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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 LCDs 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. LCDs • 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. Florida 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. Wisconsin 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 demographics • Currently: Implemented to Medicare Advantage members to predict health cost expenditures by adjusting payments on demographics & health status • 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 model • 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 nephropathy) 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 CMS – Data sources include claims and encounters for: • Inpatient • Hospital outpatient • Face to face physician, PA and NP visits HCC Payment Model - Impact • 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 conditions • 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 payment. – 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 conditions • Disorders of heart rhythm such as paroxysmal supraventricular tachycardia or atrial fibrillation are typically treated with medications such as Digoxin. – 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 miscoded. 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, clinically • 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 resources • ICD-9 coding cards • Correct “superbills” • Electronic coding newsletters • Quarterly hard copy coding newsletters • Coding in-services • Office specific feedback Risk Adjusted Payment System (RAPS) IF IT’S NOT DOCUMENTED – IT DIDN’T HAPPEN!
"Billing and Coding Update"