I asked my team at Intellicure earlier this week what are the three most important words were in healthcare data security? I've already given you the answer in the title to this entry, but just like real estate has location, location, location; we have breach, breach, and breach!

You've by now seen one of the many articles that have cited the recent study by the Ponemon Institute titled the "2011 Benchmark Study on Patient Privacy and Data Security". The numbers are so startling that even the NY Times has covered the report. In short, data breaches were significantly on the rise, up 30 percent, and costing the healthcare industry $6.5 billion a year. It is also important to note that the report was commissioned by IDExperts, a company that entered the market to sell identity theft insurance, but is now selling breach prevention and remediation services.

Equally important was that Larry Ponemon, chairman and founder of the Ponemon Institute, said "It is not too surprising that the rate of data loss increased ... we that that finding may not be as negative as it appears, and could be a discovery-rate increase with more control and governance practices and the use of enabling technologies." Leading to the conclusion that the raw breach count increase is at least partially due to better detection capabilities.

The full study can be downloaded here, but the root causes graph is what interested me most.

Some call it intentional, others call it Murphy's law, but I tend to call it the law of unintended consequences.  As a software developer, I am intimately aware that any time you intervene in a complex system you have the opportunity to create an unanticipated and sometimes undesirable outcome.

At Intellicure, we've spent months getting ready for some dramatic changes to debridement coding.  For a quick refresher, the AMA has dispensed with the system of coding multiple surgical debridements as multiple independent procedures and replaced it with a system of adding the surface areas of the multiple sites and then using a series of primary and add-on codes to reflect the total surface area debrided.  Our Chief Medical Officer, Dr. Caroline Fife has done a great job of describing these changes using a series of real world examples to illustrate the new process using a series of slides and webinars (available to Intellicure clients).

We recently noticed that CMS' Medically Unlikely Edits (MUE) have not been updated to reflect the new code instructions for CPT 97598, and still list it with a quantity of “1”.  We've begun making inquiries to certain Medicare contractors, but at the time of this writing correctly coded claims are going to get rejected presuming they have a quantity of more than "1" which would of course occur when you debride a wound (or wounds) with a collective surface area that measures more than 40 sq. cm.We are also going to be following CMS' guidance to get a MUE updated so this may all be resolved when the second quarter NCCI/OCE edits are released in April. Until then, for the answer of how to report the any extra 97598s, I suggest that providers contact their pertinent Medicare medical directors, explain the issue, and ask how their particular system will process the claims.  Until CMS changes the MUEs, the Medicare contractors will have to program their computers to accept additional units of this code, which will probably be done by modifier which they'll have to share.

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.

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'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