documentation and the governmentstatic.aapc.com/a3c7c3fe-6fa1-4d67-8534-a3c9c8315...• cms titled...

Documentation and the Government

Melissa Brown, RHIA, CPC, CPC-I, CFPC

Peggy Stilley, CPC, CPMA, CPC-I, COBGC

Documentation and the

Government


• PQRS

• Meaningful Use

• CERTs

• ICD-10-CM

Program Overview

2


Physician Quality

& Reporting System

(PQRS)


• On December 20, 2006 the President signed the Tax Relief and Health Care Act of 2006 authorizing the establishment of a physician quality reporting system by CMS.

• CMS titled the statutory program the Physician Quality Reporting Initiative.

• PQRI establishes a financial incentive for a voluntary quality reporting program.

• Quality Measures are created by physician organizations working with the AQA Alliance, National Quality Forum (NQF), and the AMA Physician Consortium.

– Each quality measure is assigned a CPT Category II code, along with modifiers, or a temporary G-code.

PQRS

4


Incentive Payment

5

• Anyone paid based on the Medicare Physician

Fee Schedule Doctor of Medicine

Doctor of Osteopathy

Doctor of Podiatric Medicine

Doctor of Optometry

Doctor of Oral Surgery

Doctor of Dental Medicine

Chiropractor

Physician Assistant

Nurse Practitioner

Clinical Nurse Specialist

CRNA

Certified Nurse Midwife

Clinical Social Worker

Clinical Psychologist

Registered Dietician

Nutrition Professional

Physical Therapist

Occupational Therapist

Qualified Speech-Language Pathologist


• Authorized incentive payment for each program

year

Incentive Payment

6

YEAR PAYMENT

2007 1.5% subject to a cap

2008 1.5%

2009 2.0%

2010 2.0%

2011 1.0%

2012 0.5%

2013 0.5%

2014 0.5%


• The recently passed Patient Protection and

Affordable Care Act (PPACA) will require mandatory

reporting in 2015 by eligible professionals

Mandatory Reporting

7


• Those who do not satisfactorily report data on

quality measures for covered professional services

will receive a payment adjustment

– In 2015, provider will be paid 1.5% less than the

MPFS amount for that service

– In 2016 and subsequent years, the payment

adjustment is 2.0%

Unsuccessful Reporting

8


• Select the method that is best for your practice

– Claims-based:

• PQRS is reported with your claims submitted to Medicare

– Registry & EHR:

• Require the provider to use vendors for reporting

How to Participate

9


• Group Practice Reporting Option

– Practice will report as a group instead of individually

• In 2013, CMS has changed the definition of a group to

two or more eligible professionals operating under the

same TIN

– Practices of 100+ eligible professionals must self-nominate

and report as a GPRO in order to avoid the Value-based

modifier that takes effect in 2015 and is based on 2013

reporting

Group Reporting

10


• Impacts incentives and penalties beyond the current year’s

reporting

– Determines if you will receive an adjustment in 2015

• CMS will analyze each professional or group practice

patient’s Medicare claims to determine whether they have

performed the clinical quality actions indicated in a

designated set of PQRS quality measures over a specified

reporting period

Impact

11


• A professional or group practice would not be required to

submit quality data codes (QDCs) on claims to CMS for

analysis

• Avoids the 2015 penalty

• Does not earn an incentive for 2014

• Earn more in 2014 with an incentive from Medicare

• Prevent future adjustments from Medicare

Impact

12


Upcoming CMS Penalties for Non-Participation in Quality Programs

13 All Rights Reserved

Value = Quality / Cost

Value-Based Purchasing—Using payment incentives to encourage higher quality and avoidance of unnecessary

costs, to enhance the value of care




The degree to which we

comply with

performance measures


Upcoming CMS Penalties for Non-Participation in Quality Programs Year eRx EMR PQRS Total Penalty

2012

-1.0% No penalty

No penalty

-1.0%

2013

-1.5% No penalty

No penalty

-1.5%

2014

-2.0% No penalty

No penalty

-2.0%

2015

No penalty -1.0% -1.5% -2.5%

2016

No penalty -2.0% -2.0% -4.0%

2017

No penalty -3.0% -2.0% -5.0%



Meaningful Use


• Requires actual “meaningful use” not just adoption

• Evidence of significant clinical improvements

• Secretary of HHS tasked with establishing clear

objectives

Meaningful Use

18


• Payments through Medicare & Medicaid

– Clinicians

– Hospitals

• Resources committed to adoption and use

– $27 Billion over 10 years

– Per clinic

• Up to $44,000 Medicare

• Up to $63,750 Medicaid

Meaningful Use

19


• Improvements in delivery of patient care

• Achieved through documentation in EMR

• Reporting of quality measures

– Rolled out in stages

Meaningful Use

20


• Medication orders directly entered

• Implement drug and allergy interaction checks

• Maintain active problem list for current/active dx

• Generate and transmit permissible information

Eligible Professional Core Objectives

21


• Medical record should include basic data

– Patient demographic info

– Patient vital signs

– Active medication

– Allergies

– Up-to-date problem list

• Use EHR to improve

– Safety

– Quality

– Efficiency in patient care

Objectives

22


• To be considered meaningful users, the provider

must meet specific guidelines

– Example: Core objective #7

Recording of patient demographic must be recorded on

___% of all patients.

Core Items

23


• Payment adjustments beginning 2015

– 2015 1% reduction of physician fee schedule



– 3% to continue each subsequent year

Election Not to Participate

24


• If it is determined that for 2018 and subsequent

years that less than 75% of EPs are meaningful

users

– Payment adjustment will change by one percentage

point each year until the payment adjustment reaches

95%

Payment Adjustments

25


• The Act allows for a hardship exception

– Could exempt certain EPs from the payment

adjustment

– Exemption is subject to annual renewal

– Exemption will not be given for more than five years

Hardship Exemption

26


Comprehensive Error

Rate Testing (CERT)


• Created by CMS to ensure Medicare claims are paid

correctly

• Assist in reducing the national fee-for-service (FFS) paid

claims error rate

– Measures the rate of claims paid in error for Medicare claims

submitted to

• Medicare Administrative Contractors (MACS)

• Carriers

• Durable Medical Equipment Regional Carriers (DMERCS)

• Fiscal Intermediaries (FIs)

CERT

28

Documentation and the Government 29

Error Rates

• CERT program determines error rates

– Medicare FFS Improper Payment Rate

– Provider Compliance Error Rate

– Other Error Rates


Medicare FFS Improper Payment Rate

• Medicare FFS Improper Payment Rate

– Good indicator of how claims errors impact Medicare

– Based on payments made

– Percentage of total dollars all Medicare FFS

contractors erroneously paid or denied

– Gross rate = (underpayments + overpayments)

divided by total dollars paid


Provider Compliance Error Rate

• Provider Compliance Error Rate

– How claims looked when first arriving at MAC before

any edits or reviews

– Good indicator of MAC’s provider education

– Measure of how well providers prepare claims

submission


Other Error Rates

• Other Error Rates

– May be included in CERT report

– Target problem areas


• CERT errors can have potential negative impacts on

providers

– Future claims may be subject to review

• Pre-payment

• Post-payment

• CERT results identify “error prone providers”

Impact

33


Prior Results

• 10.5% error rate nationally

• 9 out of 10 errors are overpayments

• In 2009, approximately 100,000 claims were

sampled

• Failure to respond resulted in auto overpayment

error

• Term “fraudulent claim” was not assigned


• Select random samples of paid claims

• Request records

– Failure to submit records is counted as improper

payment and is recouped

• Compare to Medicare guidelines & payer

determinations

• Calculate error rates based on charts reviewed

• Report these errors

CERT Process

35


• Two contractors responsible for administering

CERT for CMS

– CERT review contractor

• Selects samples of claims from each Medicare claims

processing contractor

– CERT documentation contractor (CDC)

• Requests medical records from providers who billed the

services and prepares the documentation for review

CERT Reviewers

36


Contractor Responsibility

• Contractor’s responsibility is to review

documentation and determine annual improper

payment rate

– Statistically-valid random samples of Medicare FFS

claims

– Postpayment reviews

• Reviews are conducted by at least one nurse


Contractor Responsibility

• Review contractor must

– Verify that the services were billed correctly

– Ensure that the Medicare contractor’s decisions

regarding the payment and processing of the claim(s)

were:

• Accurate

• Based on sound policy


CERT Guidelines

• Guidelines used

– Medicare regulations

– Medicare billing instructions

– National Coverage Determinations (NCDs)

– Local Coverage Determinations (LCDs)

– Coverage provisions


CERT Results

• Potential results

– Postpayment denials

– Payment adjustments

– Other administrative/legal actions

• Contractors are mandated to issue refund request

for all overpayments

• Provider may file appeal at MAC level


CERT Impact

• How can an MS-DRG prepayment review affect the Part B

services provider?

– The MAC begins performing data analysis preparing for Part B

post-payment recoupment from

• The surgeon

• The assistant surgeon

• The co-surgeon

– The MAC then issues notification letters advising Part B surgeons

of the intent to recoup Part B payment

• This is NOT an overpayment demand letter


CERT Impact

• A MAC has placed prepayment medical reviews on

the following service-specific claims:

– Modifier -24

– CPT 99215

– Surgical treatment of nails

– Select MS-DRGs


How to Prepare for CERT

• Scrutinize your EOBs

– Denials

– Check for prepayment edits from MAC

• Review updates

– National Coverage Determination (NCD)

– Local Coverage Determination (LCD)

• Make sure the documentation supports the medical

necessity of the service being rendered


CERT

www.cms.gov/CERT

http://www.cms.gov/CERT




E-Prescribing

(eRx)


eRx Program Overview

• Reporting program that encourages electronic

prescribing by eligible professionals

• Payment adjustments began in 2012

– Applied to eligible professionals who do not succeed

• Program is mandated by federal legislation


Getting Started

1) Determine if you are eligible to participate

a. No sign-up or pre-registration required

2) Review list of eRx eligible codes

a. At least 10% of Part B covered services must be one of

the eligible CPT/HCPSC codes

3) Adopt a qualified eRx system

4) Determine which reporting method suits you best


eRx 2012 Incentive

• Eligible professionals must report the eRx measure

for at least 25 unique services during 2012

• Amount of incentive is 1% of total allowed charges

for professional services

– See Medicare Part B Physician Fee Schedule


eRx 2012 Payment Adjustment

• Eligible professionals (EPs) and groups who are not

successful are subject to 1% payment adjustment

on services dated January 1, 2012 through

December 31, 2012

– To avoid, EPs would have had to report G8553 for at

least 10 unique events from January 1, 2011 through

December 31, 2011


eRx 2013 Incentive

• 2013 incentive is limited to those eligible

professionals whose estimated allowed charges for

these codes are at least 10% of their total Part B

allowed charges for the reporting period

– Should be easily met by most internal medicine

physicians and subspecialists


eRx 2013 Payment Adjustment

• Eligible professionals (EPs) and groups who are not

successful are subject to 1.5% payment adjustment

on services dated January 1, 2013 through

December 31, 2013

– To avoid, EPs would have had to have been a

successful ePrescriber in 2011 or will need to report

G8553 for at least 10 billable services provided from

January 1, 2012 through June 30, 2012


eRx Penalties

• Eligible professionals who do not become

successful by end of 2012 or are unable to

successfully submit at least 10 claims during first 6

months of 2013 face 2% penalty for 2014 charges

– Hardship exemptions are available


eRx Penalties

• Penalty is applied to eligible professional or group unless

one of the following criteria is met

– EP is not a physician, nurse practitioner or physician assistant

– EP does not have at least 100 cases with an applicable eRx code

for first 6 months of the year

– EP/group becomes successful during defined period

– EP/group claims indicate that <10% of estimated total allowed

charges for the 6 month period are applicable eRx codes


eRx Penalties

• Eligible professionals using 6 month qualifying

period to avoid payment adjustment can only

submit qualifying encounters through claims

– Can be submitted for any code, not just the applicable

ones defined by the incentive


eRx Eligible Professionals

• Physicians and other Medicare-recognized

practitioners who have prescribing authority

– See Medicare Act to determine types of other

recognized professionals

• Submitting required documentation automatically

enrolls provider


Eligible Patients

• Only patients in Medicare Part B Fee-For-Service

programs are eligible

• Services for patients covered under Medicare

Advantage plans are not eligible


Eligible Systems

• System must be able to generate a complete active

medication list

– Select medications, print prescriptions & electronically transmit

• Incorporate electronic data from pharmacies and benefits

managers if available

– Provide information on formulary or tiered formulary medications,

patient eligibility & authorization requirements received

electronically from patient’s drug plan, if available

• Includes any lower-cost alternatives that are therapeutically appropriate


Eligible Systems

• Conduct all alerts that warn providers of possible unsafe or

undesirable situations

– Potentially inappropriate dose or route of administration, drug-drug

interactions, allergy concerns, warnings and cautions

• Free eRx programs which meet these requirements are

available, i.e. National ePrescribing Patient Safety Initiative

• Definition of eligible system was expanded to include ONC

Certified EHR Technology


eRx Reporting Event

• A reporting event is submitting G8553 when performing one of these

codes

– 90801-90802, 90804-90809, 90862

– 92002, 92004, 92012, 92014, 96150-96152

– 99201-99205, 99211-99215

– 99304-99310, 99315-99316, 99324-99327, 99341-99345, 99347-99350

– G0101, G0108, G0109

• G8553 indicates that at least one prescription was generated and

transmitted through a qualified system


eRx Reporting Periods

• January 1 through December 31 every year

• Successful 2013 providers are eligible to receive

incentive payment for those charges as long as

they are submitted by February 28, 2014


Successful Provider Determination

• Determination of eRx success is done at individual

professional level and based on NPI

• Payment is made to practice represented by Taxpayer

Identification Number to which payments are made for the

individual professional

• If professional is associated with more than one practice,

determination of success will be made for each unique NPI-

TIN combination.

• 2013 incentive payments will be made by Fall 2014


eRx Successful Providers

• A successful provider meets all eligibility

requirements

• Generates and reports at least one eRx during 25

or more unique patient visits during reporting year


Significant Hardship Exemption

• Significant Hardship Exemption criteria: – EP/group practices in a rural area with limited high speed internet access

– EP/group practices in area with limited available pharmacies for ePrescribing

– EP/group obtained or registered to participate in Meaningful Use program by

January 31, 2013

– EP/group is unable to electronically prescribe due to local, state or Federal

law or regulation

– EP/group prescribes <100 prescriptions during a 6 month payment

adjustment reporting period

• Submit through Medicare Web Portal tool

• Submit by June 30, 2013 to avoid 2014 payment adjustment


Other Exemptions

• Hardship exemption is available for participants in

Medicare or Medicaid EHR incentive program

– Can avoid 2013 payment adjustment

– Approved through 1/31/2013


eRx Exemptions

• Additional hardship exemptions were extended

through 2014

– Inability to electronically prescribe due to local, state

or Federal law or regulation

– Eligible professionals who prescribe fewer than 100

prescriptions during a 6 month payment adjustment

reporting period


eRx Reporting Methods

• Encounters may be submitted through 1 of these methods:

1) Claims

• Submit G8553 with $0.00 charge on same claim as the service

code

2. Registry

• May use self-nominated registries who are qualified to participate

in PQRS

• If choose this method, must also participate in PQRS and use

this method to report those encounter as well

• List of qualified registries is located on CMS website


eRx Reporting Methods

3) Electronic Health Record

• May use self-nominated, CMS-approved vendor

• If choose this method, must also participate in PQRS and use

this method to report those encounter as well

• A list of approved vendors is located on CMS website

4) Group Practice Reporting Option

• If choose this method, must also participate in PQRS

• Must notify CMS of desire to choose this option

– Self-nomination letter requirements and instructions are located on CMS

website


Group Practice Reporting

• 2013 definition of practices eligible for group practice

reporting

– At least 25 eligible professionals

– Report at least 1 prescription generated and transmitted

electronically with qualified system during unique visit

– If group includes 25-99 EPs, the required minimum number of visits

is 625

– If 100 or more professionals, minimum is 2500


ICD-10

Unspecified Codes


Clinical Documentation

Use of Unspecified

codes

Medical Necessity

Coding for ICD-10-CM r ICD-10-CM


• Granularity

– Acute, Chronic, Acute on Chronic, Recurrent

– Mild, Moderate, Severe

– Site or location

• Laterality

– Left, Right, Bilateral

• Injury details

– External cause, Activity, Place of occurrence

Clinical Documentation Documentation


ICD-10

• According to CMS, Medical Societies and physicians

asked for the specific diagnosis for reporting and

tracking

• Quoting Joseph Nichols, MD “It is generally believed

that ICD-10 will require greater coding specificity,

although there are still many unspecified codes within

the selection of the more specified codes.”


Unspecified Codes Impact of

unspecified codes

Medical necessity not

supported

Denials

Frequent requests for

records

Frequency for reporting

unspecified

Circumstances may warrant

Not coding from

Documentation

Payer interpretation

Lack of medical

necessity

Lack of knowledge

Lack of documentation


• No reimbursement for unspecified codes

• Use of unspecified code does not guarantee

payment

• Lower reimbursement for continued use of

unspecified codes

Response to Unspecified Codes

74


Contracts Fee Schedules

Medical Necessity Member Benefits

Payer Reimbursement


• Frequency of unspecified codes

– Are they being assigned as default codes?

• Audit the documentation

– Not just the Assessment and Plan

• Provide feedback

Review of Documentation Review


Training and Education

Coders

– Anatomy

– Pathophysiology

– Terminology

– Visual aids

Physicians/Providers

– Audit results

– Code choices


Physician

Coder

Payer

Beneficiary

Collaboration Collaboration


Being Proactive

Being Professional

Success


Health Data Consulting White Paper; ICD-10 Specified or Unspecified; Joseph C

Nichols MD.Centers for Medicare and Medicaid Services, Daniel Duvall, Hospital and

Ambulatory Policy Group

http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/ERxIncentive/index.html

http://www.acponline.org/running_practice/technology/eprescribing/medicare_2013_epres

cribing_incentive.htm

http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.html









http://www.acponline.org/running_practice/technology/eprescribing/medicare_2013_eprescribing_incentive.htm

http://www.acponline.org/running_practice/technology/eprescribing/medicare_2013_eprescribing_incentive.htm

documentation and the governmentstatic.aapc.com/a3c7c3fe-6fa1-4d67-8534-a3c9c8315...• cms titled...

Documents