2014 reimbursement update impact on education and clinical practice for communication sciences and...
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2014 Reimbursement Update Impact on education and clinical practice for communication Sciences and Disorders- Part twoRobert C. Fifer, Ph.D.Mailman Center for Child Development, University of Miami
Disclosures
Program evaluator for Duke University Medical School and University of Texas Medical Branch
Presenter at New Mexico Speech and Hearing Association, North Carolina Academy of Hearing Rehabilitation
Member Genetics and Newborn Screening Advisory Council, Florida Department of Health
Consultant to Children’s Medical Services Audiology Review Committee
Member ASHA’s Health Care Economics Committee
Documentation Requirements
1997 Documentation Guide for E/M Coding• History (Soap):
– Medical necessity for why the patient is there• “Referred by” is not medical necessity• Requires a history covering the following areas
as appropriate– Chief Complaint– Duration of symptoms– Family history– Social / occupational history– Prior medical history– Relevant diagnoses
– This section justifies all that is done
Documentation Requirements
Actions and results (sOap)Describing what was done
The test forms cannot stand on their ownMost professionals don’t know what it is or
what the raw results meanDescription of procedures and observations
Procedure description can be “canned”Description of what was found (results)
Documentation Requirements
– Clinical Assessment (soAp)• Must have a clear statement of practical and
clinical significance• Must flow logically from the history and the
findings
– Recommendations (soaP)• Logical conclusion to the matter.• Based on these outcomes, the following
recommendations are offered:…………• Each recommendation must be supported by
history, findings, and interpretation• Do not list unsupported recommendation
Additional Notes on Recommendations
Medical NecessityAll recommendations must be supported by the
concept of “medical necessity”Recommendation should not be offered that is
for the convenience of health care provider or patient
Transfer to plan of careUse of reportSeparate document (Recommended)
Other Requirements
• Signature– If a paper report, must be an original signature– Facsimile or stamped signature is not appropriate– If electronic medical record (EMR), your login
constitutes your signature
• Date– Date of service must be specified and prominent
in report– Other dates may include date of review, date of
“signing”, date of dictation. These must be distinguished from date of service.
Impact of ICD-10 on Documentation
ICD-10 allows greater specificity in diagnosis coding and will be even more so if functional scales are added
Description of patient status in report will need to be more detailed in order to complement and justify the specific ICD-10 code selected
Will affect descriptions of what was found and clinical assessment statement.
BE CLEAR IN WHAT YOU WRITE!
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Say What You Mean – Clearly!
I saw your patient today, who is still under our car for physical therapy
The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week."
Patient has chest pain if she lies on her left side for over a year.
Discharge status: Alive but without permission. Patient needs disposition; therefore we will get Dr. Blank to dispose of him
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Say What You Mean – Clearly!
The patient was to have a bowel resection. However, he took a job as stockbroker instead.
The patient is tearful and crying constantly. She also appears to be depressed.
The patient refused an autopsy.
The respiration tube was disconnected and the patient quickly expired.
Personal Observations
Consists of audiogram with some notesEx: Referred by Dr. Razzelfratz for hearing
test. Recommend hearing aids
Fails to meet federal guidelines for minimum documentation standards for covered services
Therapy notes incomplete or has sign-in sheets only
Diagnosis Coding
October 1, 2014
To International Classification of Diseases, 9th Revision, Clinical Modification ICD-10-CM
ICD-9-CM: Approximately 18,000 codes
ICD-10-CM: Approximately 64,000 codesProvides more flexibility for adding new codes
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Clinical BillingCoding “Normal”
DiagnosisMedicare guidelines on code selection
Not allowed to be “normal” within the ICD-9 or ICD-10 coding system
Code signs / symptoms that caused you to do the test
Some recommend use of a V code for test encounter following (for example “Examination following a failed screening”
ICD-10-CMH90 Conductive and Sensorineural Hearing Loss
Includes: Congenital deafness
Excludes: Deaf mutism NEC (H91.3)Deafness NOS (H91.9)Hearing loss NOS (H91.9)Noise-induced (H83.3) Ototoxic (H91.0) Sudden (idiopathic) (H91.2)
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ICD-10-CMH90.0 Conductive hearing loss, bilateral
H90.1 Conductive hearing loss, unilateral with unrestricted hearing on the contralateral side
H90.2 Conductive hearing loss, unspecified Conductive deafness NOS
H90.3 Sensorineural hearing loss, bilateral
H90.4 Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side
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ICD-10-CM
H90.5 Sensorineural hearing loss, unspecifiedCongenital deafness NOSHearing loss:
central } NOSneural } NOSperceptive } NOS sensory } NOS
Sensorineural deafness NOS
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Emphasis on Outcomes
Congress is eager to do away with the therapy caps and the exceptions process and go to a simpler system.
Now requires CMS to collect functional status and outcomes measurements
Seven-level functional outcome system to be phased in this year for therapy services
Similar to NOMS in structure
Changing Landscape
International Classification of Functioning, Disability and Health (ICF)
Describes body functions, body structures, activities, and participation
Useful for understanding and measuring outcomes
ASHA has information available online
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ICF Levels
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0 No impairment means the person has no problem
1Mild impairment means a problem is present less than 25% of the time, with an intensity a person can tolerate, and happened rarely over the last 30 days.
2Moderate impairment means a problem is present less than 50% of the time, with an intensity that is interfering in the person’s day-to-day life, and happened occasionally over the last 30 days.
3Severe impairment means a problem is present more than 50% of the time, with an intensity that is partially disrupting the person’s day-to-day life, and happened frequently over the last 30 days.
4Complete impairment means a problem is present more than 95% of the time, with an intensity that is totally disrupting the person’s day-to-day life, and happened every day over the last 30 days.
8 Not specified means there is insufficient information to specify the severity of the impairment.
ICF Levels
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Documentation and Audits
Greatest problem in audits
Often inadequate and over-simplified
Often not clear
Mismatch between CPT and diagnosis codes unsupported by documentation
Audits
To protect the Medicare Trust Fund Medicare QIO (Quality Improvement
Organization) CERT (Comprehensive Error Rate Test) RAC (Recovery Audit Contractor) ZPIC (Zone Program Integrity Contractor) MAC (Medicare Administrative Contractor) PSC (Program Safeguard Contractor) OIG (Office of Inspector General Audits)
Audits
To protect Medicaid funds MIP (Medicaid Integrity Program) MFCU (Medicaid Fraud Control Unit) RAC (Recover Audit Contractor) IMRO (Independent Medical Review
Organization
“In Your Presence” Audits
QIO: Improve effectiveness, efficiency, economy, and quality of services provided to Medicare patients
MAC Audits: Sampling of patient records to ensure quality of service delivery and completeness
MIC reviews: Looking for overpayments and billing errors
MIC Audits: Looking for fraud often with local law enforcement (can also be behind the scenes)
“Behind the Scenes” Audits
ZPIC oversees the RACs and approves their CPT code selection for data-mined audits
RAC searches the Medicare and Medicaid data bases for inappropriate billing patterns that violate principles of code reporting
PSC obtains information from RACs regarding possible fraud and abuse
Recovery Achievements
RAC Pilot Project 3 year demonstration 6 states $1.3 billion recovered in overpayments
Overpayments Medicare: $49.9 billion in 2013 Medicaid: $14.4 billion in 2013
Point of comparison Deficit reduction bill by Rep. Ryan cut $20 from
budget
Attributes of Overpayments
Administrative and documentation errors
Medically unnecessary services
Diagnosis coding errors
Inappropriate procedure code reporting
Prevention of Bad Outcomes
KNOW THE RULES!!!!! Correct coding
Types of codes Don’t go “code fishing” Be truthful in code selection
Documentation “If it wasn’t documented, it never happened” The audiogram cannot stand alone, not even with
notes Six elements of documentation – EVERY TIME
Medical necessity – justify ALL procedures
Clinical BillingCode Selection
With rare exception, do not go outside of our family of codes for SLP and Aud services
Do not code shop for what sounds good without understanding the procedure represented by that code
If a procedure does not have a code, use the unspecified/unlisted code 92700
Know the difference between a unit code, contact code, and timed code
Clinical BillingCode Type
Contact code Untimed code reported once per date of service Will have no unit or timed designation in the descriptor
Unit code Report the code up to a maximum number of times per
date of service Designated by maximum number of units in descriptor
Timed code Designated in descriptor by “1st hour” or “each
successive 15 minutes”
Clinical BillingTimed Codes
Usually the report preparation is included in the intra-service time. It will be designated “with report” if that is true
Be conservative when reporting the portion of time devoted to report writing
Document in progress notes the start time and stop time for the face to face contact
Clinical BillingSupervision
Medicare requires 100%, in the room supervision Medicare pays for the licensed professional’s time
and not the student’s effort Decision-making must be by the professional Cannot be involved with care of a second patient
Medicaid Supervision may vary from state to state Typically professional contact with family and
student to ensure appropriate procedures, outcomes, and decision-making
Depending on the student, may not require 100% supervision
The Question of Whether to See
Medicare PatientsDepends on supervision level and medical necessity
Practice patients / clients
If supervision CAN be met and the decision is to see Medicare patients, then must use an ABN if medical necessity is not met (more on ABNs momentarily)
If decision is to NOT see Medicare patients, then a sign must be posted informing all patients / clients that Medicare is not accepted because level of student supervision cannot be done in accordance with Medicare regulations
Per Capita Spending for Health Care; Source: Kaiser Family Foundation
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38 years of per capita spending by country
Health Care Costs for American FamiliesSource: Milliman Medical Index
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Health Care Costs for American FamiliesSource: Milliman Medical Index
Health Care Costs for American FamiliesSource: Milliman Medical Index
Miami most expensive at $24,965.00
Phoenix least expensive at $18,365.00
Primary utilization factors influencing out of pocket and overall expenses: Inpatient facility care Outpatient facility care Professional services Pharmacy Other
Health Care Economics
Cost inflationRisen 78% since 2000 vs. 20% for salariesAverage 9% per year with range of 7%-13%Defensive medicine (malpractice)Unnecessary procedure/treatment (fee for
service)Ineffective treatmentInefficient service delivery modelsPharmaceuticalsEnd of life care
Factors Affecting Reimbursement
Sustainable Growth Rate (SGR)
PQRS
New models of reimbursement
Procedure reviews
New Challenges
Sustainable Growth Rate
Part of the 1997 Balanced Budget Amendment to keep Medicare budget neutral
Includes several factors to calculate the reimbursement of Medicare services
Independent from RVU assignments from AMA
Annual budget allocation from Congress
Sustainable Growth Rate
Intended to control the growth of Medicare costs
Payments for services not withheld if SGR targets are exceeded
If target expenditures exceed budget, the next year’s update is reduced
If target expenditures are below budget, the next year’s update is increased
Sustainable Growth Rate: How does it work?
The estimated percentage change in fees for physicians’ services.
The estimated percentage change in the average number of Medicare fee-for-service beneficiaries.
The estimated 10-year average annual percentage change in real gross domestic product (GDP) per capita. (from 2008 forward)
The estimated percentage change in expenditures due to changes in law or regulations.
Year % decrease
Year % decrease
Year % decrease
1996 -0.3 2004 6.6
1997 3.2 2005 4.2
1990 9.1 1998 4.2 2006 1.5
1991 7.3 1999 6.9 2007 3.5
1992 10.0 2000 7.3 2008 4.5
1993 10.0 2001 4.5 2009 6.4
1994 7.5 2002 8.3 2010 8.9
1995 1.8 2003 7.3 2011 4.7
SGR Adjustments: 1990-2011
The “Doc Fix”: Introduced February
2014 Immediate repeal of SGRTransition period with 0.5% increase annually for 5
yearsMerit Based Incentive Program
PQRS Value Based Modifier Meaningful Use for Electronic Medical Records
5% added incentive payment to physician payment under new Alternative Payment Models
Increased funding for technical assistance to small physician practices (<15 physicians)
Creation of a technical advisory panel to review and recommend Alternative Payment Models
Noteworthy Features of “The Fix”
Consolidates quality programs (e.g., PQRS, Value Based Modifier, Meaningful Use) into one.
Payments based on achieving performance thresholds
Introduces the concept of alternative payment models
Incentivizes care coordination and shared responsibility of patient care
Requires ongoing development of quality measures to evaluate performance
Other Noteworthy Features of “The Fix”
Increases transparency of metrics and quality Physician Compare website Posts quality and utilization data for patients to
make informed decisions about their care Allows qualified clinical data registries to
purchase claims data for purposes of quality improvement and patient safety
Latest News on Doc Fix 3/31/14
Congress passed a bill to delay to freeze the current situation for one year.
Suspend 24% reduction in payments
Extend the therapy caps exceptions until March 2015
Delay implementation of ICD-10 for one year
Other Factors Affecting Reimbursement
CMS Screens of billed codes looking for Codes frequently reported together Codes that have never been surveyed by the
RUC or HCPAC Codes believed to be overvalued based on
utilization increases
AMA Responses to CMS Overseeing survey process Facilitating potential methods of payment
revision
Physician Quality Reporting Initiative
(PQRS)One of three performance based
reimbursement factors affecting physicians – the primary performance based factor for audiologists at present
Began as an enticement to physicians to abide quality of care standards
Participation is now a requirement to maintain full Medicare reimbursement
Each health care discipline / specialty will develop performance standards
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PQRS
Quality measures as evaluated by National Quality Alliance, Physician Consortium for Performance Improvement, and CMS
Has moved to mandatory participationPenalty Adjustment: -1.5% in 2015; -2% in 2016
and beyond
Most recent rule for 2014 requires reporting on 9 measures. Audiology and speech-language pathology exempted from that for now.
PQRS MeasuresAudiology
Document or confirm the patient's current medications for 50% of the eligible patient visits for evaluation AND
Indicate a referral to a physician for 50% of the patients who report or are diagnosed with dizziness
PQRS MeasuresSpeech-language
PathologyDocument or confirm the patient's
current medications for 50% of the eligible patient visits for therapy
PQRS Measures
PQRS applies to audiologists and SLPs in private practice, group practice, or university clinics.
At this time, PQRS does not apply to providers in facilities such as hospitals or skilled nursing facilities.
Separate enrollment is not required.
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Additional PQRS Item:
Under SGR repeal, each “society” will develop discipline-specific measures
Audiology is represented in this effort by the Audiology Quality Consortium (AQC)
AQC is comprised of representatives of 10 audiology organizations (list on ASHA, AAA, and ADA websites)
At this moment, there are 5 proposed measures in development
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Health Care economics: Do I turn right or left to
get to the future?
Current Recommendation
MedPAC: Move Away From Fee-for-ServiceEncourages increased utilizationMore services => more paymentQuestions of true medical necessity
IOM and CMS: Move Away From Fee-for-Service
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Medicare/CMS Actions
Value-Based PurchasingBased on Medicare vision of “the right care for every
person, every time”Aligns payment to efficiency and quality of care
deliveryRewards providers for measured performance (read:
outcomes)
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Value-Based Purchasing
Promote evidence-based medicine
Require clinical and financial accountability across all settings
Focus on episodes of care
Better coordination of care
Payment based on outcomes, not number of sessions (performance-based payment)
Focus on effectiveness of treatment59
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Levels of Evidence
Level Type of evidence (based on AHCPR 1992)Ia Evidence obtained from meta-analysis of randomized controlled trialIb Evidence obtained from at least one randomized controlled trialIIa Evidence obtained from at least one well-designed controlled study
without randomizationIIb Evidence obtained from at least one other type of well-designed
quasi-experimental studyIII Evidence obtained from well-designed non-experimental descriptive
studies, such as comparative studies, correlation studies and case
control studiesIV Evidence obtained from case reports or case seriesV Evidence obtained from expert committee reports or opinions and/or
clinical experience of respected authorities
Bundled Payments
Bundled payment models de-emphasize services that increase utilization and cost
Initiative by Center for Medicare and Medicaid Innovation called Bundled Payments for Care Improvement
Working to identify procedure groups to bundle, based on diagnosis rather than procedure(s)
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Current CMS Actions to Reduce Payments
Medicare screens for procedures reported together => new, combined procedure CPT codes (92540, 92550, 92570)
Re-survey and re-validation of procedure value (92587)
Bundled payments under Medicaid reform (more on this later)
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Medical Home Model
Primary care physician becomes medical manager
All referrals will go through PCPDifferent from “gate-keeper” concept of HMOsPCP paid to coordinate and manage all care of that
patientWith rare exception, no physician/health care provider
will have “direct access” under medical home model
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Physician Private Practice Diminishing
Physicians are facing same pressures as hospitals
Leaving private practice to become salaried employees of hospitals and other large medical organizations Lower costs Meet government mandates on electronic medical
records Percentage of physicians who own their own
practices 2000 – 57% 2009 – 43% 2013 – 33% (projected)
Physicians and Private Practice
Giving up fee for service or a salary… Physicians lose autonomy Gain more regular hours Gain more predictable income level Hospitals gain a guaranteed supply of patients
from the physicians practices
Intent of health care changes under Obama More coordinated care (shared patient
management) Leading to cost reductions and better patient
outcomes Eliminate “silo” style of operation for patient care
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Emphasis on Outcomes
Patient Satisfaction and Wellness
Patient Centered (What do you want me to do?)
FQHC payment per encounter Average payment Diagnosis based
Influence by Medical Home
Shared responsibility for care (Again, emphasis on Care Coordination and elimination of silos)
Emphasis on Patient Centered Care
Remove traditional prescriptive perspective from SLPs and Auds
Patient / family actively participate in decision-making
Patient / family establish goals to be achieved
SLP / Aud role to educate, evaluate, guide, empower
Standard Versus Custom Protocols
Every procedure must be supported by history or other test findings
Every protocol must be customized for each patient based on the clinical question to be answered
What we currently know of reimbursement directions indicate that it will be necessary to do what is necessary and stop there
Bottom line: the individualized clinical question will be the driving force for what is done diagnostically
Effects on Audiology
We are not physicians, but sometimes the system treats us like physicians for payment and policy
We don’t know what our reimbursement will look like, but we have some hints based on physician-center proposals and movements away from fee-for-service
Pay attention to the diminishing physician private practice and move toward joining large health care organizations
Effects on Audiology
Changes in health care will require that you determine cost of service delivery
Carefully evaluate each procedure being performed (e.g., develop a clinical question and determine what tools are necessary; stay away from graduate school protocol …Time is money and each additional procedure is
timeJustify what you do based on case history and
outcome of previous test
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Effects on Audiology
Anticipation that payment may be based on diagnosis or “per patient” rather than procedureReplace fee-for-service with bundled code
crosswalked to diagnosisBundled fee based on data-mining median costs of
procedures “typically done” to derive diagnosisMay combine severity with diagnosis via ICF or similar
scaleFocus on participation in life activities (NOT ADLs—life
activities)
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Effects on Speech-Language Pathology
Anticipate episodic / periodic payments Single payment Covers all services Covers specified period of time Already appearing in Medicaid “reform”
Single payment for date of service
Based on diagnosis and level of severity
Focus on FUNCTIONAL outcomes Realistic achievement of goals Activities of life
Reimbursement Summit
Factors Pressuring ChangeUnsustainable increasing cost of medical care
Patient Protection and Accountable Care Act
Increasing demands for quality, efficiency, and accountability by Regulators Health Care Rating Organizations Accrediting bodies Employers Commercial payers The Public
Triple Aim Focus of ChangeInstitute for Health Care
Improvement
Improving the patient experience of care (including quality and satisfaction)
Improving the health of populations
Reducing the per capita cost of health care
Impact on Graduate School Training
Teach clinical judgment rather than strictly procedures and protocol
Mechanics of test administration are important, but know when to stop (emphasis: Aud)
Mechanics of test administration and therapy techniques are important, but know how to set realistic goals (emphasis: SLP)
Develop a true sense of medical necessity, clinical questions, patient-centered recommendations and plan of care
Value of Health Care
“We practice according to how we are paid”
Peter Hollmann, MDChair, AMA CPT Editorial PanelOctober 2011