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 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.

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'm certain you have all been waiting with bated breath for this crucial definition to be released.  Well, for those of you who have entrusted me with the breath holding, (drum roll please), it's here!  Today at the HIT Policy Committee meeting, the Workgroup on Meaningful Use presented its work, as a preamble and a matrix.

The meaningful use matrix is organized into specific meaningful use goals to be achieved by 2011, 2013, and 2015. It also lists metrics for these goals to evaluate hospital and clinician progress in meeting them.

I'm happy to say that most, if not all, of the 2011 Objectives (via IntelliTrak) and Measures (via PQRI and the Intellicure Research Consortium) are already available to Intellicure Clients.

The 2011 Objectives are listed below, each following the appropriate Health Outcomes Policy Priority.

Improve quality, safety, efficiency, and reduce health disparities

• Use CPOE for all order types including medications [OP, IP]
• Implement drug-drug, drug-allergy, drug-formulary checks [OP, IP]
• Maintain an up-to-date problem list [OP, IP]
• Generate and transmit permissible prescriptions electronically (eRx) [OP]
• Maintain active medication list [OP, IP]
• Maintain active medication allergy list [OP, IP]
• Record primary language, insurance type, gender, race, ethnicity [OP, IP]
• Record vital signs including height, weight, blood pressure [OP, IP]
• Incorporate lab-test results into EHR [OP, IP]
• Generate lists of patients by specific condition to use for quality improvement, reduction of disparities, and outreach [OP]
• Send reminders to patients per patient preference for preventive /follow up care [OP, IP]

Engage patients and families

• Provide patients with electronic copy of- or electronic access to- clinical information (including lab results, problem list, medication lists, allergies) per patient preference (e.g., through PHR) [OP, IP]
• Provide access to patient-specific educational resources [OP, IP]
• Provide clinical summaries for patients for each encounter [OP, IP]

Improve care coordination

• Exchange key clinical information among providers of care (e.g., problems, medications, allergies, test results) [OP, IP]
• Perform medication reconciliation at relevant encounters [OP, IP]

Improve population and public health

• Submit electronic data to immunization registries where required and accepted [OP, IP]
• Provide electronic submissions of reportable lab results to public health agencies [IP]
• Provide electronic syndrome surveillance data to public health agencies according to applicable law and practice [IP]

Ensure adequate privacy and security protections for personal health information

• Compliance with HIPAA Privacy and Security Rules and state laws
• Compliance with fair data sharing practices set forth in the Nationwide Privacy and Security Framework

Among the provisions included in the “stimulus bill” rapidly making its way through Congress at the time of this writing are $19 billion directed toward health information technology. Of this amount, $17 billion are allotted to incentives and $2 billion to jump-start healthcare IT adoption. By the time this article reaches press, the details of the provisions may have changed. However, The Health Information Technology for Economic and Clinical Health Act (HITECH) is a significant part of the $789 billion American Recovery and Reinvestment Act.  The first component of HITECH to hit the streets is a $2 billion project which includes measures to establish an open and transparent process, led by the Office of the National Coordinator for Health Information Technology (ONC), to develop standards that allow for “secure nationwide electronic exchange of health information.” This aspect is often called the National Health Information Network (NHIN) and the goal is to have this ready by 2010.

 

Nationwide exchange of electronic information will likely be the target of strong opposition from the privacy lobby. In a pre-emptive strike against likely opposition, the bill improves and expands current federal privacy and security protections for health information, commonly known as HIPAA, such as requiring that an individual be notified if there is an unauthorized disclosure or use of his or her health information and requiring a patient's permission to use his or her personal health information for marketing purposes.  The largest change implemented by this bill is the practical abolition of the Business Associate Agreement, or BAA.  In making this step, contractors and vendors who have in the past been seen as Business Associates are now going to be considered, and held accountable to the standards of, Covered Entities.

 

The second part of this legislation is the allocation of $17 billion in incentives to support health information technology (HIT) through Medicare and Medicaid, beginning in 2011. CMS will be offering reimbursement incentives to eligible professionals and hospitals that exhibit a “meaningful use” of certified electronic health records (EHR). Most notable is the provision of temporary bonus payments ranging from $44,000 to $64,000 for physicians and up to $11 million for hospitals.  The goal is a 90% HIT adoption rate for physicians and a 70% adoption rate for hospitals. The bill’s authors hope to generate savings of more than $12 billion through improvements in quality and coordination of care and reductions in both medical errors and duplicative care.  If the carrot doesn't work, the bill phases in Medicare payment penalties for physicians and hospitals not using electronic health records starting in 2014.

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.

On October 6, 2008, CMS announced that its Recovery Audit Contractors (RAC) demonstration program was expanding. By 2010, CMS plans to have 4 RACs in place.  Each RAC will be responsible for identifying overpayment and underpayments in approximately ¼ of the country. The new RAC jurisdictions match the DME MAC jurisdictions.

The RAC demonstration program has proven to be successful in returning dollars to the Medicare Trust Funds and identifying monies that need to be returned to providers. It has provided CMS with a new mechanism for detecting improper payments made in the past, and has also given CMS a valuable new tool for preventing future payments.

The new RACs are:

• Diversified Collection Services, Inc. of Livermore, California, http://www.performantcorp.com, in Region A, initially working in Maine, New Hampshire, Vermont,  Massachusetts, Rhode Island and New York.
• CGI Technologies and Solutions, Inc. of Fairfax, Virginia, http://www.cgi.com, in Region B, initially working in Michigan, Indiana and Minnesota.
• Connolly Consulting Associates, Inc. of Wilton, Connecticut, http://www.cca-audit.com/, in Region C, initially working in South Carolina, Florida, Colorado and New Mexico.
• HealthDataInsights, Inc. of Las Vegas, Nevada, http://www.healthdatainsights.com, in Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.

Additional states will be added to each RAC region in 2009.