Last November I posted information on CMS' new interpretation of their Direct Supervision Rules, Direct Supervision Rules Have Changed.  Since that post I have recevied a number of additional questions and am posting my answers here for all to see.

 

Question #1

Does this ruling apply to Home Health and Physical Therapy as well as Wound Care Departments?

These rules are specific to all services rendered under the umbrella of HOPPS.  Home Health Services are billed under the HH-PPS and not the HOPPS.

This supervision requirement applies to the category of outpatient services covered as "incident to" a physician’s services. Certain hospital outpatient services (e.g., physical therapy) have their own benefit category and therefore are not subject to these supervision rules.

Question #2

Does it apply to simple dressing changes as opposed to debriding and hyperbaric units?

Pursuant to Section 42 C.F.R. Section 410.27 (the “Outpatient Therapeutic Services Regulation”), therapeutic services which hospitals provide on an outpatient basis are those services and supplies (including the use of hospital facilities) which are “incident to” the services of physicians in the treatment of outpatients. This regulation requires that services furnished at a department of a hospital, that has Medicare provider-based status, must be under the direct supervision of a physician. "Direct supervision" means the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.  Outpatient wound care done in a physician directed clinic is considered “incident to” the services of the ordering physician.

Question #3

If a Nursing Home or LTC facility has to have a physician or NP in house for a wound care nurse to render treatment, do these facilities have a qualified person on staff 24/7?

Like Home Health, Skilled Nursing Home’s and LTC facilities are not billed under the HOPPS guidelines and are subject to the rules that govern their own perspective payment systems not the Hospital Outpatient Perspective Payment System.

There is no such specified requirement for hospital inpatient services.

Question #4

How do ostomy appliance changes and peristomal care fit into this mix?

If these services are being billed as an outpatient therapeutic service, they too are considered to be a therapeutic service that is “incident to” the physician and would have to meet the same direct supervision requirements.

I spend a fair amount of time providing appropriately resourced answers to our clients who use our physician and facility billing consulting services.  The most frequently used bookmark in my web-browser is the Medicare Coverage Database (MCD) located at http://www.cms.hhs.gov/mcd.  The MCD is fully searchable and it contains all Medicare National Coverage Determinations (NCDs), National Coverage Analyses (NCAs), Local Coverage Determinations (LCDs), and local policy articles.  I have found that navigating the MCD is still a little challenging for some clients, so I was very pleased to see CMS publish a “how to” booklet via the Medicare Learning Network (MLN) which as an aside happens to be another excellent learning tool.  The new “How To” booklet is a free, downloadable, 2.5 MB PDF, that provides an explanation of the MCD, as well as how to use the Search, Indexes, Reports and Downloads features.

You can ‘currently’ find the booklet at http://www.cms.hhs.gov/MLNProducts/downloads/MedicareCvrgeDatabase.pdf.  In the event that CMS makes changes to their website structure, again, you can find this and similar tools by visiting the MLN Publications page at http://www.cms.hhs.gov/MLNProducts/MPUB/list.asp. Once there use the search key words “how to” to locate this publication quickly.

I suppose I can take down my article about ‘Did I Document a Consult?’ from the Intellicure members website.  You may not have noticed, what with healthcare reform, proposed Medicare cuts, "meaningful use," and the Red Flag Rule all taking center stage for the past six months, but Medicare made a recent decision to eliminate consultation codes.  Frankly, this decision may have a greater affect on your practice than any of these other issues.

This decision isn’t part of the HOPPS Final Rule which we’ve been discussing, but CMS' October 30 decision to eliminate outpatient and inpatient consultation codes, effective January 1, which will affect all medical practices, including the physicians who practice in your outpatient wound care center.  These plans are budget-neutral to the Medicare program as a whole, however they have the potential of crushing the bottom line of many practices.

Consultation code blues

Across the Intellicure Wound Registry, participating physicians code 10-15 percent of their new outpatients and more than 75 percent of their initial inpatient work as consultations.  In Texas, outpatient consultation codes (99241-99245) pay between 29 and 55 percent more than new office patient codes (99201-99205).

On the inpatient side, admission codes (99221-99223) will be used in lieu of consultation codes. The "true" admitting physician will use a modifier along with their admit code, while all consulting physicians will use the admit code without the admit modifier. Who here thinks that physician practices are going to grasp this change by January 1 or that the minor increase in admit and follow-up RVUs will offset their loss of income?

The direct cost of this decision to your practice will vary as your consultation practice varies, but in any event, the effect is likely to be substantial.  For one local practice that I’ve been working with, the revenue loss across their four physicians is projected to be $87,000; a rough equivalent to 1.4 FTEs in their practice billing office.

What about the other payers?

At this time, I'm not aware of any other payer who has announced its intention to follow Medicare's lead, but as we are all aware, it is one of the easiest justifications to make, and if/when they do, the loss of income will be even greater.

In the mean time, you will have decisions to make and work to do. Physicians will have to use consultation codes for non-Medicare patients, but not for Medicare patients; or you can stop billing consultation codes for all payers and face the income reduction.  Then there is the real kicker, if your patient has Medicare as secondary insurance and you bill a consultation, Medicare will not pay you because it no longer recognizes the code submitted. If a patient has Medicare as secondary insurance and you bill a new patient code, Medicare will pay you, but at the lower new patient rates.  We're working hard to get an update ready to deal with this situation, so if you're a client, we will have a billing solution done in time, but you will need to set some special custom keys.  We'll likely have all that done just before Christmas.  Happy Holidays!

For those of you who hang on my every word (I think that's 3 of you. :) I told you last week that I would be doing an in depth detailed review of the 1900+ pages in the 2010 OPPS Final Rule which was published on 10/30/2009.  Considering some of what I've researched, it may have been more appropriately released a day later, but I digress.

One of the 'treats' that you my kind reader can expect for 2010 is in the “direct supervision” requirement for on-campus and off-campus Hospital Outpatient Departments (HOPD). I'll get to some of the 'tricks' next week.

You should remember (or lets hope you do) that the 2009 OPPS Final Rule greatly affected wound clinics that were operating without any direct physician supervision.  Those which were directly supervised by non physician practitioners (NPPs, Nurse Practitioners, Physicians Assistants, etc) or, worse yet, those which were staffed by wound care nurses without any direct supervision could not bill a facility fee.  Go ahead, do a double-take.  If this is *still* the way you practice, PLEASE STOP.  You are committing fraud. If a physician was not present in the 'footprint' of the wound care department, not the hospital campus, the doctors' lounge doesn't count, its been clear for over a year that you out of compliance with the regulation if you drop the facility fee.  Now, if a NPP provided the service, they could still bill for their professional fee, but the hospital could not bill the facility fee.

Well, this 2009 clarification to the 2000 rule was not well received by the industry.  You made your voices heard and listening occurred.  From the Final Rule:


Translation:  We listened, we changed things.

Remember, for the full text of the Final Rule, browse on over to http://federalregister.gov/OFRUpload/OFRData/2009-26499_PI.pdf.  If reading 2000 pages of dry text isn't your thing, head on over to http://www.Intellicure.com and give our sales team a ring.  We have some great options on our Business Consulting Services.  Ok, enough with the shameless plug, back to Direct Physician Supervision.

Great, so what's that mean to me?
So, in summary, there are three points of clarification in this rule pertaining to direct supervision all of which will be effective January 1, 2010:

1. Physicians Orders

2. On-Campus Supervision

"For services provided in the hospital or on-campus PBD of the hospital, the supervisory physician or non physician practitioner must be present on the same campus and immediately available to furnish assistance and direction throughout the performance of the procedure."

Ok, so it can be a NPP, big change, but what's the first question on most people's minds? Exactly, what does immediately available mean? Those of you who have been operating hyperbaric departments for more than a few years will remember that "immediately available" most directly translates into that person cannot be performing another procedure or service that he or she could not immediately interrupt. 

"The physician or non physician practitioner must be prepared to step in and perform the service, not just to respond to an emergency.  This includes the ability to take over the performance of a procedure and, as appropriate to both the supervising physician or non physician practitioner and the patient, to change a procedure or the course of treatment being provided to a particular patient. The physician or non physician practitioner is not required to be in the room where the procedure is performed."

Still looking for it to be spelled out more clearly in black and white?


3. Off-Campus Direct Supervision
Ok, for those of you operating a HOPD off-campus, don't expect any miracles.  Medicare only made a minor modification to also allow NPPs to provide direct supervision of the services that they may perform themselves in those locations.
 

That's all for this week.  Check back next week to hear what is being planned for enforcement for those HOPDs not in compliance for the last decade.

After more than a decade of fighting, the primary roadblock to widespread acceptance of multi-layer compression systems has been taken down. The AMA has created a new Category I CPT^® code that describes the application of the numerous multi-layer compression systems available on the market today. CPT code 29581 – “Application of multi-layer venous wound compression system, below the knee.” becomes effective on January 1, 2010.

In addition to the publication of the CPT code, CMS recently released the Outpatient Prospective Payment final rule (CMS-1414-FC). Look for me to discuss this in more detail in the coming weeks. In the final rule CPT code 29581 has been assigned to the APC payment group 0058 which has a 2010 payment rate of $71.03 and a status indicator of S. The S indicator is important because it means that the service is significant and not discounted for multiples. So, unlike a debridement where you have diminishing returns for debriding multiple ulcers, the application of the second compression system will not result in reduced payment.

I got an email today asking about 'Preparation and Preservation of Skin Graft'.  Since this code made it into the UHMS' approved indications list, this code has been a sticky-wicket.  For at least the past decade, Medicare has determined that the ICD-9-CM code 996.52 is the most appropriate code to represent the concept of ‘Preparation and preservation of compromised skin grafts’.  The actual definition for the code is ‘Mechanical complication of prosthetic graft of other tissue not elsewhere classified’.

 

Here is the specific text from the Local Coverage Determination for Hyperbaric Oxygen Therapy from Trailblazer’s (Texas MAC) website:

 

•  Preparation and preservation of compromised skin grafts (ICD-9-CM diagnosis code 996.52; excludes artificial skin):

HBO is utilized for graft or flap salvage in cases where hypoxia or decreased perfusion has compromised viability of an existing skin graft. HBO enhances flap survival. Treatments are given at a pressure of 2.0 to 2.5 atm lasting from 90–120 minutes. It is not unusual to receive treatments twice a day. When the graft or flap appears stable, treatments are reduced to daily. Medicare coverage does not apply to the initial preparation of the body site for a graft. HBO therapy is not necessary for normal, uncompromised skin grafts or flaps or for primary management of wounds.

 

For your convenience, I’ve attached a PDF copy of the current policy.

 

So, while our clinicians will correctly refer to the situation of preservation of a compromised skin graft, Medicare still refers to it as mechanical complication of graft.   Your facility's coding is done by professional coders reading your documentation, probably using a computerized tool to help them find the code, and then selecting your code from the ICD-9-CM system.  If they do not select 996.52, then Medicare will deny your claim.  So, if you don’t refer to the skin graft in terms that translate into 996.52, you are at a risk of having the coder select a different code.  I am not advocating coding for payment, I am explaining reality.  Let me repeat that.  If your coders do not select 996.52 for the diagnosis to reflect the preservation of a compromised skin graft, Medicare WILL DENY THE CODE.  It's all about a computer matching CPT to ICD-9 codes.  You may win on appeal, but probably only after someone has appropriately refined the claim to reflect the code 996.52.

 

Now, to better understand the issue, let's talk about ICD-9 usage. To find 996.52 in the alphabetic index, which is what your coder is trained to do, you have to go down a road of failure > transplant > skin.  Difficult to do when you start with ‘preservation of skin graft’.  So, to facilitate this process, at Intellicure we have had a long standing policy of referring to the issue in the same terms that Medicare uses; Mechanical complication of graft.  It absolutely sucks that this is a NEC (not elsewhere classified) code, but those are the cards we’ve been dealt.

2009 10 29 - Trailblazer LCD - HBOT.pdf (111.4 KB)

I still get this question quite routinely.  'Can't I only use 99211 for a nurse-only visit?'  The description of 99211 indiates that the physician's presence is not required.

The physician presence statement in CPT is not applicable to the Hospital Outpatient Prospective Payment System (HOPPS).  CMS instructed hospitals to develop their own criteria for the assignment of these E/M codes.

For the facility portion of a followup encounter, where ONLY the nurse saw the patient, the hospital may bill 99211 through 99215 depending on the hospital's self-developed criteria.

I got an email today asking about the consult codes (99241-99245) in the APC payment system.  Specifically, what happened!?!

Well, what happened, actually happened over a year ago.  CMS decided that the consultation codes were "unnecessary and superfluous" and no longer recognizes them in the APC system.  I love that word, superfluous.  There are plenty of parts of CMS that I think are superfluous, but alas, that's for a different day.

Now, nothing happened to the physician's ability to drop a consultation code, though there is a minefield of documentation to mind when doing that inside a wound care center.  However, the facility should use the appropriately mapped clinic visit level for a new (99201-99205) or established patient (99211-99215).

The Hospital Outpatient Prospective Payment System has been in place for nearly a decade, but I still get calls at least once per week about the correlation between the facility and physician level of service as reported by IntelliTrak.

For example, here is a recent comment, "We can’t have the physicians charging a 99214 and the clinic charging a 99212, this will surely throw red flags up!"

This concern about the disparity between the physician level of service and the facility level of service, while intuitive, is unwarranted.

CMS is clear in their expectations that in the facility setting, the physician is being paid for the cognitive effort of delivering care and the facility is being reimbursed for the work effort of delivering care.  In fact in the Federal Register, 4/7/2000, Medicare Prospective Payment System for Hospital Outpatient Departments, pp 18450 – 18451: CMS instructed facilities in the use of 31 CPT codes to reflect the work performed by hospital outpatient departments.  This is the original work where CMS required that HOPDs use codes 99201 – 5 and 99211 – 5.  CMS also points out that these codes (as described by the AMA) don’t adequately describe facility resources.

“We realize that while these HCPCS codes appropriately represent different levels of physician effort, they do not adequately describe non-physician resources. However, in the same way that each HCPCS code represents a different degree of physician effort, the same concept can be applied to each code in terms of the differences in resource utilization.”

Further, CMS went on to say that they didn’t expect to see correlation between the codes.

“Therefore, we would not expect to see a high degree of correlation between the code reported by the physician and that reported by the facility.”

I hope that this reference to CMS' stance is useful as you work through this issue.

Oops They Did It Again!

How many times is CMS going to change the codes for Skin Substitutes? ...Anyone ...Anyone?  I don't know really, probably as often as they feel like.

So what happened?

1. CMS deleted all of the J codes for skin substitutes,  (J7340-J7349 and C9357); gone.
2. CMS created a whole bunch of new Q codes for the existing skin substitutes, copied over the old descriptions from the J codes to the Q codes, AND they added the product brand names to the descriptions.
3. CMS awarded GammaGraft a new Q code.

What didn't happen?

1. OrCel and TransCyte were left out in the cold.  They did not get new Q codes.
2. The payment for the existing codes did not change.  All of these products are on the NDC-HCPCS Crosswalk will continue to be paid based on the Average Sales Price (ASP) list that is released quarterly.  Remember, doctors who use the products in their offices get paid ASP+6% and HOPDs get paid ASP+4%.

What do I have to do?

1. IntelliTrak users don't have to do anything to your clinical procedures in the software.  We're handling all of these changes in IntelliTrak 3.8 SP1.
2. Everyone (including IntelliTrak users) should make sure that your chargemasters are up to date and reflect these new changes.  I will be posting an Excel file to the blog that summarizes the code changes soon to help you out.

CMS has approved six new ICD-9-CM codes for use in 2009.  If you are a regular reader of this blog, odds are very good that these codes are a required change on your superbills.  The new codes are in the 707 Skin Ulcer classification, but they do NOT replace any of our existing codes, they are meant to give you a mechanism to reflect additional information, specifiically, the pressure ulcer stage.

The new codes are as follows:

• 707.20   Pressure ulcer, unspecified stage
• 707.21   Pressure ulcer, Stage I
• 707.22   Pressure ulcer, Stage II
• 707.23   Pressure ulcer, Stage III
• 707.24   Pressure ulcer, Stage IV
• 707.25   Pressure ulcer, unstageable

Another interesting change also happened in this section.  The codeset was updated so that the codes 707.00 through 707.09 are no longer called 'Decubitus' ulcers, but are referred to as 'Pressure' ulcers.  Novel.

There are some days that I really do think that some people just won't be happy with IntelliTrak until we implement the oft-requested Mind Reading feature!  I'm not quite sure how we're going to implement it, but I certainly think that we'll need some form of electronic feedback loop to go along with it.

One of my favorite requests that goes down this line is the use of generic diagnosis codes.  Frequently, the best reasoning we're given is that the practitioner is too busy to use the correct diagnosis codes.

I think by now we all know that in the United States, we use the International Classification of Diseases, Ninth Revision, Clinical Modification or ICD-9-CM, to indicate the diagnoses associated with our patients.  The majority of ICD-9 codes are 3, 4, and 5 digits long and have a lengthy description.  Sometimes....VERY LENGTHY... and thus highly specific.

At the opposite end of the spectrum we have a large number of 'unspecified' codes littered throughout the classification system.  They are codes which are designated with the abbreviations NOS and NEC and for the most part do NOT justify the medical necessity for most of the work we perform on our patients.

NOS, short for not otherwise specified, is the code to be used by a coder who has been provided insufficient detail by the clinician to code the diagnosis out to a more specific disease.

NEC, the abbreviation for not elsewhere classified, is found on ill-defined terms that should alert the coder to find a more specific code, because one probably exists.  This isn't always the case, and it is the frequent culprit when the clinician asks for us to load this 'generic' diagnosis code into their coding short list.

All that said, I guess we will have to ask the clinicians to pause, take a second, and select a more specific code, at least until we get the mind Reading feature fully tested.  At the end of the day, they really do owe it to themselves, the hospitals where they practice, and their patients to select the most appropriate code.