare Credit Balance Detail Report 838. Let me remind you that part of the basis for the Tennessee settlement was that the provider groups maintain their records to conceal the credit balances. Hopefully, your internal records will agree with the Medicare Credit Balance Detail Report. The Highmark Medicare Services reminder can be accessed at:

http://www.highmarkmedicareservices.com/bulletins/parta/news/credit-balance-qe-123106.

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JOINT COMMISSION PROPOSES STANDARDS FOR DISRUPTIVE PHYSICIANS

The Joint Commission (which has always been the informal name for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and which will now be its formal name) has proposed disruptive behavior standards for Joint Commission accreditation, which it intends to apply in early 2007.

The new standard, LD.3.15, will state: “As a critical component of the culture of safety, leaders set expectations for behavior among those who work in the organization.” The new elements of performance will be as follows:

1.         The leaders develop a code of conduct that applies to everyone who works in the organization.

2.         The code of conduct defines desirable and disruptive behavior.

3.         All who work in the organization are educated about both desirable and disruptive behaviors.

4.         The leaders develop processes for managing disruptive behavior.

5.         Leaders identify the rules of individual leadership groups in managing disruptive behavior.

6.         The organized medical staff manages disruptive behavior exhibited by physicians or individuals who are granted clinical privileges.

7.         Leaders establish a fair hearing process for those who exhibit disruptive behavior.

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Two former employees of East Tennessee Heart Consultants, a forty physician cardiology practice in Tennessee, tipped off federal prosecutors, who then filed a qui tam claim alleging the cardiology practice had a policy of retaining overpayments for services provided unless refunds were specifically requested, and that the practice maintained its billing records to conceal the credit balances.

Under the terms of the settlement agreement, the cardiology practice will pay $1.5 million to the federal government, $200,000 to the State of Tennessee, $44,000 to Blue Cross Blue Shield, $123,000 to private insurers, and $1 million to thousands of patients. East Tennessee Heart Consultants has also entered into a 5-year corporate integrity agreement with the Office of Inspector General, the terms of which can be viewed on the OIG website accessible through the health law links on this Blog.

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Highmark Blue Cross Blue Shield plans to follow the Medicare reductions for the technical component of multiple diagnostic imaging services beginning in the spring of 2007. Following is a quote from the announcement in the December 2006 PRN:

“Highmark Blue Cross Blue Shield plans to reduce payment for certain diagnostic imaging services when more than one service is performed for the same patient, during the same session, on the same service date.

Blue Cross Blue Shield’s payment reduction will be similar to the policy implemented by the Centers for Medicare & Medicaid Services in January 2006.

Blue Cross Blue Shield’s payment reduction will affect only the technical component of the diagnostic imaging services. Implementation of the payment reduction is planned for spring of 2007.”

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It seems that electronic health records (EHRs) are constantly being touted as the next best way to improve both healthcare quality and medical practice profitability, but adoption of EHRs by physician practices continues to languish. The range for provider adoptions in small and solo practitioners’ offices, as determined by the Robert Wood Johnson Foundation, is somewhere between 13% and 19%. The impediments to adoption of EHR appear to be cost, doubt as to the benefits, and uncertainty regarding new technology, despite some of the following claims:

§      The Alliance for Health Reform recently reported that “research has shown that computerized physician order entry (CPOE) systems for prescriptions can reduce preventable medication errors by as much as 55%,”

§      Early Family Practice Management reports indicated that physicians are undercoding E&M Codes by as much as 33%, while overcoding by only 16%, leading to estimates that physicians are losing as much as $60,000 annually through coding inefficiencies and mistakes, and

§      The Institute of Medicine Report first indicated that as many as 100,000 Americans die each year due to preventable medical mistakes.

In the next month or so, Tucker Arensberg is planning to arrange a program that will assist you in evaluating EHR adoption. The purpose of the program is to explain the practical and contracting steps you must take to adopt an EHR program, educate you regarding the new federal Safe Harbors allowing hospitals to provide EHR hardware and software, and provide an opportunity for a hands-on demonstration of an actual EHR application as it would operate in your practice.

Since we are just planning this program, would do not have dates or times to announce yet, but I would be most interested in knowing if you would be interested in attending, assuming the times and locations work with your schedule. Please respond via email to mcassidy@tuckerlaw.com.

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