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Billing and Coding Update


									Billing and Coding Update

      Peter A. Boling, MD
  2008 Annual AAHCP Meeting
             Special Thanks
•   Steve Phillips (HCC info)
•   Gresh Bayne
•   George Taler
•   Jim Pyles
•   Connie Row
         Things I Will Cover
• Medicare fee schedule update
• Update on LCD efforts
  – Florida
  – Connecticut
  – Wisconsin LCD
• Importance of attention to diagnosis
  coding in managed care
  – CPT code selection is not enough
          Medicare Fee Schedule
• Extinction level cuts were adopted by CMS in early 2007
• Rare event occurred summer -> fall of 2007
   – CMS re-opened a final decision, and in Nov 2007 reversed some
     of the cuts to home and domiciliary care visit payments
• Value of
   –   Dogged persistence
   –   Righteous cause
   –   Individual and organizational credibility
   –   Supportive relationships with friends
• Translated: ~ $50 million more nationally to providers of
  these services each year in Medicare-B
• Still, we have lost ground compared with best year
 Medicare Home Visit Fee
 Schedule: New Patients
CPT     2008   2008   2005   1998   1997
Code    RVUs   $       $      $      $
99341   1.48   47     58     58     57

99342   2.21   69     86     80     75

99343   3.51   109    125    114    99

99344   4.60   143    164    146    NA

99345   5.54   172    203    174    NA
  Medicare Home Visit Fee
Schedule: Established Patients
  CPT     2008   2008   2005   1998   1997
  Code    RVUs   $       $      $      $

  99347   1.45   45     45     45     45

  99348   2.19   68     72     67     58

  99349   3.20   100    111    98     73

  99350   4.46   139    164    142    NA
LCD Battles
A Local Coverage Determination (LCD), as established by Section 522
of the Benefits Improvement and Protection Act, is a decision by a fiscal
intermediary or carrier whether to cover a particular service on an
intermediary-wide or carrier-wide basis in accordance with Section
1862(a)(1)(A) of the Social Security Act (i.e., a determination as to whether
the service is reasonable and necessary). The difference between
Local Medical Review Policies (LMRPs) and LCDs is that LCDs consist
only of "reasonable and necessary" information, while LMRPs may also
contain category or statutory provisions.

The final rule establishing LCDs was published November 11, 2003.
Effective December 7, 2003, CMS' contractors began issuing LCDs
instead of LMRPs. Over the next 2 years (until December 31, 2005)
contractors converted all existing LMRPs into LCDs and articles. For
the purposes of a LCD challenge, the LCD only contains reasonable
and necessary language. Any non-reasonable and necessary language
a contractor wishes to communicate to providers must be done through an article.
• Local Coverage Determinations
• Made by Medicare carriers
• Can be changed at any time
  – 45 day public comment required
  – Regional medical directors write them
  – Review by Carrier Advisory Committee (CAC)
• LCDs often appear in response to local
  “outbreaks” or blips in coding patterns
• Carriers tend to be skeptical of providers
     AAHCP Success: LCDs
• After much dialogue
  – Phone conferences
  – E-mail
  – Letters
  – In-person meetings
• Carriers revised the most egregious of the
  proposed restrictions
• There are still some potential issues
  Summary of Key LCD Issues
• “Homebound” is not required
• Medically reasonable and necessary (not
  for convenience alone)
• “Equal quality and frequency” of visits as
  seen in other settings such as office
  – Potential area of concern to AAHCP
• Providers may not solicit services
  (example going door-to-door or cold calls)
          Key General Issues
• Clear documentation of necessity of
  diagnostic tests each time they are done
• Several visits at one location one date = OK
  – Total billed time may not exceed time at the site
• Can bill a visit on same day as home health
  nurse, but not if services are duplicative or
  simple supervision
                      Two Carriers
Under the home health benefit (Medicare Part A) the beneficiary must be
confined to the home for services to be covered. For home services provided
by a Medicare Part B provider using these codes, the beneficiary does not
need to be confined to the home. The medical record must document the medical
necessity of the home visit made in lieu of an office or outpatient visit.
The physician/qualified non-physician practitioner must be the provider of record
and be responsible for managing the entire disease process addressed in the visit.
If the home/domiciliary care provider is only rendering care for a limited condition,
the service will be presumed not medically necessary, unless the provider of record
requests a consultation and the care is medically necessary and clearly documented
in the medical record. Services provided in the home or domiciliary setting must not
unnecessarily duplicate services provided to the patient by other practitioners,
regardless of whether those practitioners provide the service in the office, facility or
home/domiciliary setting. Home/domiciliary services provided for the same diagnosis,
same condition or same episode of care as services provided by other practitioners,
regardless of the site of service, may constitute concurrent or duplicative care.
When such visits are provided, the record must clearly document the medical
necessity of such services. When documentation is lacking, the service may be
considered not medically necessary.

It is important to note that services performed to a beneficiary in a
Residential Care Facilities/Rest Homes/Assisted Living Facilities
is expected to occur in the beneficiary’s own personal living space or a
room set aside for such visits. In the event of the latter occurrence,
such rooms are not considered a doctors office, and shall not be used
 for the routine performance of rounds on beneficiaries.

Services performed to beneficiaries who are also seeing other Medicare
Part B providers in their offices for the same diagnosis will be assumed
not medically necessary.
  HCCs and RAPs

Thanks to Steve Phillips and
     Catherine Duffy
   Risk Adjustment Payment
      Model - Background
• Glossary
  – HCCs (Hierarchical Condition Categories)
  – RAPS (Risk Adjusted Payment System)
• Initiated by Balanced Budget Act of 1997
• Phase in schedule 2003 - 2008
• Most MA plans will be paid 100% HCC
  model by 2007
   Risk Adjustment Payment
      Model - Background
• Formerly: Traditional payments based on
• Currently: Implemented to Medicare Advantage
  members to predict health cost expenditures by
  adjusting payments on demographics & health
• Hierarchical Conditional Categories (HCCs) - ICD-9
  codes grouped into HCC categories for
  submission/reimbursement by Medicare
• Each code assigned a specific weight – calculated
  for reimbursement for each code submitted
• Reimbursement is cumulative based on number of
  HCCs (ICD-9 codes) documented and reported
    Risk Adjustment Payment
       Model - Background
• 2007 Payment Blend (2006 Encounters)
   – TEFRA – 100% HCC
   – SHMO – 75% HCC plus frailty
     adjuster/25% SHMO

• 2008 Payment (2007 Encounters)
   – TEFRA – 100% HCC
   – SHMO – 100% HCC
 Risk Adjustment Payment
   Model - Components
– Selected Significant Disease Model
  • Serious manifestations of a condition are considered
    rather than all levels of severity of condition
  • Coefficients are assigned to each HCC included in the
  • The model is cumulative by diagnosis
  • Includes medical and prescription HCCs
– Predictive Model
  • Uses diagnostic information from a base (prior) year to
    predict (risk adjust) total costs for the following year
  Risk Adjustment Payment
    Model - Components
Disease interactions and hierarchies
– Interactions – certain combinations of
  coexisting diagnoses can increase medical
  costs; this model allows for additional
  payment (i.e., CHF, COPD, DM)

– Hierarchies allow for payment based on the
  most severe manifestation of disease when
  less severe manifestations also exist (e.g. a
  controlled diabetic that develops diabetic
   Risk Adjustment Payment
              Model – Part D
• Part D Risk Adjustment Model
  – Shares most characteristics of the CMS-HCC
    Medical model (i.e. prospective, cumulative,
    hierarchical and contains demographic new
    enrollee model)
  – Key differences are:
    • Part D Model predicts liability for Medicare
      prescription drug benefit rather than Part A/B costs
    • 3,000 ICD-9 codes assigned to Medical HCCs
    • 3,562 ICD-9 codes assigned to Rx HCCs
  HCC Payment Model –
    Data Submissions
• Risk Adjustment Submissions
  – All coded relevant diagnoses submitted to
  – Data sources include claims and
    encounters for:
    • Inpatient
    • Hospital outpatient
    • Face to face physician, PA and NP visits
     HCC Payment Model -
• RAPS Challenges
  – Providers have been reimbursed based on
    CPT codes and are not familiar with ICD-9
    Coding Guidelines
  – Incorrect and incomplete coding results in
    reduced Medicare revenue
  – Under/Over Coding Diagnoses
  – Not reporting all diagnoses
  – Lack of documentation
Risk Adjustment Payment Model
 – Common Coding Problems
• Frequently miscoded HCCs include
  – CVA coded on the office encounter as active
  – Breast, prostate, colorectal and other cancers
    and tumors coded as active vs. “history of”
  – Diabetes with complications
  – Renal Failure
  – Angina Pectoris
  – Old Myocardial Infarction (MI)
  – Depression
 Risk Adjustment Payment
Model – Top Ten Diagnoses

       Top Ten CMS-HCCs - Frequency, By Occurrence
 HCC #                   HCC Description                      Frequency
  108    COPD                                                     12.2%
   80    CHF                                                      11.2%
   19    Diabetes without Complications                           10.8%
  105    Vascular Disease                                          9.4%
   92    Specified Heart Arrythmias                                8.9%

  10     Breast, Prostate, Colorectal & Other Cancer Tumors        7.0%
  83     Angina, Old MI                                            5.0%
  96     Ischemic or Unspecified Stroke                            4.0%
         Rheumatoid Arthritis & Inlammatory Connective
  38     Tissue Disease                                            3.9%
  82     Ischemic Heart Disease                                    3.5%
 Examples of impact of missing
• A patient with a chronic ischemic heart
  disease does not qualify for additional
  payments, but a patient with an old healed
  myocardial infarction does get additional

  – Under 100% risk adjustment, not
    identifying this could reduce annual plan
    payments by $2,121 for every member in
    Northern NV.
 Examples of impact of missing
• Disorders of heart rhythm such as paroxysmal
  supraventricular tachycardia or atrial fibrillation
  are typically treated with medications such as

   – Under 100% risk adjustment, unreported
     asymptomatic patients who have this
     disorder (but are being successfully
     treated) could reduce annual plan
     payments $2,709 for every member in
     Northern NV.
 Examples of negative impact of
     misscoded conditions
• Incorrectly coded diagnostic conditions submitted to
  Medicare can indicate a “red flag” for Medicare to audit
  the records.
• The assignment of a “Stroke” code on an office
  encounter when the “stroke” is actually a prior condition,
  is incorrect coding

   – Under 100% risk adjustment, a miscoded
     stroke when it is actually a residual
     condition (e.g., hemiparesis), could cause
     a plan to reconcile $3,048 for every
     member in Northern NV where this was
Risk Adjustment Payment Model
    - Optimization Strategies
• Approaches Taken to Optimize Reimbursement
  & Coding
  – Retrospective – Previously reported diagnoses
     • Use of vendor software to identify “suspect” HCC diagnoses,
     • Internal targeting application prioritizes “suspects” based on
       experience, site visits
     • Use of disease management registry data
         – DM, CHF, COPD
     • Experienced credentialed/certified coders to research
       medical records
Risk Adjustment Payment Model
    - Optimization Strategies
• Approaches Taken to Optimize Reimbursement
  – Prospective - Educational coding tools and
     •   ICD-9 coding cards
     •   Correct “superbills”
     •   Electronic coding newsletters
     •   Quarterly hard copy coding newsletters
     •   Coding in-services
     •   Office specific feedback
Risk Adjusted Payment System


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