Med Law Blog

ASC PAYMENT REGS RELEASED

The Medicare Ambulatory Surgical Center (ASC) payment system final rule was published in the Federal Register by HHS on August 2, 2007. The link below is to the text of the regulations. The new payment rates will be effective for Medicare 2008, although the first impact will not be fully phased in until 2011, as follows:

                                    2008   -   25%

                                    2009   -   50%

                                    2010   -   75%

                                    2011   - 100%

The new system will increase the number of covered procedures from 2,571 5o 3,300. ASC groups expect payment reduction to a schedule that pays about 65% of hospital outpatient department payment rates.

Modern Healthcare reports in its July 23, 2007 issue that "ACS's Can't Drive at 65". The final rule established only policies and formulas for CMS to use in calculating payment rates, and the 65% is an estimate.

http://www.cms.hhs.gov/snfpps/downloads/CMS-1545-F-display.pdf

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

PART 414--PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES

24.       The authority citation for part 414 is revised to read as follows:

Authority:       Secs. 1102, 1871, and 1881(b)(1) of the Social Security Act (42 U.S.C. 1302, 1395hh, and 1395rr(b)(1)).

Subpart B--Physicians and Other Practitioners

25.       Section 414.50 is revised to read as follows:

§414.50 Physician billing for purchased diagnostic tests.

(a)        General rule.  (1) For services covered under section 1861(s)(3) of the Act and paid for under part 414 of this chapter (other than clinical diagnostic laboratory tests paid under section 1833(a)(2)(D) of the Act, which are subject to the special rules set forth in section 1833(h)(5)(A) of the Act), if a physician or medical group bills for the technical or professional component of a diagnostic test that was performed by an outside supplier, the payment to the physician or the medical group (less the applicable deductibles and coinsurance) for the technical or professional component of the test may not exceed the lowest of the following amounts:

(i)         The supplier's net charge to the physician or medical group.

(ii)        The physician's or medical group's actual charge.

(iii)       The fee schedule amount for the test that would be allowed if the supplier billed directly.

(2)        This provision applies regardless of whether the test or its interpretation was purchased by the physician or medical group billing for the test or the interpretation, or whether the right to bill for the test or its interpretation was reassigned to the physician or medical group billing for the test or the interpretation.

(3)        For purposes of paragraph (a) of this section--

(i)         The physician's or other supplier's net charge must be determined without regard to any charge that is intended to reflect the cost of equipment or space leased to the outside supplier by or through the billing physician or medical group.

(ii)        An outside supplier is someone other than a full-time employee of the billing physician or medical group.

(b)        Restriction on payment. (1)  The physician or medical group must identify the supplier and indicate the supplier's net charge for the test. If the physician or medical group fails to provide this information, CMS makes no payment to the physician or medical group and the

physician or medical group may not bill the beneficiary.

(2)        Physicians and medical groups that accept Medicare assignment may bill beneficiaries for only the applicable deductibles and co-insurance.

(3)        Physicians and medical groups that do not accept Medicare assignment may not bill the beneficiary more than the payment amount described in paragraph (a) of this section.

26.       Section 414.65 is amended by revising paragraph (a)(1) to read as follows:

§414.65 Payment for telehealth services.

(a) *   *   *

(1)        The Medicare payment amount for office or other outpatient visits, consultation, individual psychotherapy, psychiatric diagnostic interview examination, pharmacologic management, end stage renal disease related services included in the monthly capitation payment (except for one visit per month to examine the access site), individual medical nutrition therapy, and neurobehavioral status exam furnished via an interactive telecommunications system is equal to the current fee schedule amount applicable for the service of the physician or practitioner.

            *          *          *          *          *

| Posted By Michael Cassidy In Reimbursement | 1 Comments | Permalink

The text of both of the discussions of the Independent Diagnostic Testing Facility (IDTF) regulations and of the specific regulations themselves are posted below in full. The fundamental changes from the earlier proposals are as follows:

1.      IDTF must maintain comprehensive general professional liability insurance in the amount of $300,000 per location.

2.      There will no longer be retroactive enrollment. The enrollment date will be the later of the completion of the application or the date the IDTF actually begins services, and enrollments will be processed through an online application.

3.      The IDTF will be required to provide updated information regarding any changes contained in the enrollment application regarding ownership, location, general supervision or adverse legal actions within 30 days of occurrence.

4.      The IDTF must have a documented complaint process. 

5.      The physician responsible for general supervision will not be ultimately responsible for the operations of the IDTF. The regulations will clarify that these responsibilities remain the responsibilities of the owners/shareholders.

6.      A physician may be responsible for only three IDTF sites, whether they be fixed or mobile. The responsibility clarification will not change the existing requirements for direct or personal supervision of tests.

7.      The sharing of facilities at fixed sites will be prohibited.

The specific requirements regarding these changes are listed in the proposed regulations and discussed in the comments below.

 Download file

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

2008 MEDICARE CHANGES:

PHYSICIAN BILLING FOR PURCHASED DIAGNOSTIC TESTS

CMS is proposing to revise the rules on prohibited mark-ups for purchased diagnostic tests. Revised proposed Section 414.50 will state that “if the physician or medical group bills for the technical or professional component of a diagnostic test that was performed by an outside supplier, the payment to the physician or the medical group (less the applicable deductible and coinsurance) for the technical or professional component of the test may not exceed the lowest of the following amounts:

            (i)         The supplier’s net charge to the physician or medical group.

(ii)        The physician’s or medical group’s actual charge.

(iii)       The fee schedule amount for the test that would be allowed if the supplier billed directly.

This provision applies regardless of whether the test or its interpretation was purchased by the physician or medical group billing for the test or the interpretation, or the right to bill for the test or its interpretation was reassigned to the physician or medical group billing for the test or the interpretation.

For purposes of this provision, the physicians’ or other suppliers’ net charge must be determined without regard to any charge that is intended to reflect the cost of equipment or space leased to the outside supplier, buyer or through the billing physician or medical group, and an outside supplier is somewhat other than the full-time employee of the billing physician or medical group.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

CMS PROPOSES MEDICARE CHANGES FOR 2008

The Centers for Medicare and Medicaid Services (CMS) has issued its proposed rules to revise the Medicare Physician Fee Schedule (MPFS) for 2008. Links to both the CMS press release announcing the proposed rules and to the proposed rules themselves are contained below:

·        Press Release:

http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=2239&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

·        Medicare Proposed Rule:

http://www.cms.hhs.gov/physicianfeesched/downloads/CMS-1385-P.pdf?agree=yes&next=Accept

The proposed rule implements the update procedure required by the sustainable growth rate (SGR) methodology, which result in a negative 9.9% update, i.e., a decrease, in Medicare payments. CMS notes that Congress has intervened to eliminate the negative update or decrease for each of the last five years.

Med Law Blog will post an article on what we believe to be the items of most interest to physicians over the next several weeks regarding the following items: proposals to close the perceived Stark loopholes, revisions in the enrollment process for independent diagnostic testing facilities (IDTF), and establishment of mark-up prohibitions for both the technical and professional component of diagnostic tests. Following is a description of the provisions in the proposed rule by CMS:

·        Updating the Geographic Practice Cost Indices (GPCI) to reflect more recent data.

·        Revising certain physician payment localities according to one of three proposed options

·        Using the Physician Assistance and Quality Initiative Fund (PAQI), created by TRHCA that provides $1.35 billion for physician payment and quality improvement initiatives, to extend voluntary quality reporting bonus payments into 2008.

·        Requiring that persons furnishing physical and occupational therapy services to people with Medicare meet licensing, registration, or certification requirements in the state in which they practice, and that they complete an approved educational program for the services they are furnishing. The proposed rule would also change the time frames for certifying a plan of care.

·        Updating regulations governing payment of certain services furnished in Comprehensive Outpatient Rehabilitation Facilities (CORF's), to reflect payment under the MPFS. This conforms to a statutory mandate.

·        Adding neurobehavioral status exams to the list of telemedicine services eligible for Medicare payment.

·        Adding certain ophthalmologic imaging procedures to the list of procedures that would be subject to the Deficit Reduction Act of 2005 (DRA) provision that caps payment for the technical component of imaging procedures at the payment amount under the hospital outpatient prospective payment system.

·        Modifying the requirements under the competitive acquisition program (CAP) for Part B drugs for verifying that a drug ordered by a physician has been administered.

·        Requiring the reporting of hemoglobin or hematocrit data on claims for drugs used to treat anemia secondary to anticancer treatment.

·        Modifying a number of physician self-referral provisions to close loopholes that have made the Medicare program vulnerable to abuse.

·        Modifying enrollment standards for Independent Diagnostic Testing Facilities (IDTFs).

·        Eliminating the exemption for computer-generated faxes from the e-prescribing standards.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

Following is the text of a post from Alan Goldberg  identifying the CMS hospital report card. My thanks to Alan.

List Sponsor: FTI Healthcare/FTI Cambio – One of the nation's leading experts in healthcare consulting – Operations & Strategy, Turnaround Solutions, Regulatory & Disputes, Restructurings. Visit http://www.ftihealthcare.com to learn more.
--------------------------------------------------

*Admitted VA, NY, DC, FL, MA

[Nothing in this email is legal or tax advice; if that's what you want, please retain a competent lawyer. Electronic communications are subject to US government interception, surveillance, and eavesdropping and US Postal Service mail is subject to US government examination, without a warrant.]

--------------------------------------------------
Listserve hosted by American Health Lawyers Association, http://www.healthlawyers.org . Email webmaster@healthlawyers.org for assistance. For rules and disclaimers, go to http://www.healthlawyers.org/listserves/rules . For information about other listserves, go to http://www.healthlawyers.org/listserves .
---
You are currently subscribed to hhs as:
To unsubscribe go to http://www.healthlawyers.org/listserves/manager or send a blank email to leave-987928-35457A@lists.healthlawyers.org

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

KEY FACTS: PHYSICIAN QUALITY REPORTING INITIATIVE (PQRI)

PQRI is a precursor to Medicare pay for performance (P4P) or quality incentives established by the Tax Relief and Healthcare Act of 2006 (TRHCA). The first quality reporting period will be July 1, 2007 through December 31, 2007.

Payment Amount: Congress budgeted $1.35 billion but the payment amount per provider is;

(1)        Subject to the number of participating/reporting physicians;

(2)        Limited to no more than 1.5% of the total allowed charges for covered services provided during the reporting period, i.e., 7/1/07 - 12/31/07;

(3)        Will be paid in a single consolidated payment in “mid 2008.”

Eligible Providers: Doctors, Dentists, Chiropractors, Podiatrists, Optometrists, PT, OT, PA, CRNA, CNS, NM, Psychologist, Dietician.  

Eligible Services: CMS has identified 74 measures for 2007 PQRI; eligible services for 2008 are being developed.

Procedure and Reporting Thresholds: Providers should select services applicable to their patient panels. In order to “successfully report” and receive the bonus payments, certain reporting thresholds must be met:

(1)        When 3 or fewer measures are selected, providers must report in at least 80% of the potential cases.

(2)        When more than 3 measures are selected, the 80% threshold must be satisfied for at least 3 measures.

Sample instructions for 4 measures follows:

2007 Physician Quality Reporting Initiative (PQRI)Measure Specifications

DESCRIPTION:

Percentage of patients aged 18 through 75 years with diabetes (type 1 or type 2) who had most recent hemoglobin Al c greater than 9.0%

INSTRUCTIONS:

This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. The performance period for this measure is 12 months. The most recent quality code submitted will be used for performance calculation. It is anticipated that clinicians who provide services for the primary management of diabetes mellitus will submit this measure.

This measure can be reported using CPT Category II codes:

ICD-9 diagnosis codes, CPT E/M service codes, G-codes, and patient demographics (age, gender, etc..) are used to identify patients who are included in the measure's denominator. CPT Category II codes are used to report the numerator of the measure.

When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable performance exclusions for this measure.

NUMERATOR:

Patients with most recent hemoglobin Alc level > 9.0%

Numerator Instructions: This is a poor control measure. A lower rate indicates better performance (e.g., low rates of poor control indicate better care)

Numerator Coding:

Most Recent Hemoglobin Al c Performed

CPT II 3046F: Most recent hemoglobin Alc level > 9.0% OR

CPT II 3044F: Most recent hemoglobin Alc level < 7.0% OR

CPT II 3045F: Most recent hemoglobin Alc level 7.0% to 9.0%

OR

Hemoglobin Al c not Performed, Reason Not Specified

Append a reporting modifier (8P) to CPT Category II code 3046F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

• 8P: Hemoglobin Alc level was not performed during the performance period (12 months), reason not otherwise specified

DENOMINATOR:

Patients aged 18-75 years with the diagnosis of diabetes

Denominator Coding:

An ICD-9 diagnosis code for diabetes and a CPT E/M service code or G-code are required to identify patients for denominator inclusion.

ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.00, 648.01, 648.02, 648.03, 648.04

AND

CPT ERA service codes or G-codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211,99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99343, 99324, 99344, 99325, 99345, 99326, 99347, 99327, 99348, 99328, 99349, 99334, 99350, 99335, G0270, 99336, G0271, 99337, 99341, 99342,

RATIONALE:

Intensive therapy of glycosylated hemoglobin (Al c) reduces the risk of microvascular complications.

CLINICAL RECOMMENDATION STATEMENTS:

A glycosylated hemoglobin should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than three-month intervals. (AACE/ACE)

The Al c should be universally adopted as the primary method of assessment of glycemic control. On the basis of data from multiple interventional trials, the target for attainment of glycemic control should be Al c values 6.5%. (AACE/ACE)

Obtain a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care. In the absence of well-controlled studies that suggest a definite testing protocol, expert opinion recommends glycosylated hemoglobin be obtained at least twice a year in patients who are meeting treatment goals and who have stable glycemic control and more frequently (quarterly assessment) in patients whose therapy was changed or who are not meeting glycemic goals. (Level of evidence: E) (ADA)

Because different assays can give varying glycated hemoglobin values, the ADA recommends that laboratories only use assay methods that are certified as traceable to the Diabetes Control and Complications Trial Al c reference method. The ADA's goal for glycemic control is Al c <7%. (Level of evidence: B) (ADA)

Monitor and treat hyperglycemia, with a target Al C of 7%, but less stringent goals for therapy may be appropriate once patient preferences, diabetes severity, life expectancy and functional status have been considered. (AGS)

DESCRIPTION:

Percentage of patients aged 18 through 75 years with diabetes (type 1 or type 2) who had most recent LDL-C level in control (less than 100 mg/dl)

INSTRUCTIONS:

This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. The performance period for this measure is 12 months. The most recent quality code submitted will be used for performance calculation. It is anticipated that clinicians who provide services for the primary management of diabetes mellitus will submit this measure.

This measure can be reported using CPT Category II codes:

ICD-9 diagnosis codes, CPT E/M service codes, G-codes, and patient demographics (age, gender, etc.) are used to identify patients who are included in the measure's denominator. CPT Category II codes are used to report the numerator of the measure.

When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable performance exclusions for this measure.

NUMERATOR:

Patients with most recent LDL-C < 100 mg/dL

Numerator Coding:

Most Recent LDL-C Performed

CPT II 3048F: Most recent LDL-C < 100 mg/dL

OR

CPT II 3049F: Most recent LDL-C 100-129 mg/dL

OR

CPT II 3050F: Most recent LDL-C 130 mg/dL

OR

LDL-C Level not Performed, Reason Not Specified

Append a reporting modifier (8P) to CPT Category II code 3048F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

• 8P: LDL-C was not performed during the performance period (12 months), reason not otherwise specified

DENOMINATOR:

Patients aged 18-75 years with the diagnosis of diabetes

Denominator Coding:

An ICD-9 diagnosis code for diabetes and a CPT E/M service code or G-code are required to identify patients for denominator inclusion.

ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.00, 648.01, 648.02, 648.03, 648.04

AND

CPT EIM service codes or G-codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99343, 99324, 99344, 99325, 99345, 99326, 99347, 99327, 99348, 99328, 99349, 99334, 99350, 99335, G0270, 99336, G0271, 99337, 99341, 99342

RATIONALE:

Persons with diabetes are at increased risk for coronary heart disease (CHD). Lowering serum cholesterol levels can reduce the risk for CHD events.

CLINICAL RECOMMENDATION STATEMENTS:

A fasting lipid profile should be obtained during an initial assessment, each follow-up assessment, and annually as part of the cardiac-cerebrovascular-peripheral vascular module. (AACE/ACE)

A fasting lipid profile should be obtained as part of an initial assessment. Adult patients with diabetes should be tested annually for lipid disorders with fasting serum cholesterol, triglycerides, HDL cholesterol, and calculated LDL cholesterol measurements. If values fall in lower-risk levels, assessments may be repeated every two years. (Level of evidence: E) (ADA)

Patients who do not achieve lipid goals with lifestyle modifications require pharmacological therapy. Lowering LDL cholesterol with a statin is associated with a reduction in cardiovascular events. (Level of evidence: A)

Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and morbidity for all patients with known coronary artery disease and type 2 diabetes. (ACP)

Statins should be used for primary prevention against macrovascular complications in patients with type 2 diabetes and other cardiovascular risk factors.

Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at least moderate doses of a statin.

Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction, therefore monitor and treat hypertension and dyslipidemias. (AGS)

DESCRIPTION:

Percentage of patients aged 18 through 75 years with diabetes (type 1 or type 2) who had most recent blood pressure in control (less than 140/80 mm Hg)

INSTRUCTIONS:

This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. The performance period for this measure is 12 months. The most recent quality code submitted will be used for performance calculation. It is anticipated that clinicians who provide services for the primary management of diabetes mellitus will submit this measure.

This measure can be reported using either CPT Category II codes:

ICD-9 diagnosis codes, CPT E/M service codes, G-codes, and patient demographics (age, gender, etc.) are used to identify patients who are included in the measure's denominator. CPT Category II codes are used to report the numerator of the measure.

When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or G-codes, and the appropriate CPT Category II codes OR the CPT Category II code with the modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable performance exclusions for this measure.

NUMERATOR:

Patients whose most recent blood pressure < 140/80 mm Hg

Numerator Instructions: To describe both systolic and diastolic values, two codes must be reported for this measure. For the systolic blood pressure value, report one of the systolic codes; for the diastolic blood pressure value, report one of the diastolic codes. If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure.

Numerator Coding:

Most Recent Blood Pressure Measurement Performed

Systolic codes

CPT II 3074F: Most recent systolic blood pressure < 130 mm Hg

OR

CPT II 3075F: Most recent systolic blood pressure 130 to 139 mm Hg

OR

CPT II 3077F: Most recent systolic blood pressure > 140 mm Hg

AND

Diastolic codes

CPT II 3078F: Most recent diastolic blood pressure < 80 mm Hg OR

CPT II 3079F: Most recent diastolic blood pressure 80-89 mm Hg

OR

CPT II 3080F: Most recent diastolic blood pressure > 90 mm Hg

OR

Blood Pressure Measurement not Performed, Reason Not Specified

Append a reporting modifier (8P) to CPT Category II code 2000F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.

• 8P: No documentation of blood pressure measurement, reason not otherwise specified

DENOMINATOR:

Patients aged 18-75 years with the diagnosis of diabetes

Denominator Coding:

An ICD-9 diagnosis code for diabetes and a CPT E/M service code are required to identify patients for denominator inclusion.

ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.00, 648.01, 648.02, 648.03, 648.04

AND

CPT UM service codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99344, 99325, 99345, 99326, 99347, 99327, 99348, 99328, 99349, 99334, 99350, 99335, G0270, 99336, G0271, 99337, 99341, 99342, 99343

RATIONALE:

Intensive control of blood pressure in patients with diabetes reduces diabetes complications, diabetes-related deaths, strokes, heart failure, and microvascular complications.

CLINICAL RECOMMENDATION STATEMENTS:

Recommends that a blood pressure determination during the initial evaluation, including orthostatic evaluation, be included in the initial and every interim physical examination. (AACE/ACE)

Blood pressure control must be a priority in the management of persons with hypertension and type 2 diabetes. (ACP)

Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic blood pressure >130 mmHg or diastolic >80 mmHg should have blood pressure confirmed on a separate day. Orthostatic measurement of blood pressure should be performed to assess for the presence of autonomic neuropathy. (Level of Evidence: E) (ADA)

Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction, therefore monitor and treat hypertension and dyslipidemias. (AGS)

Measurement of blood pressure in the standing position is indicated periodically, especially in those at risk for postural hypotension. At least two measurements should be made and the average

recorded. After BP is at goal and stable, follow-up visits can usually be at 3- to 6-month intervals. Comorbidities such as heart failure, associated diseases such as diabetes, and the need for laboratory tests influence the frequency of visits. (JNC)

All individuals should be evaluated during health encounters to determine whether they are at increased risk of having or of developing chronic kidney disease. This evaluation of risk factors should include blood pressure measurement. (NKF)

Additional information is available as follows:

(1)        CMS PQRI Link: http://www.cms.hhs.gov/PQRI/

(2)        Three National Provider teleconferences; see:

parta-education@highmarkmedicarservices.com

| Posted By Michael Cassidy In Reimbursement | 1 Comments | Permalink

View David Harlow's HealthBlawg for an update onn CMS PQRI.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

The General Accounting Office (GAO) has issued a report recommending physician profiling, which they define as identifying efficient physicians. The entire report, i.e., GAO-07-307, is available at the following link: http://www.gao.gov/new.items/d07307.pdf

Following are key findings:

GAO estimates that physician account for 20% of the total health care expenditures, but influence 90% of total expenditures through referrals, admissions, etc.

Physician profiling activities occur in Medicare today, but they focus largely on improper billing practices rather than on efficient care delivery.

The report (1) estimates the prevalence in Medicare physicians who are likely to practice medicine inefficiently, (2) examines physician-focused strategies used by public and private sector health care purchasers to encourage efficient medical care, and (3) examines the potential for CMS to profile physicians in traditional Fee For Service (FFS) Medicare for efficiency and use the results in ways that are similar to other purchasers that encourage efficiency.

Overly expensive beneficiaries account for nearly one-half of total Medicare expenditures even though they represent only 20% of beneficiaries in the sample. 

Pittsburgh was included in the 12 metropolitan areas in which Medicare claims were examined. Pittsburgh’s percentage of outlier physicians was 3.8%, which was tenth on the list, with the lowest being Albuquerque, New Mexico, at 2.0%, and the highest being Miami, Florida, at 20.9%.

GAO recommends that CMS develop a profiling system which includes the following elements:

§      total Medicare expenditures as the basis for measuring efficiency, adjustments for differences in patients' health status,

§      empirically based standards that set the parameters of efficiency,

§      a physician education program that explains to physicians how the profiling system works and how their efficiency measures compare with those of their peers,

§      financial or other incentives for individual physicians to improve the efficiency of the care they provide, and

§      methods for measuring the impact of physician profiling on program spending and physician behavior.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

TEN TOP PHYSICIAN BILLING ERRORS

Highmark Medicare Services recently presented a teleconference on the ten top reasons for rejections and most common billing errors. The list is as follows:

1.         No performing PIN

2.         No verification HIC/entitlement

3.         Invalid procedure code

4.         Incomplete physical exam information for chiropractic services

5.         Missing or incomplete modifiers

6.         Missing CLIA information

7.         Missing facility address

8.         No referring UPIN

9.         NOC Code without description

10.       Incomplete address elements for patients, insured patient representative or service/supplier

For complete information about this program, go to the following link:

http://www.highmarkmedicareservices.com/calendar/partb/teleconferences.html

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

TEN TOP PHYSICIAN BILLING ERRORS

Highmark Medicare Services recently presented a teleconference on the ten top reasons for rejections and most common billing errors. The list is as follows:

1.         No performing PIN

2.         No verification HIC/entitlement

3.         Invalid procedure code

4.         Incomplete physical exam information for chiropractic services

5.         Missing or incomplete modifiers

6.         Missing CLIA information

7.         Missing facility address

8.         No referring UPIN

9.         NOC Code without description

10.       Incomplete address elements for patients, insured patient representative or service/supplier

For complete information about this program, go to the following link:

http://www.highmarkmedicareservices.com/calendar/partb/teleconferences.html

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

Highmark Blue Shield has expanded its list of procedures requiring pre-authorization. The full list of procedures is available on the Highmark Resource Center website:

https://www.highmarkblueshield.com/pdf_file/rc-hbs-auth-code-update-april-2007.pdf

It includes a significant number of home health and DME services, prosthetic devices and other services. 

Highmark has also removed two procedures from the list, i.e., pharmacologic management (90862) and the new technology intraocular lens Category 3 (Q1003).

These changes will be effective April 1, 2007 and will apply to members enrolled in Select Blue, Direct Blue and Freedom Blue.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

2007 Physician Quality Reporting Initiative (PQRI)

National Provider Conference Call with Question & Answer Session

The Centers for Medicare & Medicaid Services’ (CMS) Provider Communications Group will host the first in a series of national provider conference calls on the 2007 Physician Quality Reporting Initiative (PQRI). This toll-free call will take place from 3:00 p.m. – 5:00 p.m., EST, on Tuesday, March 27, 2007.

On December 20, 2006, the President signed the Tax Relief and Health Care Act of 2006 (TRHCA).  TRHCA section 101 authorizes a financial incentive for eligible professionals to participate in a voluntary quality reporting program.  Eligible professionals, who chose to participate and successfully report on a designated set of quality measures for services paid under the Medicare Physician Fee Schedule and provided between July 1 and December 31, 2007, may earn a bonus payment of 1.5% of their charges during that period, subject to a cap.   To review the list of eligible professionals, visit http://www.cms.hhs.gov/PQRI/10_EligibleProfessionals.asp#TopOfPage on the CMS website. All Medicare-enrolled professionals in these categories are eligible to participate in the 2007 PQRI, regardless of whether the professional has signed a Medicare participation agreement to accept assignment on all claims.

An overview of the 2007 PQRI will be presented that will include discussion about eligible professionals, reporting, measures and codes, and analysis and payment.   A PowerPoint slide presentation will be posted to the PQRI webpage at http://www.cms.hhs.gov/PQRI/30_EducationalResources.asp#TopOfPage on the CMS website for you to download prior to the call so that you can follow along with the presenter, Susan Nedza, M.D.

In addition, MLN Matters article MM5558, posted on the Medicare Learning Network, can be referenced prior to the call.  The article provides a program overview of the 2007 PQRI.  MM5558 is available at the following link:     http://www.cms.hhs.gov/mlnmattersarticles/downloads/mm5558.pdf.

Following the presentation, callers will have an opportunity to ask questions of CMS subject matter experts.

Conference call details:                                                

                                                Date:  Tuesday, March 27, 2007                                                                                                          Conference Title:  2007 Physician Quality Reporting Initiative

                                                Time:  3:00 p.m. – 5:00 p.m. EST

In order to receive the call-in information, you must register for the call via the internet by following the instructions below.

If you are planning to sit in with a group, only one person needs to register to receive the call-in data.  This registration is solely to reserve a phone line, not to allow participation.

1.         To register for the call participants need to go to:

https://ww4.premconf.com/webrsvp/register?conf_id=549030

2.         Click ”Continue” to be taken to the registration screen.

3.         Fill in all required data.

4.         Click ”Submit”.

5.         You will be taken to the confirmation screen where the call-in number will

be given.

6.         The pass code for the call is 549030.

7.         To view the time the call will start, registrants will need to select their

time zone in the drop down box under ”Time” on the confirmation screen.

8.         Click "Confirm Registration" to receive a confirmation email.

Online Evaluation Form

CMS has developed an online evaluation form that can be quickly completed and submitted. Participants are asked to complete this online evaluation form to help CMS make informed decisions on improving training activities. The online evaluation form titled “Training Evaluation Form” can be found on the registration page, http://www.cms.hhs.gov/medlearn/cont_eval_form.asp.  CMS looks forward to hearing your comments.

If you have questions, or require special accommodations, please contact Geanelle E. Griffith at geanelle.griffith@cms.hhs.gov or at (410) 786-4466.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

MEDICAL PAYMENT ADVISORY COMMISSION (MEDPAC) REPORTS

DEAL WITH PRACTICE EXPENSE METHODOLOGY, SGR AND P4P: 

MedPac reported to Congress on a variety of issues in March of 2007. MedPac predicted that the new practice expense methodology will produce a 7% E&M increase, but an 8-9% decrease for major imaging procedures by 2010. MedPac concluded that Sustainable Growth Rate (SGR) methodology is flawed and will continue to produce Medicare reimbursement declines unless revised.

While recommending a payment update (i.e., increase) for 2008, despite SGR projected decreases, and implementation of quality payment initiatives, MedPac nevertheless concluded that the prime indicators of Medicare physician reimbursement adequacy, i.e., participating physician members and beneficiary service volume, are stable, and concluded that any Medicare reimbursement update should be offset by expected gains in physician productivity of 1.7%, stating “Physicians, like other providers, taxpayers and firms that fund Medicare, should be expected to increase their productivity each year.”  

Access to the complete report is available at the MedPac website: http://www.medpac.gov/.,

which is also accessible through the Blog links.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

PRESCRIPTION FOR PENNSYLVANIA - GOVERNOR RENDELL’S PROPOSAL

FOR PENNSYLVANIA HEALTH CARE REFORM

Representatives of Governor Rendell’s administration reported at the Pennsylvania Bar Institute Annual Health Law Institute that Governor Rendell’s “Prescription for Pennsylvania,” the comprehensive state health care reform program, is expected to be presented to the Pennsylvania Legislature before the end of the month. Prescription for Pennsylvania is intended to increase access, affordability and quality throughout Pennsylvania.

Although the legislation has not yet been officially  proposed, so we cannot yet provide any specific analysis, it is expected that some of the significant components will be as follows:

§      Expanded required health insurance coverage for small employers (along with tax-based financial incentives), expansion of basic health insurance coverage for uninsured, and required health insurance coverage for college students;

§      Expansion of the scope of practice for nurse practitioners, physician assistants, certified registered nurse anesthetists and nurse midwifes, including such items as expanded prescription authority, expanded independent practice, and required credentialing by networks and health care providers;

§      Expansion of medical facility sites to improve access for Pennsylvanians by allowing nurse managed care centers, expansion of federally qualified health centers, allowing pharmacists to manage drug therapies in hospitals and other institutions, and supporting nurse practitioner practice in pharmacies;

§      Re-establishing of a process similar to Certificate of Need which will require regional approval based on resource budgets for new facilities such as imaging facilities and ambulatory surgery centers in Pennsylvania; and

§      Comprehensive Pay for Performance programs which will be uniform across third party payor programs to provide united incentives for performance improvement.

All of this is, of course, subject to specific proposals yet to be presented. Information can be obtained from the following websites:

http://www.gohcr.state.pa.us/prescription-for-pennsylvania/Rx-for-Pennsylvania.pdf

http://www.gohcr.state.pa.us/prescription-for-pennsylvania/Rx-for-Affordability.pdf

http://www.gohcr.state.pa.us/prescription-for-pennsylvania/Rx-for-Access.pdf

| Posted By Michael Cassidy In Reimbursement | 1 Comments | Permalink

The Centers for Medicare and Medicaid Services (CMS) has quietly reversed itself on the new standards for Independent Diagnostic Testing Facilities (IDTFs). Transmittal 187, which established new standards for IDTFs and was scheduled to be effective as of February 26, 2007,  was rescinded without explanation. Therefore, some of the more significant changes, such as:

§      Limiting the number of sites a physician can supervise to three and expanding the supervising physician’s responsibilities to include overall operation and administration;

§      Prohibiting the sharing of facilities without a Medicare supplier; and

§      Establishing 14 specific operating standards;

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that the 2007 Physician Quality Reporting Initiative (PQRI) webpage is now available.

On December 20, 2006 the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. CMS has titled the statutory program the 2007 Physician Quality Reporting Initiative.

PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services.

This newly established webpage will be updated regularly, so check it often for timely and reliable information from CMS.

For more information on 2007 PQRI, visit http://www.cms.hhs.gov/PQRI/01_Overview.asp#TopOfPage on the CMS website.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

The Centers for Medicare and Medicaid Services (CMS) announced significant changes to the regulatory requirements for operating independent diagnostic testing facilities (IDTFs) on January 26, 2007, which new rules will become affective February 26, 2007. These new requirements affect the:

§      Performance standards for operation.

§      The requirements for both interpreting and supervising physicians.

§      Licensing requirements for technicians.

Rather than try to summarize all of the changes for you, I am including links to both explanatory and direct source materials:

A.        Summary of Independent Diagnostic Testing Facility Performance Standards from the CMS Website. www.cms.hhs.gov/MedicareProviderSupEnroll/downloads/Independentdiagnostictestingfacility.pdf

B.         CMS Manual System Pub 100-08 regarding the implementation of new compliance standards for Independent Diagnostic Testing Facilities,  found courtesy of “Health Blawg”,  which is David Harlow’s Healthcare Law Blog. healthblawg.typepad.com/healthblawg/2007/02/idtf_requiremen.html

C.        Section 42 CFR § 410.33, which are the formal federal regulations defining the requirements for Independent Diagnostic Testing Facilities.  ecfr.gpoaccess.gov/cgi/t/text/text-idx 

D.        Highmark Medicare Services Independent Diagnostic Testing Facility Billing Guide. www.highmarkmedicareservices.com/partb/bguides/idtf.html

I hope the information is helpful.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

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.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

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.”

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

Assuming siganture by the President of the "Medicare Improvments and Extension Act of  2006"  , the following will be the major Medicare changes for the coming year. The complete text of the changes and Committee reports are avaialble on the link in the article posted here yesterday.

1.        2007 PHYSICIAN FEE SCHEDULE: The conversion factor for the Medicare Physician Fee was revised for 2007 only to eliminate the 5% reduction which would have been mandatory under Medicare’s sustainable growth rate formula.

2.         QUALITY REPORTING INCENTIVES OF 1.5% FOR 2007: The Act establishes a mechanism for enhancing the quality of reporting system first established by the Medicare Improvement Act of 2003 by adopting the quality measure specified in the physician voluntary reporting program, previously established by the Centers for Medicare and Medicaid Services, and establishing deadlines for adoption new quality measures. The Act provides transitional bonus incentive payments for quality reporting in 2007 equal to 1.5% of the Secretary’s estimate of allowed charges under the federal supplementary medical insurance trust fund for the covered professional services furnished during the reporting period, and provides future funding to promote physician payment stability and quality initiatives of $60 million to be transferred from the fund in 2007, 2008 and 2009.

3.         MEDICARE GEOGRAPHIC ADJUSTMENT: Extends floor established in Section 1848 (e) (1) (E) of the Social Security Act by MMA 2003 is extended through 2007 to protect physician work component payments in rural areas.

4.         2007 END STAGE RENAL DIALYSIS (ESRD) UPDATE: The composite rate component of the basic case -mix prospective payment is increased by 1.6% for 2007.

5.         RURAL CLINICAL DIAGNOSTIC LABORATORY TESTS: Reasonable cost payments for certain clinical diagnostic laboratory tests furnished to hospital patients in rural areas is extended until 2008.

6.         COMPETITIVE ACQUISITION PROGRAM (CAP): An audit process is established for reviewing drug and biological payments in the CAP program.

7.         QUALITY REPORTING PENALTIES: The Act extends the 2% penalty for the failure to observe the quality reporting programs for hospitals and applies it to ambulatory surgery centers.

8.         MEDICARE THERAPY EXCEPTION PROCESS: The exception process for appealing additional physical therapy payments is extended through 2007.

| Posted By Michael Cassidy In Reimbursement | 1 Comments | Permalink

Both Houses of Congress have approved the Tax Relief and Health Care Act of 2006, which eliminates the planned 5% Medicare Physician Fee Schedule cut for 2007. The bill now goes to the White House and President Bush is expected to sign it. The bill contained other key health care provisions which we intend to explain in a release prepared for the end of this week. In the meantime, you can get details of the legislation at the website of the House Ways and Means Committee at http://waysandmeans.house.gov/ResourceKits.asp?section=2544

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

BNA Health Care Daily has reported that House & Senate leaders have agreed upon a compromise that will eliminate the physician fee schedule pay cut which would have been implemented by the SGR fee schedule mechanism. The House and Senate are expected to vote on the measure today.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

All health care providers covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) must begin using the standard unique identifiers for healthcare providers and health plans mandated by HIPAA no later than May 23, 2007. According to the Centers for Medicare and Medicaid Services release on November 17, 2006, “every covered health care provide must obtain a new NPI … even providers that do not conduct electronic transactions and are not covered by HIPAA may be required by health plans or employers to obtain one.” CMS states that health care providers can apply for NPIs in one of three ways:

§      For the most efficient application processing in the fastest receipt of NPIs, use the web-based application process. Simply log onto the National Plan and Provider Enumeration System (NPPES) and apply on line.

§      Health care providers can agree to have an Electronic File Interchange (EFI) organization (EFIO) submit application data on their behalf if an EFIO requests their permission to do so.

§      Health care providers may wish to obtain a copy of the paper NPI Application/Update Form (CMS-10114) and mail the completed, signed application to the NPI Enumerator located in Fargo, North Dakota.

NPI information can be obtained at the CMS website at:

http://www.cms.hhs.gov/NationalProvIdentStand/03_apply.asp.

Information can be obtained from the NPI Enumerator at Phone: 1-800-465-3203 or Email:

customerservice@npienumerator.com.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

The Office of Inspector General (OIG) issued Advisory Opinion 06-22, which is another in a series of similar approving gainsharing arrangements, i.e., 01-01 and 05-01 through 05-06. Under the current proposed arrangement, a hospital would pay a cardiac surgery group 50 percent of the hospital’s first year cost savings directly attributable to specific changes in the surgical group’s operating room practices, which changes would involve (1) limiting the use of certain surgical supplies, (2) substituting less costly items for items currently being used by the surgeons, and (3) product standardization of certain cardiac devices. As with its earlier gainsharing opinions, the OIG concluded that the proposed arrangement would implicate the civil monetary penalty (CMP) provisions, and would potentially implicate the anti-kickback law, but that the OIG would not impose sanctions under these authorities against the requestors, given the following safeguards:

Civil Money Penalties

(1) The practices and savings would be “clearly and separately identified” allowing “for public scrutiny and individual physician accountability for any adverse effects.”

(2) There was “credible medical support” for that position that the arrangement would “not adversely affect patient care.”

(3) The payments would be based on all surgeries regardless of payor.

(4) The arrangement would protect against “inappropriate reductions in services” by utilizing “objective historical and clinical measures.”

(5) The physicians would nevertheless have the same selection of surgical devices available, regardless of standardization.

(6) Full disclosure of the program would be provided to patients.

(7) The financial incentives under the proposed arrangement would be “reasonably limited in duration and amount.

(8) The surgical group’s profits would be distributed on a per capita basis and, as such, “any incentive for an individual surgeon to generate disproportionate cost savings” would be “mitigated.

Anti-Kickback Law. 

(1) The arrangement would have a one-year term, participation would be limited to surgeons already on the Hospital’s medical staff, and the potential savings derived from procedures for Federal healthcare program beneficiaries would be capped (based on the prior year’s admissions of such beneficiaries).

(2) Because the surgeon group would be composed only of cardiac surgeons, the proposed arrangement could not be used to reward cardiologists or other physicians in a position to make referrals to the surgical group.

(3) Because the cost saving recommendations carry “some increased liability risk for the physicians,” it is “not unreasonable for the surgeon to receive compensation,” particularly where it would be limited in amount, duration, and scope.

Stark Law. 

Finally, as in its earlier gainsharing opinions, the OIG declined to provide any guidance regarding the Stark Law because it is outside the scope of the advisory opinion process.  

The full opinion is available on the OIG website at http://oig.hhs.gov/.

| Posted By Michael Cassidy In Reimbursement | 1 Comments | Permalink

In accordance with § 626 of the Medicare Modernization Act of 2003, which commissioned a study by the GAO to evaluate a payment system using groups of covered services under the outpatient prospective payment system, the Centers for Medicare and Medicaid Services (CMS) proposed a new reimbursement system for Ambulatory Surgery Centers (ASC) on August 23, 2006 in the Federal Register. The full text of the proposal is available at www.cms.hhs.gov/ASCPayment/06_CMS1506P.asp#TopOfPage. Key changes include:

1.         A new ASC Fee Schedule protocol which will link the ASC procedure payment rate to approximately 62% of the reimbursement rate for the procedures as done in hospital outpatient departments, which rates will be phased in beginning January 1, 2008 and will become fully operational as of January 1, 2009;

2.         The addition of 14 procedures to the lists in 2007;

3.         The addition of 750 new procedures to the lists for 2008, which procedures will primarily be office-based procedures but for which the reimbursement will be capped at the lower of the non-facility expense for that procedure as provided in the Medicare Physician Fee Schedule or the new ASC rates; and

4.         The bundling of most surgical implants into the new ASC rates.

The goal of the new ASC reimbursement protocol is to coordinate ASC payments with hospital outpatient department payments at a rate which is intended to maintain neutrality between site of service choices. The proposed uniform conversion rate is intended to implement such neutrality. However, given the significant relative discrepancies between certain groups of ASC reimbursement at current rates, with some categories increasing and some categories decreasing, the new payment rate may change the economics of current ASC structures. The proposals fail to maintain relative neutrality between site of service by failing to have uniform inflation adjustments or update factors and failing to provide the same set of professional services for ambulatory surgery centers.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

http://www.cms.hhs.gov/PhysicianFeeSched/PFSFRN/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=4&sortOrder=descending&itemID=CMS1188377

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

The Centers for Medicare and Medicaid Services (CMS) issued the final rule for the 2007 Physician Schedule on November 1, 2006, which will soon be published in the Federal Register.

§      The final rule provides a 5% reduction in the 2007 Fee Schedule, which is just a slight change from the proposed 5.1% reduction proposed in August of 2006. 

§      The work component RVU for the intermediate office visit E & M Code will increase by 37%.

§      There will be a 25% reduction in the technical component for multiple imaging services rather than the original proposed 50% reduction.

§      Nuclear imaging services will be included as a Stark designated health service.

A link to the Physician Fee Schedule will be published as soon as it is posted.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

CMS Gainsharing Demonstration

            The Centers for Medicare and Medicaid Services (CMS) announced its Physician-Hospital Collaboration Demonstration (PHCD) Project. This is a three year demonstration program designed to examine whether allowing hospitals to provide financial incentives for physicians to support better care can improve patient outcomes without increasing costs. The CMS Press Release is available in the CMS website in the CMS Press Release Archives at http://www.cms.hhs.gov/apps/media/ questionmedia=pressr.

Congressional Advisory Board Analyzes Physician Payment System Options

            The Supplemental Medical Insurance program (Part B of Medicare), which will cost about $158 billion in 2006, pays for physicians' services, outpatient hospital services, durable medical equipment, physical therapy, and certain other outpatient services. About 38 percent of those expenditures are payments for services provided by physicians, which are based on a schedule of fees that specifies the amount to be paid for each type of service. Most of Medicare's payment rates are simply adjusted each year for inflation -- but not those for physician's services. Those rates are governed by a complex formula -- the Sustainable Growth Rate (SGR) mechanism -- that, unless overridden by legislation, will reduce fees by about 4 percent or 5 percent annually for at least the next several years.

            Legislation has overridden the formula's results in each of the past four years, and the prospect of future, year-after-year rate reductions raised the question of whether the SGR formula is a viable mechanism -- and if not, what alternatives might be appropriate. This brief describes the SGR mechanism and presents the potential budgetary effects of several other approaches. Many of the possible alternatives would be costly. For example, overriding the formula with a 1 percent rate increase in 2007 would raise outlays by $6 billion over the next 10 years. Replacing the formula with an inflation index would cost more than $200 billion over the coming decade.

            The full report is available at http://www.cbo.gov/ftpdocs/75xx/doc7542/09-07-SGR-brief.pdf.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

In the Proposed Rules, the link for which was provided in the August 29, 2006 MedLaw Blog post, CMS announced proposed changes to the reassignment exceptions for purposes of Medicare billing and to the definition of “centralized building” for purposes of the ancillary services exception of Stark II.

REASSIGNMENT

CMS is basically proposing to treat purchased technical components of diagnostic tests and the purchased professional component (i.e., interpretations) of tests similarly. Section 1861 (s)(3) of the Social Security Act already prohibits the purchase and mark-up of diagnostic tests, i.e., the technical component. CMS is concerned that the reassignment changes enacted by § 952 of the Medicare Modernization Act of 2004 (MMA), which amends Social Security Act § 1842 (b)(6)(A)(i) to allow Prescription Drug, Improvement, and "where the service was provided under a contractual arrangement between such physician or other person and entity" would be misunderstood to allow the purchase of the professional component of a test for less than the Medicare Fee Schedule and an resulting mark-up through the reassignment provisions. Prior to MMA, reassignment was basically allowed only among employers/employees and when services were performed on the premises of designated healthcare facilities (i.e., hospitals and physician directed clinics). CMS commented that the reassignment rules were basically intended to accommodate hospital emergency department staffing companies that employed physicians on a contract basis.

By permitting reassignment for “contractual arrangements”, CMS is concerned that this reassignment exception can be used in conjunction with the “physician services” exception for purposes of the Stark Act to justify arrangements in which physicians are enrolled in multiple assignment accounts under contractual arrangements to provide services on a basis that would permit the mark-up of those services by the billing physician group. CMS stated that its concerns in this area are best illustrated by the “pod laboratory” concept, the legality of which was questioned in Advisory Opinions 04-18 and 04-17, in which an entity would lease space in a medical building, sub-divide the space into separate areas or cubicles for different physician groups, and enroll the pathologists in the assignment accounts of each of the physician groups in order to allow those physician groups to bill directly for those services. 

In order to restrict or prevent these arrangements, CMS is proposing two amendments and is considering a third, as follows:

1.         CMS is proposing that the amount billed to Medicare by the billing entity may not exceed the lowest of the following amounts:

a.         The physician or other supplier's net charge to the billing physician or medical group,

b.         The billing physician's or medical group's actual charge, or

c.         the fee schedule amount for the service that would be allowed if the physician or other supplier billed directly.

2.         CMS is proposing that, in order to bill for the technical component, the billing entity would be required to perform the interpretation.

3.         CMS is considering further amendments that would impose conditions on when a physician or medical group may bill for reassigned professional components of diagnostic tests such as requiring that the test must be ordered by a physician that is financially independent of the person or entity performing the test and also of the physician or medical group performing the interpretation, requiring that the physician or medical performing the interpretation does not actually see the patient, and requiring the physician or medical group billing for the interpretation to have performed the technical component of the test.

Frankly, these requirements existing would not appear to restrict enrollment in multiple assignment accounts any more than group practice requirements. Perhaps, that is why the amendment of these “centralized building” definition is key to these provisions.

CENTRALIZED BUILDING

The pod concept concerns CMS because it theoretically allows the establishment of multiple centralized buildings at a single location for the performance of ancillary services in situations where none of the individual spaces is actually independently capable of performing the professional services. Therefore, CMS is proposing to revise the definition of “centralized building” to add the following language:

“A centralized building does not include space that is owned or leased by a group practice if that space is less than 350 square feet. This limitation does not apply to space owned or rented in a building where no more than three group practices own or lease space in the ‘same building’ (as defined in this section) and share the same ‘physician in the group practice’ (as defined in this section). A centralized building does not include space owned or leased by a group practice if equipment needed to perform substantially all (at least 90% of the designated health services furnished in that space in any given calendar year) is not permanently located in that space. That is, equipment needed to perform more than 10% of the designated health services furnished in that space in a calendar year cannot be temporarily moved into that space from another space in the ‘same building’ or from outside ‘the same building'."

The purpose of this amendment is obviously to make it impossible to establish centralized buildings for multiple physician practices, but to still recognize the fact that many physicians legitimately practice in relatively small physical facilities for purposes of providing ancillary services.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

CMS and the OIG are concerned with the potential for erroneous payments for either unjustified or medically unnecessary services in the independent diagnostic testing facilities (IDTF), which concern is initially based upon an audit performed for fiscal year 2001 by the OIG (A-03-03-00002). Therefore, in the August 22, 2006 Proposed Regulations, a link to which was posted here in yesterday's MedLAw Blog post,  the Department of Health and Human Services (HHS) is proposing to subject IDTFs to standards similar to Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) as promulgated at 42 CFR 424.57 on October 11, 2000. IDTF would be required to meet the following standards as of January 1, 2007 and any new or re-enrolling IDTF would be required to certify compliance with those standards at the time of application, which standards are as follows:

1.         Operate its business and compliance with all applicable federal, state and local licensure and regulatory requirements with regard to the health and safety of patients;

2.         Provide complete and accurate information on Medicare participation enrollment applications;

3.         Maintain a physical facility with space and equipment appropriate for the services designated on the enrollment application;

4.         Have all applicable testing equipment available at the physical site, excluding portable equipment;

5.         Maintain a primary business telephone, listed under the name of the business and located at the physical site which numbers must be available through directory assistance;

6.         Maintain comprehensive liability insurance of at least $300,000 or 20% of its average annual Medicare billings, whichever is greater, obtain from an insurance company not owned by a relative;

7.         Agree not to directly solicit patients, which would include but not be limited to solicitation through telephone, computer or in-person contacts and agree not to accept patients unless referred for diagnostic testing by an attending physician (or non-physician practitioners in accordance with § 410.32 (a)(3);

8.         Answer beneficiary questions and respond to complaints with appropriate documentation;

9.         Openly post the standards for review by the public and by patients;

10.       Disclose to the government any person having ownership, financial or control interest or any other legal interest in the supplier at the time of enrollment or within 30 days of any change;

11.       Have its testing equipment calibrated per equipment instructions in compliance with applicable national standards;

12.       Have technical staff on duty with the appropriate credentials to perform designated testing along with maintain appropriate licensure or documentation for such individuals;

13.       Have proper medical storage along with retrieval of medical records upon request from CMS or designated contractors; and

14.       Permit CMS, and any agents or contractors, to conduct unannounced on-time inspections to confirm compliance with each standard.

In addition to the compliance standards, the physician supervision standard of  42 CFR § 410.33 (b)(1) would be revised to limit physicians who provide supervision to no more than three IDTF sites.

The discussion of these revisions are contained on pages 49060 through 49062 of the Proposed Rules and the proposed regulation is 42 CFR § 410.33 contained on page 49080 of the August 22, 2006 Proposed Rules.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

The Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services issued the 2007 Proposed Physician Fee Schedule in the August 22, 2006 Federal Register: http://www.cms.hhs.gov/quarterlyproviderUpdates/downloads/cms1321p.pdf.  In addition to the fee schedule reductions arising out of the proposed revisions to the work relative value units (RVUs) as proposed in the Federal Register on June 29, 2006, as reported in the Med Law Blog at that time, the new proposed physician fee schedule also incorporates the 5.1% reduction which would be mandated by the Sustainable Growth Rate (SGR) parameters currently in place. Congress has legislatively overridden the mandatory reductions for the past several years, and there are proposals not only to do so again this year but to reform the Medicare payment system using Pay For Performing (P4P) or quality incentives.

The combined impact of the SGR reductions and the work RVU reductions by specialty are projected in Table 7 of the Proposed Rules, August 22, 2006 Federal Register at page 49070.

In addition to the reimbursement changes, the Proposed Rules also make significant revisions to the participation requirements for Independent Diagnostic Testing Facilities, and proposed changes to the Stark II definition of “centralized billing” and clarifications of the Reassignment Rules, both of which will be the subject of separate MedLaw Blog posts in the next few days. 

| Posted By Michael Cassidy In Reimbursement | 2 Comments | Permalink

Following is the text from the payment delay reminder issued by HGSAdministrators (now Highmark Medicare Services):

A brief hold will be placed on Medicare payments for all claims during the last 9 days of the Federal fiscal year (September 22 through September 30, 2006).   These payment delays are mandated by Section 5203 of the Deficit Reduction Act of 2005. No interest will be accrued and no late penalties will be paid to an entity or individual by reason of this one-time hold on payments. All claims held during this time will be paid on October 2, 2006.

This policy only applies to claims subject to payment. It does not apply to full denials, no-pay claims, and other non-claim payments such as periodic interim payments, home health requests for anticipated payments, and cost report settlements.

Please note that payments will not be staggered and no advance payments will be allowed during this 9-day hold.

| Posted By Michael Cassidy In Reimbursement | 0 Comments | Permalink

Senator Bill Frist has launched a new healthcare Blog. MedicalMatter.org: a21st Century Discussion of Health Care Issues. According to the inaugural post, the blog is about "healthcare and the politics of healthcare", and will address issues such as electronic health records (EHR), stem cell research, health savings accounts (HSA), and many other topics.

| Posted By Michael Cassidy In Compliance , Electronic Health Records , Reimbursement | 0 Comments | Permalink

Physician Care Plan Oversight (CPO) is paid under the Medicare Physician Fee Schedule (MPFS), and due to a provision in the Medicare Claims Processing Manual (Publication 100-04, Chapter 12, Section 180), Non-Physician Practitioners (NPPs) have been prohibited from billing for this service in a home health setting.

The current manual section (Section 180) provides that the physician who signs the plan of care for home health services must be the same person that bills for physician CPO. Since only a physician can sign the plan of care for home health services, NPPs have been unable to bill for physician home health CPO.

Under the Final Physician Fee Schedule Rule, published in the Federal Register