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.

This information is a repost about the PQRI Feedback Reports for the 2007 Re-Run and 2008 program.  If I could find it online, I'd just point you there, but all I have is the text from a CMS list serve.  If you are an Intellicure user that we submitted on your behalf, please don't hesitate to ask for help in accessing this.  Here you go...

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Important Information About Accessing 2007 Re-Run and 2008 Physician Quality Reporting Initiative (PQRI) Feedback Reports

The Centers for Medicare & Medicaid Services (CMS) would like to remind Physician Quality Reporting Initiative (PQRI) participants that there is a  “Verify Report Portlet” look-up tool available on the PQRI Portal for Eligible Professionals (EPs) to verify if a 2007 re-run and/or 2008 PQRI feedback report exists for your organization's Tax Identification Number (TIN) or National Provider Identifier (NPI). The TIN or NPI must be the one used by the EP to submit Medicare claims and valid PQRI quality data codes. This tool is available at (https://www.qualitynet.org/portal/server.pt) on the internet.

Bottom of Form

 

If a report is available for your organization’s TIN or NPI there are two ways to access 2007 re-run and/or 2008 PQRI feedback reports:

 

1) An individual EP can simply call their respective Carrier or A/B MAC provider contact center to request confidential 2007 PQRI re-run and/or 2008 PQRI feedback reports that will contain information based on their individual NPI.  If an EP is part of a group practice, each EP in the group practice must individually call their respective Carrier or A/B MAC provider contact center to request a feedback report based on the individual NPI.  To obtain a list of Provider Contact Centers, visit (http://www.cms.hhs.gov/MLNProducts/Downloads/CallCenterTollNumDirectory.zip) on the CMS website. In addition to PQRI information, these reports will provide individual EPs with information on their Medicare Part B Physician Fee Schedule allowed charges for the 2007 or 2008 PQRI reporting period, upon which an incentive payment is based.       

 

Additional information about this alternative feedback report request process can be found by accessing special edition Medicare Learning Network (MLN) article (SE0922) “Alternative Process for Individual Eligible Professionals to Access Physician Quality Reporting Initiative (PQRI) and Electronic Prescribing (E-Prescribing) Feedback Reports.”  Visit (http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0922.pdf) on the CMS website.

 

or

2) EPs can logon to the secure PQRI Portal on QualityNet at (http://www.qualitynet.org/portal/server.pt) to access their feedback report(s) based their TIN, or for a group.  Access to the PQRI Portal requires registration in the Individuals Authorized Access to CMS Computer Services (IACS) system to obtain a userID and password. 

Important Information on Updating IACS User Accounts and Passwords

 

CMS would like to remind users that the CMS Security policy requires IACS passwords to be changed every 60 days. An IACS user who has not changed his or her password in over 60 days will be prompted to do so at the next login attempt.

 

An IACS user who has not changed his or her password in over 120 days will first be prompted to answer the security questions established at registration. After successfully answering security questions, the user will then be prompted for a password change.

 

Updating IACS user accounts and passwords is essential to maintaining this access and functionality.

 

Resources

The IACS account management page is at (https://applications.cms.hhs.gov/category.html?name=acctmngmt). Click on “My Profile” to login, change your password, or use the “Forgot Password?” option.

If you are having difficulty with IACS registration or disabled accounts, follow the self-service instructions below on how to recover your IACS userId and/or password and/or change your IACS password.

Instructions for Retrieving Your IACS UserID

1.        Go to the CMS Applications portal at (https://applications.cms.hhs.gov)

2.       Enter the portal; select the Account Management tab, and then the “Forgot Your User ID?” link in the Account Management section. Follow the online instructions.

3.       You will receive an email at the email address on record.

 

Instructions for Retrieving Your IACS Password

1.        Go to the CMS Applications portal at (https://applications.cms.hhs.gov/warning.html)

2.       Enter the portal; select the Account Management tab, and then “My Profile” link in the Account Management section.

3.       Enter your UserID

4.      Click on “Forgot Your Password?” button on the login page and follow the online instructions.

5.       You will receive a onetime password in an email at the email address on record.

 

Instructions to Login and Change Your IACS Password:

1.        Go to the CMS Applications portal at (https://applications.cms.hhs.gov)

2.       Enter the portal; select the Account Management tab

3.       Select the My Profile link

4.      Login using your UserID and onetime temporary Password.

5.       The system will prompt you to change your password.

6.       Enter your new password in both the New Password and Confirm New Password fields and then select the Change Password button.

7.       The system will take you back to the My Profile screen.

8.       Log out.

 

Once you have successfully changed your password you may login and access your PQRI feedback report(s) on the PQRI portal at (https://www.qualitynet.org/portal/server.pt).

 

If you are still having difficulty with IACS registration or disabled accounts, please contact the External Users Services (EUS) Help Desk

at 1-866-484-8049, TTY/TDD at 1-866-523-4759 (Monday – Friday 7:00 a.m.-7:00 p.m. EST) or via e-mail at EUSSupport@cgi.com.

 

The IACS home page for the Provider/Supplier user Community, which includes PQRI, is at (http://www.cms.hhs.gov/IACS/04_Provider_Community.asp#TopOfPage) on the CMS website. Provider Community users should direct questions or concerns to the External User Services (EUS) Help Desk at 1-866-484-8049, TTY/TDD at 1-866-523-4759 (Monday - Friday 7:00 a.m.-7:00 p.m. EST) or via email at EUSSupport@cgi.com. 

 

The PQRI Portal is available at (https://www.qualitynet.org/portal/server.pt) on the internet. Although the “Forgot Password” link on the PQRI Portal sends users to the IACS website, IACS and the PQRI Portal are two separate websites.

 

Additional information about PQRI can be found at (http://www.cms.hhs.gov/PQRI) on the CMS website. For more information on the 2007 re-run and 2008 PQRI feedback reports or incentive payments, see the "PQRI and eRx Quick-Reference Support Guide for Eligible Professionals" at (http://www.cms.hhs.gov/PQRI/Downloads/PQRI-eRxEPQuickRefGuideDiagram_100209.pdf)  on the CMS website.

 

Users who still have questions or need assistance should contact the QualityNet Help Desk at 1-866-288-8912 (Monday-Friday 7:00 a.m.-7:00 p.m. CST) or qnetsupport@sdps.org.

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.

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'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

In the past two months, there has been a lot of debate as to what the meaning of “meaningful use” is in the American Recovery and Reinvestment Act (ARRA), and the definition was discussed at the April 28-29 meeting of the U.S. Department of Health and Human Services, National Committee on Vital and Health Statistics Executive Sub-Committee.

ARRA, commonly known as the stimulus bill, is providing billions in funding for electronic medical records (EMRs), but one of the tests to qualify for money is “meaningful use” of the EMR technology. Currently no clear federal definition exists to explain what qualifies. The purpose of the meeting was to conduct a hearing to help formulate the definition.

One of the speakers at the meeting was Dr. John Halamka, the CIO of Harvard Medical School, Chairman of HITSP, among other accolades.

Rather than summarize what I was able to gleam from the online broadcasts, here is Dr. Halamka's summary of the meeting taken from blog.

1. The country must rollout EHRs with baseline functionality that at a minimum includes e-prescribing, automated lab workflow, clinical summary exchange, and quality data reporting.

2. Health Information Exchanges will evolve locally based on business cases in communities. The services offered may include e-prescribing, diagnostic test results delivery, quality data warehousing, data normalization into common formats and vocabularies, and "convening services" to create data use agreements for the community.

3. Quality warehouses are needed to provide caregivers with rapid feedback and serve as population health registries. They will often be local based on the political feasibility of co-mingling data.

4. Standards will continue to evolve, but existing standards wrapped in a service oriented architecture using a common data transport approach are good enough. We should use clinical data preferentially over administrative data for quality reporting, population health analysis, and PHRs.

5. Policies in support of this technology will continue to evolve locally. Although there should some common national policies, regional variation must be allowed.

The hearing was broadcast live on the Internet, which is where I listened to it.  For more information you can read the agenda, or to listen to the archived broadcasts.

Barring any unforseen, unpaid tax situations, Governor Kathleen Sebelius of Kansas will likely be the next Secretary of HHS. Her appointment was announced by the President along with Nancy-Ann DeParle as Director, White House Health Reform Office. As we accelerate towards a Nationwide Health Information Network, strong performance from these key leadership roles will be a key towards achieving quality, cost-effective health care delivery in the U.S.

Sebelius has been a widely popular governor, but has disagreed with Kansans on a number of key issues, namely her support of abortion rights, tax increases, and same-sex marriage.

DeParle is a former director of the Health Care Financing Administration (HCFA), the predecessor to CMS. DeParle is on the board of directors at Cerner, a Commissioner on the Medicare Payment Advisory Commission (MedPAC), a trustee at the Robert Wood Johnson Foundation, and a director of the National Quality Forum, Accredo Health Inc., Triad Hospitals, Guidant Corporation and DaVita Corporation.

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.