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.

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).

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.

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.

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.

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.

The Centers for Medicare and Medicaid Services (CMS) announced today that the Intellicure Research Consortium (IRC) was qualified to submit quality data to CMS on behalf of their eligible professionals for 2008 PQRI reporting.

David Walker, Intellicure’s President and CEO says “working with the IRC, physicians using IntelliTrak™, Intellicure’s premier electronic medical record, can expect to receive a bonus payment between $1,500 and $5,000 from CMS for participating in this exciting quality program.”

The IRC went through a thorough vetting process including checking Intellicure’s capability to provide the required PQRI data elements, reviewing measure flows, and transmitting the data to CMS in the correct file format.

Physicians still have time to join the IRC and be eligible to participate in the 2008 PQRI submission.

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.