Clinician MIPS Participation Status Letters Coming

Posted on May 1, 2017 by kellyausiello

CMS is now reviewing claims and will be notifying practices which clinicians will need to take part in the Merit-based Incentive Payment System (MIPS), under the new Quality Payment Program (QPP).

In late April through May, you will get a letter from your Medicare Administrative Contractor (MAC) providing the participation status for each MIPS clinician associated with your Taxpayer Identification Number (TIN). Clinicians are included in MIPS if they bill Medicare Part B more than $30,000 a year in allowable charges and provide care for more than 100 Medicare patients a year, and you are a:

Physician
Physician assistant
Nurse practitioner
Clinical nurse specialist
Certified registered nurse anesthetist
For those of you with multiple TINs or with clinicians who practice under multiple TINs, eligibility notifications will be at the TIN level of their eligibility and therefore may have different eligibilities for each of the TIN/practice combinations.

Also note that if your group chooses to report as a group, MIPS assessment will be based on all individuals in the group including those clinicians who do not exceed the low-volume threshold as individuals.

The Quality Payment Program (QPP) is designed to shift reimbursement from the volume of services provided towards payment that rewards clinicians for their overall work in delivering the best care for patients. QPP replaces the Sustainable Growth Rate (SGR) formula and streamlines the “Legacy Programs” – Physician Quality Reporting System,(PQRS) the Value- based Payment Modifier, and the Medicare Electronic Health Records Incentive Program, also known as “meaningful use”.

During the first performance period that began January 1, 2017, CMS will allow you to pick your pace of participation. If you are participating in MIPS you will have three flexible options to submit data to MIPS and a fourth option to join an Advanced APM in order to potentially become a Qualifying APM Participant.

The first performance period of MIPS is 2017, and the first payment year is 2019. This means that your submitted data in calendar year 2017 will be used to determine your MIPS adjustment to Part B payments for items and services provided in 2019.

We recommend you participate, if for no other reason than to avoid the 4% payment reduction that will be assessed in 2019 if you don’t send in any 2017 data. You can avoid the downward payment adjustment by just submitting a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017)

This will ensure that you do not receive a negative payment adjustment in 2019.

If you submit 90 days of 2017 data to Medicare, you may earn a neutral or positive payment adjustment and if you submit a full year of 2017 data to Medicare, you could earn a positive payment adjustment for 2019. To potentially earn a positive payment adjustment in 2019, you should send in your data to Medicare no later than March 31, 2018.

There are several ways to report;

Report as an individual.

If you report as an individual, your payment adjustment will be based on your performance.

An individual is defined as a single clinician, identified by a single National Provider Identifier (NPI) number tied to a single Tax Identification Number (TIN).

You will need to send your individual data for each of the MIPS categories through an electronic health record or a registry or include quality data through your routine Medicare claims process.

Report as a group.

Each Clinician participating in MIPS via a group will receive a payment adjustment based on the group’s performance.

Under MIPS, a group is defined as a single Taxpayer Identification Number (TIN) with 2 or more eligible clinicians (including at least one MIPS eligible clinician), as identified by their National Provider Identifiers (NPI), who have reassigned their Medicare billing rights to the TIN.

If your group would like to participate in MIPS via the CMS Web Interface and/or elect to administer the CAHPS for MIPS survey, you should register between April 1 and June 30, 2017.

Only these two options require registration.

If your group registered for the GPRO Web Interface in 2016 to report for The Physician Quality Reporting System (PQRS), CMS automatically registered your group to use the CMS Web Interface in 2017 for MIPS. If you want to report under another method, you need to cancel the GPRO election during the registration period (4/1 to 6/30/2017)

If you registered for the Web Interface in 2016 and wish to continue in 2017, you should review and update your information, between April 1-June 30, 2017, if:

The number of eligible clinicians in your group has changed since 2016
Your group wants to enroll in the Consumer Assessment of Health Providers and Systems (CAHPS) for MIPS survey
https://qpp.cms.gov/learn/about-group-registration

What should you do “NOW”.

We strongly suggest you complete the following action items to insure you are ready for MIPS.

Make sure your electronic health record is certified by the Office of the National Coordinator (ONC) for Health Information.

Check if you want to use a qualified clinical data registry or other registry to submit your quality data.

See what MIPS data your practice can choose to send in. Figure out which measures and activities best fit your practice.

Go to: Explore the MIPS Measures

Decide whether you should report as an individual or with a group.

CMS has provided quite a few educational resources to help you. Please visit their site https://qpp.cms.gov/resources/education

Moderate Sedation – 2017

Posted on April 27, 2017April 27, 2017 by kellyausiello

References: CR10001 – Medicare Claims Processing Manual – Pub 100-04 Chapter 12, Sections 50 and 140. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Effective May 15, 2017 CMS revises their manual to bring it in line with current payment policy for moderate sedation and other anesthesia services in light of the CPT changes for January 1, 2017.

Anesthesia services range in complexity from least to the most complex as follows:

local or topical anesthesia,
moderate (conscious) sedation,
regional anesthesia and
general anesthesia.

General Payment Rule:

The fee schedule amount for physician anesthesia services furnished is typically based on the allowable base and time units multiplied by an anesthesia conversion factor specific to the geographic locality and communicated to the MACs by means of the annual updates to the Healthcare Common Procedure Coding System (HCPCS) file. The base units and conversion factor are available at https://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html

Moderate sedation is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation but does not include minimal sedation, deep sedation or monitored anesthesia care. Practitioners are instructed to report the appropriate CPT and/or HCPCS code that accurately describes the moderate sedation services performed during a patient encounter, which are performed in conjunction with and in support of a procedural service, consistent with CPT™[1] guidance.

CPT codes 99143-99150 previously used for reporting moderate sedation were deleted from CPT 2017™ and replaced with;

NEW 99151	Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age
99152	initial 15 minutes of intraservice time, patient age 5 years or older
99153	each additional 15 minutes intraservice time (List separately in addition to code for primary service) [Regardless of age of patient.]
99155	Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age
99156	initial 15 minutes of intraservice time, patient age 5 years or older
99157	each additional 15 minutes intraservice time (List separately in addition to code for primary service)

According to the AMA guidelines,

Preservice activities required for moderate sedation are included in the work described by each code 99151-99157 and are not reported separately.

Intraservice time:

is used to determine the appropriate CPT code to report moderate sedation services:

Begins at the administration of the sedating agent(s);
Ends when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified healthcare professional providing the sedation and personal continuous face-to-face time with the patient;
Includes ordering and/or administering the initial and subsequent doses of sedating agents;
Requires continuous face-to-face attendance of the physician or other qualified healthcare professional;
Requires monitoring patient response to the sedating agents, including:
- Periodic assessment of the patient;
- Further administration of agent(s) as needed to maintain sedation; and
- Monitoring of oxygen saturation, heart rate, and blood pressure

Intraservice time of less than 10 minutes should NOT be reported.

If the physician or other qualified healthcare professional who provides the sedation services also performs the procedure supported by sedation (99151, 99152, 99153), the physician or other qualified healthcare professional will supervise and direct an independent trained observer who will assist in monitoring the patient’s level of consciousness and physiological status throughout the procedure.

An independent trained observer is defined as an individual who is qualified to monitor the patient during the procedure and who has no other duties during the procedure.

Postservice Work

The postservice activities required for moderate sedation are included in the work described by each code 99151-99157 and are not reported separately.

If the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation, such as a local or topical anesthesia, then the conscious sedation code should not be reported and no payment should be allowed by the A/B MAC (B). There is no CPT code for the performance of local anesthesia and as payment for this service is considered in the payment for the underlying medical or surgical service.

[1] CPT is a registered trademark of the American Medical Association, used with permission.

Fraud Enforcement UP UP UP! Are you next?

Posted on February 18, 2017 by kellyausiello

20 Years after HIPPA established a national Fraud and Abuse Control Program, the enforcement agencies are still providing impressive results.

During Fiscal Year (FY) 2016, the Federal Government won or negotiated over $2.5 billion in health care fraud judgments and settlements. As a result of these efforts, as well as those of preceding years, they recovered over $3.3 billion.

The Department of Justice (DOJ) opened 975 new criminal health care fraud investigations, filed criminal charges in 480 cases involving 802 defendants and secured a total of 658 convictions Also in FY 2016, DOJ opened 930 new civil health care fraud investigations and had 1,422 civil health care fraud matters pending at the end of the fiscal year.

FBI investigative efforts resulted in over 555 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 128 health care criminal enterprises.

In FY 2016, investigations conducted by HHS’ Office of Inspector General (HHS-OIG) resulted in 765 criminal actions against individuals or entities that engaged in crimes related to Medicare and Medicaid, and 690 civil actions, which include false claims and unjust-enrichment lawsuits filed in federal district court, civil monetary penalties (CMP) settlements, and administrative recoveries related to provider self-disclosure matters.

HHS-OIG also excluded 3,635 individuals and entities from participation in Medicare, Medicaid, and other federal health care programs.

New Exclusion Authority and Penalties:
On Dec. 6, 2016, the OIG issued rules that incorporate new civil monetary policies (CMP) authorities, clarify existing authorities, and reorganize regulations regarding CMPs. The final rule also implements provisions of the PPACA of 2010 that authorize CMPs for the following;
*Failure to grant the OIG timely access to records.
*Ordering or prescribing while excluded.
*Making false statements, omissions, or misrepresentations in an enrollment application.
*Failure to report and return over-payments.
*Making or using a false record or statement material to a false or fraudulent claim.

In addition, under both the Federal Civil Penalties Inflation Act and the 21st Century Cures Act, Congress adjusted certain civil fines and penalties for inflation and increased the OIG’s authority to issue exclusions for the following:
• Expand CMP for false claims related to contracts and grants funded by Medicare and Medicaid or other HHS programs.
• Authorize the OIG to impose CMP on individuals or entities that knowingly submit false claims, up to $10,000 for each claim.
• Expansion would include false statements on applications or proposals for HHS-funded grants/contracts, up to $50,000 for each false statement.
• $15,000 for each day the entity fails to allow OIG access to audit or investigate false claims.
• Filled in a gap to expand OIG authority to allow the imposition of exclusion of an officer or managing employee who left the organization prior to the pursuit of fraud that such person was involved in, even if they are not currently employed by the prior company.

Fraud and/or abuse differ only in the “intent” of the person committing the offense. Most “abuse” cases are pursued as civil actions while actual “fraud” with intent are criminal. In other words, fraud can send you to the “big house” while stupidity just sends you to the “poor house”.

2017 CPT will expand Therapy Evaluation Codes.

Posted on July 8, 2016 by kellyausiello

For CY 2017, the CPT Editorial Panel will deleted four CPT codes (97001, 97002, 97003, and 97004) and create eight new CPT codes (97X61-97X68) to describe the evaluation procedures furnished by physical therapists and occupational therapists. There are three new codes, stratified by complexity, to replace a single code, 97001, for physical therapy (PT) evaluation, three new codes, also stratified by complexity, to replace a single code, 97003, for occupational therapy (OT) evaluation, and one new code each to replace the reevaluation codes for physical and occupational therapy – 97002 and 97004.

Here is an advanced look at the requirements……

New CPT Code/ CPT Long Descriptors for Physical Medicine and Rehabilitation
97X61 Physical therapy evaluation: low complexity, requiring these components:
● A history with no personal factors and/or comorbidities that impact the plan of care;
● An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
● A clinical presentation with stable and/or uncomplicated characteristics; and
● Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face-to-face with the patient and/or family.

97X62 Physical therapy evaluation: moderate complexity, requiring these components:
● A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
● An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following body structures and functions, activity limitations, and/or participation restrictions;
● An evolving clinical presentation with changing characteristics; and
● Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 30 minutes are spent face-to-face with the patient and/or family

97X63 Physical therapy evaluation: high complexity, requiring these components:
● A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
● A clinical presentation with unstable and unpredictable characteristics; and
Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 45 minutes are spent face-to-face with the patient and/or family.

97X64 Reevaluation of physical therapy established plan of care, requiring these components:
● An examination including a review of history and use of standardized tests and measures is required;
and
● Revised plan of care using a standardized patient assessment instrument and/or measurable assessment
of functional outcome
Typically, 20 minutes are spent face-to-face with the patient and/or family.

97X65 Occupational therapy evaluation, low complexity, requiring these components:
● An occupational profile and medical and therapy history, which includes a brief history including
review of medical and/or therapy records relating to the presenting problem;
● An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or
psychosocial skills) that result in activity limitations and/or participation restrictions; and
● Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.
Typically, 30 minutes are spent face-to-face with the patient and/or family.

97X66 Occupational therapy evaluation, moderate complexity, requiring these components:
● An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance;
● An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or
psychosocial skills) that result in activity limitations and/or participation restrictions; and
● Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
Typically, 45 minutes are spent face-to-face with the patient and/or family.

97X67 Occupational therapy evaluation, high complexity, requiring these components:
● An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance;
● An assessment(s) that identify 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
● A clinical decision-making is of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
Typically, 60 minutes are spent face-to-face with the patient and/or family.

97X68 Reevaluation of occupational therapy established plan of care, requiring these components:
● An assessment of changes in patient functional or medical status with revised plan of care;
● An update to the initial occupational profile to reflect changes in condition or environment that affect
future interventions and/or goals; and
● A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.
Typically, 30 minutes are spent face-to-face with the patient and/or family

The changes are shown in CMS proposed plan for 2017.

Medicare Audits Result In Large Paybacks on Therapy Services.

Posted on June 19, 2016 by kellyausiello

By R.L. Ramsdell, PhD, FACFEI, DABFE, CFC, LFMAAMA. Executive Director.

Physical medicine and rehabilitative services are designed to improve, restore, or compensate for loss of physical functioning following disease, injury or loss of a body part which makes them an ideal ancillary inclusion for pain management and rehabilitation practices. Clinicians use the clinical history, systems review, physical examination, and a variety of evaluations to determine the impairments, functional limitations, and disabilities of the individual patient and then address them through design and implementation of a plan of care tailored to the specific needs of the individual patient. The services are not only beneficial for the patient but are a good source of revenue for the practice. Therapy service income often out performs other clinical services on a consistent basis.

Unfortunately many multidisciplinary consultants are apparently uninformed on Medicare “requirements” on who can actually “perform” the therapy services and often misrepresent permissible delegation and the actual supervision requirements over unlicensed individuals in the non-facility (Doctor’s office) setting.

Practitioners are learning the rules the hard way as whistle blower, disgruntled employees and competitor reports prompt on site audits and recoveries in the hundreds of thousands of dollars.

The premise for therapy is based on patients who must have a potential for restoration or improvement of lost functions and require the services of a skilled therapist. Rehabilitation services are typically short term, intensive and have clear goals for services employed to restore and maintain a level of function. Naturally Medicare patients are often subjected to illnesses and conditions effectively treated with physical therapy rehabilitation efforts.

Under Medicare policies, intervention with PM&R modalities and procedures is indicated when:

an assessment by a physician, NPP or therapist supports utilization of the intervention,
there is documentation of objective physical and functional limitations (signs and symptoms), and
the written plan of care incorporates those treatment elements that require services of a skilled therapist for a reasonable and generally predictable period of time.

Skilled therapist, for Medicare reimbursement privileges means that the covered therapy services are “personally performed ONLY by one of the following;

Licensed therapy professionals: licensed physical therapists and occupational therapists
Licensed PTA with appropriate supervision by a licensed physical therapist.
Licensed occupational therapy assistants (OTA) with appropriate supervision by a licensed occupational therapist.
Medical Doctors (MDs) and Doctors of Osteopathy (DOs).
Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency.
Qualified NPPs, including Advanced Nurse Practitioners (ANPs), Physician Assistants (PAs) or Clinical Nurse Specialists (CNS) when performing services within their licenses’ scope of practice and their training and competency (ANP, PA, CNS).
“Qualified” personnel when appropriately supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met.Qualified personnel providing physical therapy (PT) or occupational therapy (OT) services “incident to” the services of a physician/NPP must have met the educational and degree requirements of a licensed therapy professional (PT, OT) from an accredited PT/OT curriculum, but are not required to be licensed.

There always seems to be some “consultants” who spend more time advising their clients on possible ways to “beat the system” than educating them on how to do things properly and avoid potential conflicts with regulations.

The basic facts are that reimbursement for services performed have a calculated component based on the amount of “professional” time required to render the service to the patient. You may have noticed this “little requirement” in the description of various “time based” therapy codes where the language clearly states “one-on-one patient contact by provider”.

In my opinion, it is completely illogical for any provider to expect a carrier to pay for professional time when the services were provided by “trained aides” who lack the comprehensive training necessary to exercise professional judgment over the therapy or procedure. The Federal programs for example, draw fairly clear lines on who is and who is not qualified to receive reimbursement for “professional time” by reviewing Medicare regulations 230.1(C) and 230.2(C) which clearly state;

Services provided by aides, even if under the supervision of a therapist, are not therapy services in the outpatient setting and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

Services of athletic trainers, massage therapists, recreation therapists, kinesio-therapists, low vision specialists or any other profession may not be billed as therapy services. (This includes services performed by Chiropractors since they are statutorily excluded for payment for any service performed other than spinal manipulation by CMT.- DrR)

In short, Medicare will not pay for the services of a “qualified provider” unless the services are performed by a “qualified provider”. Learn the difference and apply the principles.

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies.

Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law……..o Assistants may not supervise others.

QUALIFIED PERSONNEL means staff (auxiliary personnel) who may or may not be licensed as therapists but who meet all of the requirements for therapists with the exception of a license. Qualified personnel must have been educated and trained as therapists to qualify for furnishing therapy services under direct supervision and incident to a physician or NPP.

PTAs, even if licensed, may NOT perform “incident to” a physician or NPP, since they do not meet the definition of a therapist.

Aides are “everyone other” than those described above. Med Techs, Chiropractic Assistants, Exercise Physiologists, Athletic trainers, massage therapists, LVNs, LPNs or any individual with a certificate of anything are NOT eligible to perform PT/OT for Medicare reimbursement.

So next time, your so called consultant wants you to bill the services of a med tech under your provider number, remember;

Fraud, as defined by Federal Regulation (42CFR455.2) , is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of unauthorized benefits. A scheme does not have to be successful to be considered fraudulent.
Abuse involves actions that are inconsistent with sound medical, business, or fiscal practices. Abuse, directly or indirectly, results in higher costs to the healthcare program through improper payments that are not medically necessary. (under the carrier’s published policy).

The only difference between fraud and abuse is a person’s intent. That is, did they know they were committing a crime?

In either case, the key component is that the perpetrator knew or should have known that the act was improper.

There are many “restrictions” providing PT / OT – Don’t hesitate to contact us with questions.

Merit-based Payment System (MIPS)

Posted on May 4, 2016 by kellyausiello

Merit-based Payment System (MIPS)

Writing for the Academy is Dr R.L. Ramsdell, PhD – Executive Director.

The Centers for Medicare & Medicaid Services (CMS) has added another 900+ page volume to our regulation reading pleasure outlining the proposed details on how physicians will be paid under Medicare in 2019. As I stated, this is a proposal open for public comments, submitted electronically or on paper, until 5 p.m. on June 27, 2016.

There are actually two programs here, the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) incentive regulation. According to CMS, the MIPS will consolidate components of three existing programs: the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals (EPs). The proposed rule also would establish incentives for participation in certain alternative payment models (APMs) to help advance the Obama Administration’s 2015 goals to move 30% of traditional Medicare fee-for-service payments into alternative payment models that pay providers based on the quality rather than the quantity of care they provide by 2016 and 50% by 2018.

The current proposal is a result of the 2015 law called the Medicare Access and CHIP Reauthorization Act (MACRA), which, after decades of “temporary fixes”, finally abolished the idiotic and unsustainable -sustainable growth rate (SGR) formula for physician compensation. MACRA, as it is now known, gradually shifts reimbursement from fee-for-service to pay-for-performance or value based payment.

Under MACRA, physicians choose between two payment models with MIPS being the default model which will encompass the majority of physicians. MIPS reportedly will incorporate and align three existing Medicare incentive programs:

• meaningful use of electronic health records,
• the Physician Quality Reporting System, and
• the Value-Based Payment Modifier.

Medicare will increase or decrease a physician’s fee-for-service reimbursement in MIPS according to his or her quality of care, cost (resource use), clinical practice improvement, and meaningful use of electronic health records (advancing care information).

Our understanding in reading the proposed regulation is MIPS will be based on a “point score” system for the first year where the quality-of-care component constitutes 50% of the MIPS score; cost 10%; clinical practice improvement 15%; and advancing care information (meaningful use of electronic health records) 25%.

MIPS bonuses and penalties up to 4% each debut in 2019 and increase to

5% in 2020,
7% in 2021, and
9% in 2022 and beyond.

The bonuses and penalties are based on performance 2 years earlier, meaning pay hikes and pay cuts in 2019 will reflect what a clinician did in 2017.

Let’s look briefly at the “scoring” components.

• Quality (50 percent of total score in year 1): For this category, clinicians would choose to report six measures from among a range of options that accommodate differences among specialties and practices.

• Advancing Care Information (25 percent of total score in year 1): Medicare incorporated EHR and meaningful use into this new catchy term late last year) For this category, clinicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting.

• Clinical Practice Improvement Activities (15 percent of total score in year 1): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities that match their practices’ goals from a list of more than 90 options.

• Cost (10 percent of total score in year 1): For this category, the score would be based on Medicare claims, meaning no reporting requirements for clinicians. This category would use 40 episode-specific measures to account for differences among specialties.

Advanced Alternative Payment Models

Under provisions originally created by the Affordable Care Act, many clinicians are currently participating in alternative payment models but may not meet requirements for sufficient participation in the most advanced models under the new regulations. The proposed rule appears to be designed to provide these clinicians with financial rewards within MIPS. Further it appears that those clinicians who can participate to a sufficient extent in Advanced Alternative Payment Models – would be exempt from MIPS reporting requirements and qualify for financial bonuses under the new models.

These models include the new Comprehensive Primary Care Plus (CPC+) model, the Next Generation ACO model, and other Alternative Payment Models under which clinicians accept both risk and reward for providing coordinated, high-quality care.

Let’s look at these as they are presented by CMS in the proposal.

The Comprehensive Primary Care Plus (CPC+) model
On April 11, CMS announced its largest-ever initiative to transform how primary care is delivered and paid for in America. The initiative, called The Comprehensive Primary Care Plus (CPC+) model, is a national advanced primary care medical home model which will be implemented in up to 20 regions to accommodate up to 5,000 practices.
According to CMS, the initiative is designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to be paid for achieving results and improving care.

• The CPC+ model incorporates lessons learned from the 5 year CPC initiative model tested through the Center for Medicare & Medicaid Innovation that began October 2012 and runs through December 31, 2016. Under this initiative model, CMS collaborated with 38 commercial and state health insurance plans across seven U.S. regions to support 500 primary care practices in testing aligned payment for the delivery of a single model of comprehensive primary care.

o In addition to regular fee-for-service payments, Medicare and other CPC payers provide a non-visit-based care management fee paid per member per month and an opportunity to share in savings generated in each of the CPC regions. This care management fee has provided CPC practices with the necessary financial resources to create new workflows, hire care management staff, and develop new relationships necessary to coordinate care.

• Center for Medicare and Medicaid Innovation (Innovation Center), was established by section 1115A of the Social Security Act (as added by section 3021 of the Affordable Care Act). Congress created the Innovation Center to test innovative payment and service delivery models, including primary care payment and care delivery reform, to reduce CMS program expenditures and improve quality for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries.

Primary care practices will participate in one of two tracks. While both tracks will be required to meet the criteria of the model, those in Track 2, will actually provide more comprehensive services for patients with complex medical and behavioral health needs.

CPC+ is reportedly designed to help practices move away from one-size-fits-all, Fee-For-Service (FFS) health care to a new system that will give doctors the freedom to deliver the care that best meets the needs of their patients.

• In Track 1, CMS will pay practices a monthly care management fee in addition to the FFS payments under the Medicare Physician Fee Schedule for activities

• In Track 2, practices will also receive a monthly care management fee and, instead of full Medicare FFS payments for Evaluation and Management services, will receive a hybrid of reduced Medicare FFS payments and up-front comprehensive primary care payments for those services

o CMS has a fact sheet on fees and payments available at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-11.html

CMS states “to promote high-quality and high-value care, practices in both tracks will receive up-front incentive payments that they will either keep or repay based on their performance on quality and utilization metrics. Practices in both tracks also will receive data on cost and utilization.”

CPC+ will bring together CMS, commercial insurance plans, and State Medicaid agencies to provide the financial support necessary for practices to make fundamental changes in their care delivery and select regions for CPC+ where there is sufficient interest from multiple payers to support practices’ participation in the initiative. CMS will enter into a Memorandum of Understanding with selected payer partners to document a shared commitment to align on payment, data sharing, and quality metrics in CPC+. CMS will accept payer proposals to partner in CPC+ from April 15 through June 1, 2016. CMS will accept practice applications in the determined regions from July 15 through September 1, 2016.

For additional information on the “specifics” of the CPC+ program, we refer the reader to;
https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Plus

The Next Generation ACO Model is a new CMS Innovation Center initiative that builds upon experience from the Pioneer ACO Model and the Shared Savings Program. With 21 participating ACOs, the new model offers a new opportunity in accountable care—one that enables providers and beneficiaries greater opportunities to coordinate care and aims to attain the highest quality standards of care. Unlike other models, this model includes a prospectively (rather than retrospectively) set benchmark, allows beneficiaries to choose to be aligned to the ACO, and tests beneficiary incentives for seeking care at Next Generation providers, including increased availability of telehealth and care coordination services.

The Next Generation Model participants will have the opportunity to take on higher levels of financial risk – up to 100 percent risk – than ACOs in current initiatives. While they are at greater financial risk they also have a greater opportunity to share in more of the Model’s savings through better care coordination and care management. In addition, the ACOs will receive their budgets prospectively, in advance of the performance year, to plan and manage care around these financial targets from the outset. The ACOs will also be able to select from flexible payment options, such as infrastructure payments that support ACO investments in care.

There are 18 ACOs currently participating in the Next Generation ACO Model in 14 States.

For more information on the Next Generation ACO Model, including the list of provider participants, and how to apply for 2017, we refer the reader to:
https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/

Deadline for submission of your letter of intent (LOI) has been extended to May 20, 2016. The actual application must be received by May 25th.

The Next Generation ACO Model is an initiative designed for ACOs that are very experienced in coordinating care for large populations of patients.

The Academy does NOT recommend this for our member practices.

Under the current proposal, as we understand it, we would suggest our members choose the MIPS program and strive to fully participate in that to receive their financial incentive bonuses.

Monitoring the ICD-10 Timeline for 2017 revisions.

Posted on April 5, 2016April 24, 2020 by kellyausiello

ICD-10 Timeline for 2017 revisions.

Revisions and additions to the ICD-10CM are a product of the ICD-10 Coordination and Maintenance Committee which meets periodically during the year to present and discuss recommendations for code changes and additions to the ICD-10 system.

For those of you who want to follow the process, the Committee met on March 9 and 10, 2016 and both the webcast and the summary report are now available on their respective webpages.

Webcast of the March 9-10, 2016 ICD-10 Coordination and Maintenance Committee meeting will be posted on the CMS webpage as follows: www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes

Summary report of the Diagnosis part of the March 10, 2016 ICD-10 Coordination and Maintenance Committee meeting report will be posted on the NCHS webpage as follows: www.cdc. gov/nchs/icd/icd9cm maintenance.htm

On April 1st, an announcement was made; “There were no requests for ICD-10 codes to capture new diseases or technology for implementation on April 1, 2016. Therefore, there will be no new ICD-10 codes implemented on April 1,2016.

To follow the process, we offer the following timeline as published by the Committee;

April 8, 2016 Deadline for receipt of public comments on proposed new codes and revisions discussed at the March 9-10, 2016 ICD-10 Coordination and Maintenance Committee meetings for implementation on October 1,2016.
April General; Notice of Proposed Rulemaking to be published in the Federal Register as mandated by Public Law 99-509. This notice will include references to the complete and finalized FY 2017 ICD-10-CM diagnosis and ICD-10- PCS procedure codes. It will also include proposed revisions to the MS DRG system based on ICD-10-CMIPCS codes on which the public may comment. The proposed rule can be accessed at: http://www.cms.gov/Medicare/Medicare-Fee- for-Service- Payment/AcutelnpatientPPS/index. html?redirect=/ AcutelnpatientPPS/IP PS/list.asp.
June, 2016 Final addendum posted on web pages as follows:Diagnosis addendum – http://www.cdc.gov/nchs/icd/icdlOcm. htm Procedure addendum –http://cms.hhs.gov/Medicare/Coding/ICD IO/index.html

The Committee will meet on September 13-14, 2016 with webcasts available at www.ems.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ meetings.html with the summary report of the diagnosis part on the NCHS homepage at www.cdc.gov/nchs

October 1, 2016 the new and revised ICD-10-CM and ICD-10-PCS codes go into effect with the associated DRG changes. The final addendum will be available as follows:

Diagnosis addendum :: www.cdc.gov/nchs/icd/icd10cm.htm

Procedure addendum will be at www.cms.gov/Medicare/Coding/ICD10

The real risk of carrier audits!

Posted on February 6, 2016February 6, 2016 by kellyausiello

Let’s face it, many practices are having a hard time staying profitable and may engage in some “creative billings” to increase what they are paid by various carriers. For some reason, practices seem to think that Medicare/ Medicaid/ and Tricare are their only real concerns when it comes to misrepresenting services for financial gain.

Typically their first concern arises when they receive a letter from an investigations unit requesting several patient files for specific dates of service that the carrier bases on their provider participation agreement authorizing the plan(s) to perform reviews, audits and statistically valid sampling techniques for peer review program activities, medical necessity reviews, data validation reviews, billing and claims payment audits, coding or quality review audits; all of which routinely hold all physicians in the practice jointly and severally liable for misreporting by any and all providers in the practice.

Healthcare fraud is a crime under most criminal codes and consists of intentional deceit within the healthcare system for the purpose of illicit gains. Healthcare abuse is similar activity or behavior where knowing intent to obtain an unlawful gain cannot be established.
The primary difference between fraud and abuse is a person’s intent. That is, did they know they were committing a crime? In either case, the key component is that the perpetrator knew or should have known that the act was improper or inconsistent with sound practices.

It’s important to distinguish health care fraud from mere mistakes, omissions, or improper payments. To commit fraud, a person must knowingly engage in a plan, scheme, or activity to provide falsehoods or misrepresentations with the intent to achieve some financial gain.

The proof of the allegations is the existence of the claims regardless of the payment or denial. The scheme does not need to be successful to be considered fraudulent.

Most practices referred by the carrier for criminal actions are due to intentional misrepresentation of the procedure performed and willful misconduct by the providers, managers and billing people to mis-code the actual service(s) and falsify the medical records to support the misrepresented service codes. The “collaboration” of the parties to the scheme is usually prima facie evidence of intent and the testimony of one of the more innocent collaborators who rolls over on the boss, is all it takes to prove intentional fraud.

Stealth Coding.
The “basic instructions” on code selection contained in the CPT®* manual prohibits “stealth” coding.
“Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. ………When necessary, any modifying or extenuating circumstances are added. Any service or procedure should be adequately documented in the medical record.”

Conservative estimates of the amount of healthcare expenditures lost to fraud is three percent of total services paid, which equates to over $70 billion annually. Frequently seen examples are;

• Billing for more expensive services or procedures than were actually provided or performed, commonly known as “upcoding”-i.e., falsely billing for a higher-priced treatment than was actually provided. This is often combined with an accompanying “inflation” of the patient’s diagnosis code to a more serious condition consistent with the false procedure code.
• Performing medically unnecessary services solely for the purpose of generating insurance payments-seen very often in nerve-conduction and other diagnostic-testing schemes.
• Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments- This is often seen in multidisciplinary settings where a non-covered service such as spinal manipulation or extremity adjustments by a Chiropractor are represented as a covered physical therapy procedures under order of a medical provider.
• Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary.
The majority of health care fraud is committed by a very small minority of dishonest health care providers.

Sadly, the actions of these deceitful few ultimately serve to sully the reputation of perhaps the most trusted and respected members of our society-our physicians. Unfortunately these fraud-doers take advantage of the confidence that has been entrusted to them in order to commit ongoing fraud on a very broad scale and their ability to spread false billings among many insurers simultaneously including public programs such as Medicare and Medicaid, where they can maximize fraud proceeds while lessening their chances of being detected by any a single insurer.

Federal Criminal False Claims Statutes (18 U.S.C. §§ 287,1001) Section 1001 applies to anyone whose action(s) related to any claim(s) for government payment consist(s) of any of the following:
• Falsifying, concealing, or covering up by any trick, scheme or device a material fact related to any claim(s) for government payment;
• Making any materially false, fictitious or fraudulent statement or representation; • Making or using any false writing or document knowing it contains any materially false, fictitious or fraudulent statement or entry.
Section 287 states that whoever makes or presents to the government a claim knowing that it is false, fictitious or fraudulent shall be imprisoned and subject to fines.
We understand from attorneys that the government is required to establish all of the following in regard to the action(s) of a false claim(s) case defendant. He/she:
• Made or presented a false, fictitious or fraudulent claim to a department of the United States;
• Knew the claim was false, fictitious or fraudulent; and
• Did so with the specific intent to violate the law or with awareness that what s/he was doing was wrong.

EMPLOYEES BEWARE: Bosses are not doing their employees any favors when the intimidate them to “do as they are told”. Filing false and miscoded claims can seem like a minor crime, but a conviction for health care fraud, especially when the defendant is a professional who depends on a license to practice, can irreparably change the course of that professional’s life. “My boss made me do it” is normally NOT going to get you absolve you of your participation in perpetrating the crime or conspiracy to cover it up.

As carriers improve investigative techniques through their National Health Care Anti-Fraud Association and refer more cases for criminal action in addition to recovering their money, we need to offer the following advice to our members;
The moment you are approached by investigators about a potential fraud case, you need to contact a criminal defense attorney. You can unknowingly incriminate yourself anytime you speak to an investigator if you don’t have legal advice. Local criminal defense attorneys are the only people capable of providing you with legal advice in light of their knowledge of the law, as well as their experience with local prosecutors, courts, and criminal investigations.

If you’re being investigated for breaking a federal law, your case will be handled in the federal court system. Be sure that the lawyer you choose has experience handling federal cases.

Naturally the best defense is to do it right in the first place.
If you are unsure of a particular billing scenario or you get a “I get paid doing this” from a “friend”, Contact us! Your Academy is here to help you.

*CPT is a registered trademark of the American Medical Association- gratefully used with their permission.

PAINT IS NOT THE ONLY LEAD HAZZARD

Posted on January 28, 2016January 28, 2016 by kellyausiello

President Obama has been crowned the greatest gun salesman in America. People are flocking to the gun ranges to shoot their newest protection piece and concealed weapons permits are up significantly.

One “medical concern” you should be looking for is “lead contamination”.

You and/or your patients are exposed to lead every time they shoot. Lead is typically contained in the primer of each bullet or shell, so when you fire your gun all of the residue and powder from the explosion lands on your hands, face and shirt and you’re essentially covered in lead particles. In the crime shows they call the GSR (gun shot residue) This vaporized lead obviously can be inhaled, but the particles of lead sheared off as an unjacketed bullet travels down the barrel are small enough to be easily inhaled as well. Once inhaled the lead readily crosses to the bloodstream and is distributed throughout the body. It is absorbed like calcium and interferes with iron absorption and can be deposited in bone and fat and other soft tissue.

In addition, if you clean your firearm when you get home, that firearm is covered in lead dust. When you’re shoving the cleaning rod down the barrel that dust is shooting out of the barrel into your house.
If you happen to walk around and pick up your brass or shell cases after you shoot, those are covered in lead. And if you put that in your pocket or scoop it up in a hat, then you have a pocket or hat covered in lead dust as well.

Symptoms of lead poisoning are varied and may affect many parts of the body. Most of the time, lead poisoning builds up slowly following repeated exposures to small quantities of lead and is difficult to detect until symptoms progress. Most doctors do not inquire about recreational gun use and when symptoms present, lead poisoning is way down the list of differential diagnoses. Typically it is diagnosed by a blood lead levels test. CDC recognizes blood lead levels (BLLs) of >25 µg/dL in adults and >10 µg/dL in children as levels of concern.

Signs and symptoms in adults may include:
• High blood pressure
• Abdominal pain
• Constipation
• Joint pains
• Muscle pain
• Declines in mental functioning
• Pain, numbness or tingling of the extremities
• Headache
• Memory loss
• Mood disorders
• Reduced sperm count, abnormal sperm
• Miscarriage or premature birth in pregnant women

HIPAA and Firearms Background Check System.

Posted on January 6, 2016 by kellyausiello

The following notice was released by OCR today. We are distributing it so our members are aware of their professional responsibility under the revisions to HIPAA.

OCR HIPAA Privacy Rule information
The following notice was released by OCR today. We are distributing it so our members are aware of their professional responsibility under the revisions to HIPAA.
Obama administration modifies HIPAA to strengthen the firearm background check system

On January 4, 2016, the Department of Health and Human Services (HHS) moved forward on the Administration’s commitment to modify the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule to expressly permit certain covered entities to disclose to the National Instant Criminal Background Check System (NICS) the identities of those individuals who, for mental health reasons, already are prohibited by Federal law from having a firearm.

This modification better enables the reporting of the identities of prohibited individuals to the background check system and is an important step toward improving the public’s safety while continuing to strongly protect individuals’ privacy interests.

The final rule gives States improved flexibility to ensure accurate but limited information is reported to the NICS. This rulemaking makes clear that, under the Privacy Rule, certain covered entities are permitted to disclose limited information to the NICS. The information that can be disclosed is the limited identifying information about individuals who have been involuntarily committed to a mental institution or otherwise have been determined by a lawful authority to be a danger to themselves or others or to lack the mental capacity to manage their own affairs – that is, only about those who are covered under the pre-existing mental health prohibitor.

The new modification is carefully and narrowly tailored to preserve the patient-provider relationship and ensure that individuals are not discouraged from seeking voluntary treatment.

This rule applies only to a small subset of HIPAA covered entities that either make the mental health determinations that disqualify individuals from having a firearm or are designated by their States to report this information to NICS.

The rule does not apply to most treating providers.

It is important to note that the vast majority of Americans with mental health conditions are not violent and that those with mental illness are in fact more likely to be victims than perpetrators. An individual who seeks help for mental health problems or receives mental health treatment is not automatically legally prohibited from having a firearm; nothing in this final rule changes that. HHS continues to support efforts by the Administration to dispel negative attitudes and misconceptions relating to mental illness and to encourage individuals to seek voluntary mental health treatment. And the Department remains committed to robust enforcement of the civil rights laws that bar discrimination based on disability by entities that receive funding from the Department.

Summary:
This rule applies only to providers who either make the mental health determinations that disqualify individuals from having a firearm or are designated by their States to report this information to NICS.

The rule does not apply to most treating providers.