ICD10 OMT Williams by deV61o

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									      AMERICAN
OSTEOPATHIC ASSOCIATION
   5010 Data Standard, ICD-10-
      CM/PSC, Osteopathic
    Manipulative Treatment and
            Medicare
          December 3, 2011
            DIVISION OF
      SOCIOECONOMIC AFFAIRS
 Socioeconomic Affairs Staff
• Yolanda Doss, MJ, RHIA,
  Director, Division of Socioeconomic Affairs
• Sandra Peter, MHA
  Assistant Director, Clinical Practice Outreach
• Michele Campbell, CPC,
  Coding & Reimbursement Specialist
• Kavin Williams, CPC, CCP
  Health Reimbursement Policy Specialist
 Yolanda Doss, MJ, RHIA
Responsibilities include:
  – Helping to secure reimbursement for
    osteopathic services
  – Securing the acceptance of osteopathic
    credentials
  – Addressing Medicare issues
  – HIPAA compliance
  – Fraud and Abuse
      Sandra Peters, MHA
Responsibilities include:
   – Develop educational material on physician
     advocacy, manage care, quality and performance
     measures impacting osteopathic medicine
   – Design and manage a set of member services to
     enhance their manage care interactions and to
     promote their opportunities to participate in manage
     care
   – Provide update to the AOA leadership on health
     care trends particularly in the areas of pay for
     performance and physician profiling
 Kavin T. Williams, CPC, CCP
Responsibilities include:
   – Assists AOA members with reimbursement
     and health payment policies.
   – Oversees and assists AOA members with
     coding and payment disputes with carriers.
   – Oversees the AOA Coding and
     Reimbursement Advisory Panel.
   – Represents the AOA at national
     reimbursement policy meetings.
Are you ready for ICD 10 and the
  HIPAA 5010 Data Standard?
• Objectives
  – To educate physicians on the ICD 10 and
    HIPAA 5010 implementation compliance
    dates
  – To educate physicians on the impact the new
    coding sets will have on the current
    reimbursement and coding structure
The Transition to HIPAA 5010
• Have you heard of the HIPAA 5010 Data
  Standard?
• Have you begun testing?
• Will you be ready for January 1, 2012?
  Background of HIPAA 5010
       Data Standard
• The current version of the standards
  (4010/4010A1) are identified as lacking
  certain functionality for health care needs
• Version 5010 will accommodate the ICD
  10 codes
      Mark Your Calendars
• Important dates for 5010 Implementation
  – January 1, 2011-begin external testing of the
    5010 version for electronic claims
  – December 31, 2011-to be at level II
    compliance external testing of the 5010 for
    electronic claims must be completed
  – January 1, 2012 – All electronic claims must
    use Version 5010. Version 4010 claims will no
    longer be accepted
            Getting Started
• Now is the time….
• Testing should be conducted both internally and
  externally with current business partners
• Internal testing of version 5010 should have
  been completed by December 31, 2010
• External should be completed by December 31,
  2011
           Getting Started
• Testing early will allow you to identify any
  potential issues, and address them in
  advance
• As HIPAA covered entity, CMS has to
  ensure that its business processes,
  systems , policies and those of ist
  contractors, providers, health plans, etc.
  are compliant with HIPAA
                 Pitfalls
• Lack of testing with your vendors, clearing
  houses, insurers to ensure that you can
  accept and send transactions is probably
  the top barrier to success
• Cost
• Timing (deadlines)
              Summarize
• Implementation date to be compliant for
  the 5010 HIPAA Data transaction is
  January 1, 2012
• If you have not begun testing the time is
  NOW!!
• Contact your vendors to inquire/schedule
  your internal and external testing
                 Vendor Model Letter
•   Dear Vendor (Clearinghouse, EMR system, Medicare, private payers):
•
•   My (name of practice)________________ uses your ___________________ product/services,
    version ___________. As ICD-10-CM implementation approaches, we would like some
    information and clarification about your plans to upgrade your systems.
•
•   Specifically, we would like to know your plans for updating software to comply with HIPAA
    transactions. Can you provide a timetable for the following.
•
•   When will you be installing upgrades and will there be a charge for this data?
•
•   Will my practice need additional hardware or support services to install the upgrade(s)?
•
•   Thank you in advance for complying with and your prompt attention to this request.
•
•   Sincerely,
•
ICD-10-CM/PCS
                           History
The International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM) is the United States' clinical modification to
the World Health Organization’s (WHO) International Classification of
Diseases, Tenth Revision (ICD-10). ICD-10 was adopted by the World
Health Assembly in 1990. Following the publication of ICD-10, a
number of countries performed an analysis to determine if the WHO
classification would meet their needs given the changes to the roles of
ICD since the ninth revision.
                       History
The United States remains the only industrialized nation
that has not yet implemented ICD-10 (or a clinical
modification) for morbidity, meaning diseases or causes of
illness typically coded in a healthcare facility. Since 1999,
however, the US has used ICD-10 for mortality reporting –
the coding of death certificates (typically done by a vital
statistics office, not the healthcare facility). Implementing
ICD-10-CM will maintain data comparability internationally
and between mortality and morbidity data in the U.S.
                      Development
In 1994 under the leadership of the National Center for Health Statistics
(NCHS), the United States began their process of determining whether an ICD-
10 modification should be developed. NCHS awarded a contract to the Center
for Health Policy Studies to decide if a clinical modification was necessary. A
Technical Advisory Panel (TAP) was formed and their recommendation was to
create a clinical modification. In 1997, the entire draft of the Tabular List of
ICD-10-CM and the preliminary crosswalk between ICD-9-CM and ICD-10-CM
were made available on the NCHS website for public comments. The public
comment period ran from December 1997 through February 1998. Since that
time revisions were based on further study and the comments submitted. Draft
versions of ICD-10-CM were made available in 2002, 2007, 2009, 2010, and
2011. Limited code updates will continue to occur to this draft prior to
implementation of ICD-10-CM.
                       Development
While ICD-10 provides many more categories for diseases and other health-
related conditions than previous revisions, the clinical modifications thus far to
ICD-10 offer a higher level of specificity by including separate codes for
laterality and additional character and extensions for expanded detail. In
addition, other changes included combining etiology and manifestations,
poisoning and external cause, or diagnosis and symptoms into a single code.
ICD-10-CM also provides code titles and language that complement accepted
clinical practice. ICD-10-CM codes have the potential to reveal more about
quality of care, so that data can be used in a more meaningful way to better
understand complications, better design clinically robust algorithms and better
track the outcomes of care. ICD-10-CM incorporates greater specificity and
clinical detail to provide information for clinical decision making and outcome
research.
                   ICD 10
•   Implementation date is October 1, 2013
•   Benefits of ICD 10
•   Have you started preparation for ICD 10?
•   How do I get started?
•   How do I find the necessary resource
    information?
              Benefits of ICD 10
• The Benefits of ICD-10-CM
• ICD-10-CM incorporates much greater clinical detail and specificity
  than ICD-9-CM. Terminology and disease classification have been
  updated to be consistent with current clinical practice. The modern
  classification system will provide much better data needed for:
• Measuring the quality, safety, and efficacy of care;
• Reducing the need for attachments to explain the patient’s
  condition;
• Designing payment systems and processing claims for
  reimbursement;
• Conducting research, epidemiological studies, and clinical trials;
               Benefits of ICD 10
•   Setting health policy;
•   Operational and strategic planning;
•   Designing health care delivery systems;
•   Monitoring resource utilization;
•   Improving clinical, financial, and administrative performance;
•   Preventing and detecting health care fraud and abuse; and
•   Tracking public health and risks.
•   Non-specific codes still exist for use when the medical record
    documentation does not support a more specific code
                 ICD 9 vs ICD 10
• Here are some SIMILARITIES AND DIFFERENCES BETWEEN
  THE TWO CODING SYSTEMS:
• ICD-10-CM uses 3–7 alpha and numeric digits and full code titles,
  but the format is very much the same as ICD-9-CM (e.g., ICD-10-
  CM has the same hierarchical structure as ICD-9-CM).
• The 7th character in ICD-10-CM is used in several chapters (e.g.,
  the Obstetrics, Injury, Musculoskeletal, and External Cause
  chapters). It has a different meaning depending on the section
  where it is being used (e.g., in the Injury and External Cause
  sections, the 7th character classifies an initial encounter,
  subsequent encounter, or sequelae (late effect)).
   Similarities & Differences
              cont’d
• Primarily, changes in ICD-10-CM are in its
  organization and structure, code
  composition and level of detail
                         ICD-9-CM
•    3–5 digits;
•    First digit is alpha (E or V) or numeric (alpha characters are not
    case sensitive);
•    Digits 2–5 are numeric; and
•    Decimal is used after third character.
•   Examples:
•   496 – Chronic airway obstruction, not elsewhere classified (NEC);
    511.9 – Unspecified pleural effusion; and
    V02.61 – Hepatitis B carrier.
                      ICD-10-CM
•   3–7 digits;
•  Digit 1 is alpha; Digit 2 is numeric;
•  Digits 3–7 are alpha or numeric (alpha characters are not case
  sensitive); and
• Decimal is used after third character.
• Examples:
   A78 – Q fever;
  A69.21 – Meningitis due to Lyme disease; and
  S52.131A – Displaced fracture of neck of right radius, initial
  encounter for closed fracture.
         What will change?
• Coding
  – Code set will increase from 17,000 to 140,000
    therefore the code books and styles will
    completely change ( both ICD 10-Cm and ICD
    10-PCS)
  – Clinical knowledge-Coders may need to be
    reeducated on anatomy and physiology
  – All staff who handle coding, from the front
    office staff to the practice manager
         Additional Changes
• Laterality ( left, right, bilateral)
• For example:
   – C50.511- Malignant neoplasm of lower-outer
     quadrant of right female breast
   – H16.013- Central corneal ulcer, bilateral
   – L89.012- Pressure ulcer of right elbow, stage
     II
            Changes Cont’d
• Combination codes for certain conditions
  and common associated symptoms and
  manifestations
  – Example:
     • K57.21-Diverticulitis of large intestine with
       perforation and abscess with bleeding
     • E11.341- Type 2 diabetes mellitus with severe
       nonproliferative diabetic retinopathy with macular
       edema
           Changes Cont’d
• Combination codes for poisonings and
  their associated external cause
  – Example
    • T42.3x25-Poisoning by barbiturates, intentional
      self-harm, sequela. (The ‘x’ character is used as a
      5th character placeholder in certain 6 character
      codes to allow for future expansion and to fill in
      other empty characters (e.g, character 5 and/or 6)
      when a code that is less than 6 characters in
      length requires a seventh character
           Changes Cont’d
• Example
  – T45.1x5A-Adverse effect of calcium-channel
    blockers, initial encounter
  – T15.02XD-Foreign body in cornea, left eye,
    subsequent encounter
  Inclusion of clinical concepts that do not exist
    currently in ICD-9-CM (e.g., underdosing,
    blood type, blood type, blood alcohol level)
           Changes cont’d
Example
  T45.526D-Underdosing of antithrombotic drugs,
  subsequent encounter
  Z67.40-Blood alcohol level of 120-199
  mg/100mL
Expansion of codes
  Example-E10.610-Type 1 diabetes mellitus with
  diabetic neuropathic arthropathy
    Other changes in ICD 10
• Injuries are grouped by anatomical site as
  opposed to type of injury
• Category restructuring and code
  reorganization have occurred in a number
  of ICD-10-CM chapters resulting in the
  classification of certain diseases and
  disorders that are different from ICD -9-
  CM
        Other changes cont’d
• Certain diseases have been reclassified to different
  chapters or sections in order to reflect current medical
  knowledge
• New code definitions
• Example-Acute Myocardial Infarction is now 4 weeks
  rather than 8 weeks
• ICD-9-CM V codes (factors influencing health status and
  contact with health services) and E codes( External
  Causes of Injury and Poisoning) are incorporated in the
  main classification as opposed to being separated into
  supplementary classifications as they do currently in
  ICD-9-CM
 Documentation Is the Center
Piece for Successful Reporting
  of ICD-10 Diagnosis Codes
       Why get started now
• Due to the potential significant financial
  and clinical impact ICD-10 and the
  changes required for transition to the
  information systems that are being
  mandated, physicians should be taking
  steps now to understand how to
  successfully prepare for ICD-10
                 ICD-10
• Coding and billing systems will need to be
  updated to support the new code set
• Currently the code set has 3-5 digits and
  ICD-10 will increase to 5-7 digits
• Documentation will be impacted severely
  which will cause a domino effect from
  productivity to increased claims delays
  Steps to take to get started
2. Understand the potential impact this will
   have on physicians practice
  – Financial: How much will this transition cost
    a practice (training, software, etc)
  – Productivity: How significant will this be for a
    practices bottom line and for how long?
  – Education-what is needed and for whom is it
    needed (coders, billers, front office staff, lab
    personnel, etc)
                                    Quiz
•   True or false? V and E codes are supplemental classifications in ICD-10-CM.
•   True or false? In ICD-10-CM, injuries are grouped by anatomical site rather
    than injury category.
•   What is the maximum number of characters in ICD-10-CM?
•   How many chapters does ICD-10-CM contain?
•   True or false? The first modification to ICD-10 was published in 2001
•   True or false? The final rule, published in the Federal Register naming ICD-10-
    CM as a new medical code set standard to replace the ICD-9-CM diagnosis
    codes, sets October 1, 2013 as the implementation for ICD-10.
•   True or false? ICD-10-CM uses extensions in some sections to identify an
    initial encounter, subsequent encounter or sequelae.
•   Which letter of the alphabet is not utilized in ICD-10-CM?
•   The first character of an ICD-10-CM code is always an alphabetic letter.
Osteopathic Manipulative Treatment
             (OMT)
•   Reporting of OMT Services
•   E/M
•   Modifier-25
•   Documentation
•   Compensatory Changes
•   OMT Survey
Osteopathic Manipulative Treatment
             (OMT)
    1-2 Body Regions Involved
        Vignette
A 25 yr. old female presents with
right lower neck pain of two weeks
duration. Somatic dysfunction of
cervical and thoracic regions are
identified on exam.
Description of Pre-Service Work
 The physician determines which osteopathic
 techniques (eg, HVLA, Muscle energy, Counterstrain,
 articulatory, etc) would be most appropriate for this
 patient, in what order the affected body regions need to
 be treated and whether those body regions should be
 treated with specific segmental or general technique
 approaches. The physician explains the intended
 procedure to the patient, answers any preliminary
 questions, and obtains verbal consent for the OMT.
 The patient is placed in the appropriate potion on the
 treatment table for the initial technique and region(s) to
 be treated.
   Description of Intra-Service Work

Patient is initially in the supine position on the treatment
table. Motion restrictions of C6 and C7 are isolated
through palpation and treated using muscle energy
technique. Dysfunctions of T1 and T2 are treated using
passive thrust (HVLA) technique. Patient position is
changed as necessary for treatment of the individual
somatic dysfunctions. Patient feedback and palpatory
changes guide further technique application as appropriate.
   Description of Post-Service Work
Post-care instructions related to the
procedure are given, including side effects,
treatment reactions, self-care, and follow-up.
The procedure is documented in the medical
record
Osteopathic manipulative treatment
             (OMT)
   9-10 body regions involved
            Vignette
 A 40 year old male presents with sub-
occipital headache, and pain in the neck,
upper and lower back, left shoulder and
chest, and right ankle. He was involved in a
rear-end MVA two weeks ago. X-rays in the
ED were negative. He has been taking
prescribed analgesic and muscle relaxant
medications with minimal improvement. On
examination, somatic dysfunction is identified
at the occipitoatlantal, left glenohumeral and
right tibiotalar joints, as well as the cervical,
thoracic, costal, lumbar, sacral and pelvic
regions.
 Description of Pre-Service Work
The physician determines which osteopathic techniques
(eg, HVLA, Muscle energy, Counterstrain, articulatory, etc)
would be most appropriate for this patient, in what order the
affected body regions need to be treated and whether
those body regions should be treated with specific
segmental or general technique approaches. The physician
explains the intended procedure to the patient, answers
any preliminary questions, and obtains verbal consent for
the OMT. The patient is placed in the appropriate position
on the treatment table for the initial technique and region(s)
to be treated.
   Description of Intra-Service Work
Patient is initially in the supine position on the treatment table. Motion
restrictions of identified joints are isolated through palpation and treated
using a variety of techniques as follows: occipitoatlantal joint and
sacrum are treated using muscle energy and counterstain techniques;
right glenohumeral joint and pelvis are treated with articulatory
technique; lumbar, thoracic, cervical and right ankle are treated with
passive thrust (HVLA) technique; costal dysfunctions are treated using
muscle energy technique. Patient position is changed as necessary for
treatment of the individual somatic dysfunctions. Patient feedback and
palpatory changes guide selection of further technique application as
appropriate.
Description of Post-Service Work
Post-care instructions related to the
procedure are given, including side effects,
treatment reactions, self-care, and follow-up.
The procedure is documented in the medical
record
                 OMT RVUs
2011                  2012
• 98925 = 0.45        • 98925 = 0.46
• 98926 = 0.65        • 98926 = 0.71
• 98927 = 0.87        • 98927 = 0.96
• 98928 = 1.03        • 98928 = 1.21
• 98929 = 1.19        • 98929 = 1.46

Conversion Factor =   Conversion Factor =
$33.9764              $24.6712
Medicare
The Objective is to Provide Information
      on the Following Topics:
 •   Medicare 2012 Updates
 •   Evaluation & Management
 •   Medicare Audits
 •   Recovery Audit Contractors (RAC)
 •   “Incident To” Services
     Medicare 2012 Updates
• Physician Fee Schedule is facing a 27.4
  percent reduction
• Physician Quality Reporting Initiative
  (PQRI) Bonus Payment 2%
• E-Prescribing Bonus Payment 2%
• OMT Survey
Physician Documentation
• This is critical to your reimbursement
• If it was not documented it did not happen
• Clear and Legible, words to document by
• Chief complaint (this is the driver to most
  insurance auditors)
• Familiarize yourself with your documentation
  style- is it 1995 guidelines that you follow or
  1997?
    Documentation Guidelines
• The medical record should be complete and
  legible.
• The documentation of each patient encounter
  should include:
   – reason for the encounter and relevant
     history, physical examination findings and
     prior diagnostic test results;
   – assessment, clinical impression or
     diagnosis;
   – plan for care
   Documentation Guidelines [Cont.]

• The patient’s progress, response to and
  changes in treatment, and revisions of diagnosis
  should be documented.
• The CPT and ICD-9-CM codes reported on the
  health insurance claim form or billing statement
  should be supported by the documentation in
  the medical record.
• Hospital visits should be included in the patient’s
  chart
   Evaluation & Management (E/M)
               Coding
• Coding for office visits
• Modifier usage when billing an E/M with a
  procedure (OMT)
• Time Based Coding
      Chief Complaint (CC)
• The chief complaint is a concise statement
  describing the symptom, problem,
  condition, diagnosis, physician
  recommended return, or other factors that
  is the reason for the encounter, usually
  stated in the “patient’s own” words.
• Documentation Guidelines states that the
  medical record should clearly reflect the
  chief complaint
         Medical Necessity
• This area is not black/white
• There are numerous definitions of medical
  necessity
• Linking the appropriate diagnosis to the
  appropriate procedure to support the necessity
  of the procedure performed is critical.
• Medicare defines medical necessity as services
  or items reasonable and necessary for the
  diagnosis or treatment of illness or injury to
  improve the functioning of a malformed body
  member.
           Coding For Time
• When is it appropriate to code for time?
• What is the auditor looking for when they
  review a chart that was billed as time
  being the controlling factor?
  Tips For Verbiage When Billing For
                 Time
Example of correct documentation of time:
• In your note it should read “ I spent 45 minutes
  with the patient and over 50% of that time was
  spent discussing …
Example of incorrect documentation of time:
• “I spent 45 minutes with the patient, discussed
  surgical options versus medical management.
          What Is An Audit?
•      An effective tool used by Medicare and
    other payors to recover monies lost to
    fraud and erroneous billings.
     Why Audits Are Initiated?

•   Suspicion (Billing Pattern)
•   Outlier Physicians
•   The Senior Patrol
•   Whistleblowers
•   Procedure Codes
          Who Are The Auditors?
•   The Office of the Inspector General (OIG)
•   Medicare
•   The Department of Justice (DOJ)
•   The Federal Bureau of Investigation (FBI)
•   Carriers
         Types of Audits

• Prepayment Audits
• Post-Payment Audits
• Statistical Sampling Method
       What Auditors Look For?
• Billing for services or supplies that were not
  provided.
• Billing for non-allowable or non-covered
  services.
• Altering claim forms to receive a higher
  payment amount.
• Unbundling claims.
How To Respond To A Request
    For Documentation

• Reply to the audit notice in a timely
  fashion.
• Gather and submit Only the requested
  documentation.
• Be cooperative.
• You may want to conduct an internal
  audit.
  How to Respond to the Audit
          Findings
• If the findings are not favorable:
• Attempt to discuss the findings with the
  reviewer.
• If necessary request redetermination.
• If necessary request a level one appeal.
     Medicare
 Recovery Audit
Contractors (RACs)



                71
          RAC Legislation
• The RAC program was created by the
  Medicare Prescription Drug, Improvement,
  and Modernization Act of 2003 which pays
  incentive fees to third-party auditors that
  identify and correct improper payments paid
  to healthcare providers in fee-for-service
  Medicare.
• The Medicare Prescription Drug,
  Improvement, and Modernization Act of 2003
  also requires permanent and nationwide RAC
  program by no later than 2010

                                    72
The RAC Demonstration Project

• The RAC demonstration project took
  place of New York, Florida, and
  California.
• By 2010 the RAC covered all 50
  states.
     RAC Program Mission
• To detect and correct past improper
  payments,
• To implement actions that will prevent
  future improper payments.
     • Providers can avoid submitting
       claims that don’t comply with
       Medicare rules
     • CMS can lower its error rate
     • Taxpayers & future Medicare
       beneficiaries are protected
                                   74
                   The New RAC’s Are:
• Diversified Collection Services, Inc. of Livermore,
  California, in Region A, initially working in Maine, New
  Hampshire, Vermont, Massachusetts, Rhode Island and New
  York.

• CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in
  Region B, initially working in Michigan, Indiana and Minnesota.

• Connolly Consulting Associates, Inc. of Wilton, Connecticut,
  in Region C, initially working in South Carolina, Florida,
  Colorado and New Mexico.

• HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D,
  initially working in Montana, Wyoming, North Dakota, South
  Dakota, Utah and Arizona.
  Additional states will be added to each RAC region in 2009
  Minimize Provider Burden
• Limit the RAC “look back period” to three
  years
   – Maximum look back date is October 1,
     2007
• RACs will accept imaged medical records
  on CD/DVD
• Limit the number of medical record
  requests

                                   76
Medical Record Limit Example
• Outpatient Hospital
  – 360,000 Medicare paid services in 2007
  – Divided by 12 = average 30,000
    Medicare paid services per month
  – x .01 = 300
  – Limit = 200 records/45 days (hit the
    max)


                                 77
Summary of Medical Record Limits
         (for FY 2009)
 • Inpatient Hospital, IRF, SNF, Hospice
    – 10% of the average monthly Medicare
      claims (max 200) per 45 days per NPI
 • Other Part A Billers (HH)
    – 1% of the average monthly Medicare
      episodes of care (max 200) per 45 days
      per NPI

                                   78
    Summary of Medical Record Limits
        (for FY 2009) Continued
• Physicians (including podiatrists, chiropractors)
      • Sole Practitioner: 10 medical records per 45 days per NPI
      • Partnership 2-5 individuals: 20 medical records per 45 days
        per NPI
      • Group 6-15 individuals: 30 medical records per 45 days per
        NPI
      • Large Group 16+ individuals: 50 medical records per 45 days
        per NPI
   – Other Part B Billers (DME, Lab, Outpatient hospitals)
      • 1% of the average monthly Medicare services (max 200) per
        NPI per 45 days



                                                       79
 RAC Validation Contractor (RVC)
• CMS has contracted with Provider Resources, Inc. of
  Erie, PA, to work as the Recovery Audit Contractor
  (RAC) Validation Contractor.
• The RAC Validation Contractor (RVC) will work with
  CMS and the RAC to approve new issues the RACs
  want to pursue for improper payments, as well as
  perform accuracy reviews on a sample of randomly
  selected claims on which the RACs have already
  collected overpayment.
• The RVC is another tool CMS will use to provide
  additional oversight and ensure that the RACs are
  making accurate claim determinations in the
  permanent program.
For Additional Information on RAC
• http://www.cms.hhs.gov/MLNMattersArti
  cles/downloads/MM6125.pdf
• http://www.cms.hhs.gov/RAC/Downloads
  /RAC%20Evaluation%20Report.pdf
• http://www.cms.hhs.gov/rac/
Medicare “Incident to” Physician
            Services
 The OIG reviews Medicare services that
 are “incident to” physicians services to
 determine the qualifications and
 appropriateness of the staff who
 performed them.
          Physician Defined
The “physician” refers to physician or other
practitioner (listed below), who are
authorized to receive payment for services
“incident to” his or her own services.
•   physician assistants
•   nurse practitioners
•   clinical nurse specialist
•   nurse midwife, and
•   clinical psychologist
       Professional Service
• A direct, personal, professional service
  which is rendered by the physician
• To meet the “incident to” guidelines, the
  physician must initiate the course of
  treatment, and
• Conduct subsequent physician services
  to show ongoing involvement
    Coverage Requirements
To be covered, service and supplies must
  be:
• An integral, though incidental, part of the
  physician’s or on-physician practitioner’s
  professional services
• Commonly furnished in a physician’s office
  or clinic
• Furnished by the practitioner or auxiliary
  personnel under the physician’s direct
  supervision
   Supervision Requirements
Direct physician supervision of auxiliary
  personnel is required.
Auxiliary personnel:
• any individual (employee, leased employee,
  or independent contractor) who is acting
  under the supervision of a physician
• Auxiliary personnel include nurses, medical
  assistants, technicians, etc.
Direct Supervision in the Office
• Physician must be present in the office
  suite
• Physician must be immediately
  available to assist if needed
• Does not require that the physician be
  in the same room
 Direct Supervision in the Office
           Continued
 Scenarios that do not meet the direct
supervision requirement:
• Availability of a physician by telephone
• Physician presence somewhere in an
institution
           Documentation
To support the use of the incident to
provision, the documentation should
clearly indicate:
• Who performed the “Incident to” service
• The physician’s presence in the office suite
during
  the service/procedure
         Division Website
• Go to www.do-online.org and sign onto
  DO-Online.
   – First time users will need their AOA
     member number to sign up.
• On DO-Online, click on Practice
  Management for the division website.
• There is also a Division email address:
  practicemanagement@osteopathic.org.
   What the DO-Online Practice
  Management Website has for You

• Billing and Coding        • CMS/Medicare
• E/M documentation           – Links to local carrier
                                information
• ICD-9-CM code
                              – Information on each CPT
  updates                       code
• OMT information             – Enrollment information
• Legal                       – CMS Medlearn
• Litigation fund             – CCI link
                              – Fee schedules, new and
• Updates on class action       prior
  suits
 What the DO-Online Practice
Management Website has for You
• Preventive health   • HIPPA
  services            • Managed care
• Demonstration       • Osteopathic
  projects              Advocacy
• CERT- fraud and       Resources
  abuse information
      Division CME Seminars
• Conducted in conjunction with state
  associations and specialty colleges.
• Seminars available include Medicare
  Compliance, HIPAA Privacy Compliance,
  and Documentation Guidelines and Coding
  Reimbursement.
• Call Yolanda Doss, MJ, RHIA at 800-621-
  1773 ext. 8187 or ydoss@osteopathic.org
  for info.
      Contact Information
• Yolanda Doss 1-312-202-8187
  ydoss@osteopathic.org
• Sandra Peters 1-312-202-8088
  speters@osteopathic.org
• Kavin T. Williams, -312-202-8194
  kwilliams@osteopathic.org

								
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