Whistleblower Suit Snares $1.2M:
Anesthesiologists Failed to Supervise

By Justin Vaughn, M.Div, CPC
Director of Compliance

4/18/2013

An anesthesiologist brought a qui tam action against his fellow physicians for failing to provide proper supervision to both CRNAs and residents.   Commonly referred to as a “whistleblower” lawsuit, the case stems from allegations asserted in 2008 that anesthesiologists in a teaching facility in Irvine, CA. submitted claims involving CRNAs and residents that were, in fact, fraudulent.  Specifically, it was alleged that the anesthesiologists would routinely document their presence and availability on the anesthesia record, when in actuality they were not even in the same building.

After years of legal wrangling, the California Board of Regents decided to settle the suit for $1.2 million, with the plaintiff anesthesiologist receiving 10% of that sum.  Considering the above facts, the message that should be driven home to every anesthesiologist is this:  Whistleblowers are everywhere.  They may even be a fellow physician within your own group.  When it comes to medically directing CRNAs or supervising residents, make sure you assiduously abide by the following documentation protocols:

2013 Anesthesia and Pain Updates

By Christine Locay, JD, RHIA, CPC
Senior Vice President of Compliance

4/18/2013

Anesthesia Coding Updates

CPT Changes: Anesthesia Codes

In Current Procedural Terminology (CPT) 2013, there were no new or deleted anesthesia codes.

There was one revision to 01991 (anesthesia for blocks, other than prone position) and 01992 (anesthesia for blocks, prone position).  These codes used to state “when block or injection is performed by a different provider.”  The descriptors now state “when block or injection is performed by a different physician or other qualified health care professional.”
CPT included the term “other qualified health care professional” to emphasize that CPT does not limit code reporting to specific specialties or providers; instead, scope of practice laws, regulations, contracts, and hospital policy/bylaws determine whether a provider is qualified to perform a service.  According to CPT a “physician or other qualified health care professional” is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports the professional service.”   CPT excludes clinical staff who do not report their services independently from the definition of “other qualified health care professional.”

Medicare Contractor Proposes Limiting Coverage of Post-Op Blocks to Post-PACU Placement
By Christine Locay, JD, RHIA, CPC

4/9/2013

Noridian Administrative Services (NAS) administers Medicare Part B for Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming.  NAS has released a draft local coverage determination (LCD) (see attached policy) governing coverage of pain blocks for all 10 states listed above.  Of particular significance, NAS is proposing to limit coverage (and thus reimbursement) of postoperative pain blocks to blocks that are placed after PACU discharge.

PQRS: Why 2013 Matters
By Justin Vaughn, M.Div, CPC
Director of Compliance

3/22/2013

This is just a reminder to our clients that the 2013 version of the PQRS program is a bit different from all previous iterations.  There are still 3 anesthesia measures to report; there is still a small bonus one can earn; there is still a reporting threshold that must be met; but something significant has changed.

In previous years, the PQRS incentive program was voluntary.  Beginning this year, the program has become mandatory.  That is, for the first time, a financial penalty will be attached to non-participation.  This penalty—a 1.5% downward adjustment in your total annual Medicare allowable—will be imposed in 2015, but it is based on 2013 reporting.

Again, all this is a reminder of what we’ve previously published.  We are nearing the end of the first quarter of 2013, so now may be a good time to review where you stand as an individual provider and as a group.  Are you participating?  Are you consistently sharing PQRS data with Medac via the medical record, etc.?  For those of you who have never participated in PQRS, you still have time to begin the process in order to (a) satisfactorily meet the 50% annual reporting threshold, (b) earn the 0.5% bonus, and (c) avoid the 1.5% 2015 penalty.  If you have questions concerning the PQRS program, please contact your Medac compliance liaison or practice manager, or visit the CMS website.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Latest HIPAA Rules Released: Significant Impact on Providers

By Justin Vaughn, M.Div, CPC
Director of Compliance

2/27/2013

The federal government has published a Final Rule that provides for sweeping changes in the HIPAA privacy and security standards.  The 563-page rule is massive in scope, and complex in content, but its key elements can be summarized as follows:

Compliance Date. While the effective date of the Final Rule is March 23, 2013, you will have until September 23 of this year to comply with most of its components.

Definition of Business Associate. The definition of “Business Associate” (BA) has been broadened to include anyone who “creates, receives, maintains, or transmits PHI.”  Examples of entities that may or may not fall into the BA category are listed below.

Medicare Targeting TENS & ESIs
By Justin Vaughn, M.Div, CPC
Vice President of Compliance

12/11/2012

As part of its ongoing efforts to ensure the medical necessity of covered services, Medicare has published two recent documents that will have a direct impact on the practices of chronic pain providers.  One of these documents deals with transcutaneous electrical nerve stimulation (TENS), while the other addresses epidural steroid injections (ESIs).  The pertinent details of these Medicare communications are provided below.

Time Running Out for TENS

On December 4, CMS published a revised Medicare Learning Network (MLN) Matters article in which it announced a change in coverage as it relates to TENS services.  While once covered, such services are now being phased out—at least as it concerns using a TENS unit for the treatment of chronic lower back pain (CLBP).  Specifically, CMS has determined that “the evidence is inadequate to support coverage of TENS for CLBP as reasonable and necessary.”  As a result, Medicare will only allow coverage of TENS in connection with CLBP when ALL of the following stipulations are met:

ASA Clarifies EHR Program Rules
By Justin Vaughn, M.Div, CPC

12/7/2012

Recently, the ASA published a set of frequently asked questions (hereinafter, FAQ) regarding anesthesiologists and the EHR Incentive Program; and, in so doing, has finally put to rest some nagging questions I had submitted to the society over the preceding weeks.  As we earlier reported, the Final Rule for Stage 2 of Meaningful Use contained a codicil exempting anesthesiologists from the program’s penalties over a 5-year period.  This was good news, but the wording of the Rule raised a few questions: 

Block and Line Placement Time:
Provider Documentation Protocol

By Justin Vaughn, M.Div, CPC
Vice President of Compliance

11/8/2012

As most of you know, both the American Medical Association (AMA) and the American Society of Anesthesiologists (ASA) have put forth the position that minutes spent in the placement of a post-op pain (POP) block or invasive line should not count in the calculation of total anesthesia time—where such placement occurs prior to induction of the “primary anesthetic” (e.g., general anesthesia) or after emergence.  As a result, we would like to reinforce for our providers the documentation protocol they should follow, and that Medac has adopted, as it concerns denoting time for block and line placement.

Invasive Line Time

From what providers consistently advise, invasive lines (e.g., arterial lines, central lines, Swan-Ganz catheters) are more typically placed after induction, and certainly before emergence.  Accordingly, where the provider indicates the placement of an invasive line on the anesthesia record, Medac will presume that the line was placed in the period between induction and emergence—obviating the need to document placement time (at least from a billing perspective).  We would therefore require the provider to document start/stop time of the line placement only where such placement occurs: (a) after the anesthesia start time, AND (b) prior to induction of the primary anesthetic (or after emergence). 

Post-Op Block Time

CRNAs and Chronic Pain: CMS Breaks New Ground
By Justin Vaughn, M.Div, CPC
Vice President of Compliance

11/7/2012

In the Final Rule relating to the 2013 Medicare Physician Fee Schedule, released this month by CMS, the federal government has fully and officially recognized the right of certified registered nurse anesthetists (CRNAs) to enter into the practice of chronic pain management.  The ruling acts to reaffirm the proposed rule that was promulgated earlier this year, and actually moves farther by authorizing a CRNA’s practice parameters, and thus reimbursement, to be based on the CRNA scope of practice laws and regulations of each state.  Theoretically, this means that CMS could sign off on many other CRNA services—in addition to anesthesia, acute pain and chronic pain—based on the extent of a given state’s scope of practice rules.  The Final Rule states, in pertinent part:

“Therefore, we are revising §410.69(b) to define the statutory benefit category for CRNAs, which is specified as ‘anesthesia and related care,’ as ‘those services that a certified registered nurse anesthetist is legally authorized to perform in the state in which the services are furnished.’”

Accordingly, if you wish to know whether or not CRNAs can submit claims to Medicare for pain management services in your particular state, you will need to:  (a) determine if that state's legislature has adopted a scope of practice for CRNAs (such as a “Nurse Practice Act”), or alternatively has authorized the executive branch to produce regulations in this regard, and (b) determine if that scope of practice includes chronic pain management services.  The Final Rule will take effect January 1, 2013. 

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

The 2013 E-Prescribing Penalty: A New Chance to Escape
By Justin Vaughn, M.Div, CPC
Director of Compliance

10/19/2012

The Centers for Medicare and Medicaid Services (CMS) announced yesterday that it will allow an extension on the filing of hardship exemptions for the purpose of avoiding the 2013 e-prescribing (eRx) penalty.  This will no doubt be deemed a positive development by many of our chronic pain providers.

As you know, the eRx Incentive Program was designed to encourage providers to transmit prescriptions electronically, and CMS authorized modest payments to those who complied.  It also, however, mandated “financial adjustments,” i.e., payment reductions, relative to those eligible providers who failed to participate in 2012—specifically a 1.5% reduction in the provider’s total annual Medicare allowable in 2013.  For those who could not participate, hardship exemptions were made available by CMS.  Unfortunately, many pain practitioners failed to take advantage of these exemptions in time.  Yesterday’s announcement means your time has just been extended. 

Originally, eligible providers wishing to avoid the 2013 eRx penalty were to have submitted their hardship exemptions by June 30 of this year.  The new exemption filing period will run from Nov. 1, 2012 through Jan. 31, 2013.  During this period, providers seeking an exemption from program participation and the 1.5% penalty must submit their requests using the Quality Reporting Communication Support Page.  CMS also advised that the period for requesting hardship exemptions relative to the 2014 penalty—originally slated for Jan 1-Jun 30, 2013—will be reconsidered and announced at a later time.

The main message is this:  If you would like to avoid the 2013 penalty, but failed to submit an exemption request earlier this year, you have a new lease on life beginning Nov 1.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

RAC To Target High-Level E/Ms
By Justin Vaughn, M.Div, CPC
Director of Compliance

9/17/2012

According to the Medical Group Management Association (MGMA), the Centers for Medicare & Medicaid Services (CMS) has authorized the Region C RAC (Recovery Audit Contractor) to undertake the targeted review of level-5 evaluation and management (E/M) services. The states falling under the aegis of this regional RAC are: Ala., Ark., Colo., Fla., Ga., La., Miss., N.M., N.C., Okla., S.C., Tenn., Tex., Va., and W.Va.

In other words, providers who perform E/M services in these states will soon be subject to having their records reviewed whenever they bill a level-5 service, such as 99205 (new patient encounter) or 99215 (established patient encounter).  Chronic pain providers should therefore double their efforts to support such claims with appropriate documentation.  Specifically, physicians must endeavor to:

• Hit all of the required history, exam and medical decision-making (MDM) documentation bullets, as outlined by HCFA’s (now CMS) 1997 Documentation Guidelines for Evaluation and Management Services.

• Denote the medical necessity rationale for the level-5 service.  Was such a high-level service really warranted? You may hit all the required documentation bullets for a level-5 E/M, but if all the patient complained of was a hangnail, the RAC auditor will ask you to repay the government.

The reason I bring this issue to your attention is because I have spoken with so many pain physicians throughout the country who revealed that they routinely or even exclusively submit high-level E/M claims.  Their rationale is that a preponderance of their patients are older with a whole panoply of problems, disorders and syndromes.  This may be, but this does not remove the target that is now squarely on your back. Therefore, proceed with greater caution; be even more judicious when selecting the appropriate code for the service performed; and make sure you are familiar with the 1997 Guidelines, as referenced above.  (A copy can be obtained from this CMS website.)  In addition, you should seek to distill these documentation requirements down to a bulleted template format for ease of use.)

In the event of a RAC audit of your pain practice, your record documentation is everything.  Therefore, make sure your claims for high-level services especially are sufficiently supported and invariably justified.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Moderate Sedation:
AMA Clarifies Billable Time

By Justin Vaughn, M.Div, CPC
9/15/2012

As many of you know, pain physicians may, under certain circumstances, bill moderate sedation in addition to the therapeutic procedure itself. The typical code reflecting such service is CPT 99144, the descriptor of which states (in pertinent part):  “first 30 minutes intra-service time.”  According to a 2011 clarification by the AMA—which we concurrently brought to your attention—a physician must perform a service for greater than half the time period specified in the code descriptor in order for that service to be billable.  Accordingly, a provider would need to spend at least 16 minutes performing moderate sedation in order to submit a claim for that service.

This 2011 guidance from the AMA seemed clear enough; however, some wondered if the doctor’s presence with the patient through the recovery process could count toward the 16-minute threshold.  This prompted a further inquiry to, and clarification from, the AMA.  In a September 2012 email to healthcare attorney David Vaughn, the CPT KnowledgeBase—the research arm of the AMA—asserted that "recovery . . . is NOT reported separately.”  Indeed, the 2012 CPT manual itself stipulates in the introductory notes of the Moderate Sedation section that recovery is not included in the intra-service time. 

Based on the AMA’s position, as promulgated by its research agency and its CPT manual, pain physicians should not count the minutes spent with the patient in recovery as part of their total moderate sedation time.  Unfortunately, this will mean that many providers will find it much more difficult to meet the time criteria necessary to bill CPT 99144.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

EHR Incentive Program: Overview and Analysis
by: Justin Vaughn, CPC, M.Div
Director of Compliance

9/6/2012

As a follow-up to last week’s client alert on the recently released Final Rule for Meaningful Use – Stage 2, we would like to offer a fresh overview of the EHR Incentive Program, outlining its key components and requirements.

As stated in last week’s alert, the Centers for Medicare and Medicaid Services (CMS), has extended to anesthesiologists, in particular, the unique opportunity to apply for an exemption from the program—which in turn allows the applicant to avoid the escalating penalties for non-participation.  However, what if the anesthesiologist wants to participate?  What if the anesthesia provider is willing to endure the complexities and hardships inherent in the program in order to have a shot at pocketing the 5-figure incentive payment?  For those intrepid individuals, the following highlights are presented:

[NOTE:  There are two versions of the program—Medicare and Medicaid.  You can only choose to participate in one.  As many will not qualify for the Medicaid version, the following only pertains to the Medicare version.]

Program Basics

1. The program starts and ends with a “certified” electronic health record (EHR).  Without this, there is no possibility of participation.  You will need to verify with your facility’s IT staff or EHR vendor as to whether or not the EHR is certified, i.e., meets CMS’s complicated criteria for program functionality.
2. You do not have to own, lease, or make any capital investment in, the EHR or its software.  You simply must adopt and “meaningfully use” the EHR.
3. Non-physician practitioners (NPPs), such as CRNAs, NPs and PAs, cannot participate.  The program is primarily for physicians.
4. The incentive payment is potentially $44,000, paid out over 5 years to each successful participant.
5. To begin participation, you must first register for the program.  Click on this link to learn more about the registration process.
6. You must then demonstrate “meaningful use” of the certified EHR during the reporting period by meeting 15 core objectives and 5 menu objectives—each of which contains a “measure” to meet.  In addition, you must report on 6 clinical quality measures.
7. The reporting period:  In your first year of participation, the reporting period is any consecutive 90-day period, as long as it takes place wholly within the same calendar year (Jan-Dec).  For all subsequent years, the reporting period is the entire year (Jan 1-Dec 31).  In order to have an opportunity to receive the full $44,000 incentive payment, providers must have begun to meaningfully use the EHR by Oct 1, 2012.  Again, you must first register for the program.  Those beginning the program next year will be eligible for a maximum payout of $39,000.
8. There are 3 stages to the program.  We are currently in Stage 1.  Stage 2 will begin in 2014—assuming the provider begins participating in 2012 or 2013.  With each successive stage, the criteria for successful completion is potentially more challenging.  The recently released final rule deals primarily with the requirements of Stage 2.
9. At the conclusion of the reporting period, a participating provider must “attest” that he/she met the meaningful use requirements.  For more on the attestation process, please go to the aforementioned link.
10. Financial penalties will be assessed by CMS beginning in 2015 against any provider who is deemed eligible to participate, but who fails to do so, or fails to obtain an exemption.

In Summation

There are a myriad of other facts concerning the EHR Incentive Program.  Our purpose herein is to simply apprise you of the latest news concerning this CMS initiative.  Specifically, we wanted to underscore, in these last two alerts, the following key facts:

• Participation in the program must begin by Oct 1, 2012 to receive the full incentive payout.

• For those deemed eligible to participate, but fail to do so, financial penalties begin in 2015, and will be based on 2013 and 2014 participation.

• CMS has recently recognized that in the current Stage, it will be exceedingly difficult (though not impossible) for anesthesiologists to meet the program requirements, and has therefore offered to these providers up to 5 years of exemption from the escalating penalties.  The provider must apply for the first exemption by July 1 of 2014.  More details on the application process will be forthcoming in future alerts.

The decision to participate or seek exemption is up to you.  Medac remains ready to assist you in the deliberative process.  Please let us know if we can provide further clarification on this program.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

The EHR Incentive Program: New Rule for Anesthesiologists
By Justin Vaughn, M.Div, CPC
Director of Compliance

8/30/2012

Late last week, CMS released a Final Rule dealing with several significant aspects of the EHR incentive program; and, in so doing, provided an answer to the critical question anesthesia groups around the country have long awaited.  Since the implementation of the incentive program under the HITECH Act in 2009, anesthesiologists have wanted to know if they are exempt from participating in this decidedly complex initiative. 

This is a reasonable inquiry.  After all, the initial language of the Act specified that “anesthesiologists,” in particular, were among those who would normally be considered “hospital-based providers” (HBP), and as such would be excluded from the program.  However, subsequent regulations changed the criteria for determining the definition of HBP.  The term, “anesthesiologists,” was excised and replaced with a numerical formula.  Specifically, in order to achieve the status of HBP, and thus receive exemption from the program, at least 90% of a physician’s case volume would have to be performed in the inpatient and/or ER setting.  The problem with this formulation, of course, is that most anesthesiologists perform more than 10% of their cases in the outpatient hospital and/or ASC setting, and thus would not reach the HBP threshold.  So, the very group that CMS originally intended to exclude from participation has, for the last few years, been under the sword of Damocles—waiting and wondering if their status will ever change.  It has.

The Final Rule, which addresses Stage 2 of Meaningful Use and the EHR program as a whole, offers anesthesiologists a brief respite.  Rather than excluding anesthesiologists from the program outright, CMS decided to offer an exemption for anesthesiologists—that must be renewed each year.  Highlights of the exemption provision are as follows:

Date for ICD-10 Implementation Officially Delayed
By Justin Vaughn, M.Div, CPC

8/27/2012

The long-awaited decision by the Center for Medicare and Medicaid Services (CMS) establishing the implementation date for ICD-10 has been reached and officially set.  Originally, the agency had planned for the healthcare industry to transition to the use of ICD-10 on Oct 1, 2013.  However, due to a growing concern that payors and providers may not be ready for the change by that date, CMS considered postponing the deadline by one year.

The final rule relative to this matter—to be published in the September 5 edition of the Federal Register—confirms the government’s recently-proposed position:  The deadline for utilizing the ICD-10 coding guidelines is now set for Oct 1, 2014.  This provides entities two full years to continue their preparations—and it will be needed.

By way of background, the entire healthcare industry currently utilizes ICD-9 (International Classification of Diseases: 9th Revision).  This is the manual that translates documented diagnoses into numerical codes for claims processing purposes.  Beginning Oct 1, 2014, all payors and providers must adopt and use ICD-10, which promises to be far more detailed and complex than the current manual.  For example, under ICD-9, there is only a single coding option to reflect a “closed fracture of the radial shaft” (813.21).  Under ICD-10, there will be 270 code variants that providers, coders and payors will have to consider.  Clearly, this is not your father’s coding manual!

Rest assured that Medac will be at the forefront in preparing for this new day in diagnosis coding, and will provide information and recommendations to our clients along the way.  We will do all we can to ensure that your transition to ICD-10 is smooth and trouble-free.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

High Rate of Post-Audit Denials
What You Need to Avoid
By Justin Vaughn, CPC, M.Div
Director of Compliance

7/18/2012

Recently, Noridian, the Medicare carrier for much of the Northwest, issued an audit report regarding vertebroplasty and kyphoplasty services.  While you may not perform these specific services in your own practice, the report is nevertheless instructive in illustrating the audit processes of at least one Medicare carrier.  Significantly, the audit report indicated an average error rate of 90%; that is, 900 of 1,000 such audited services were ultimately deemed ineligible for payment.

The Noridian report went on to outline the reasons for such a high provider error rate—many of which amount to what healthcare attorney David Vaughn labeled as “Government Gotchas.”  These included:

California Supreme Court Upholds Physician Supervision Opt Out Decision
By Christine Locay, JD, RHIA, CPC
Vice President, Corporate Compliance Counsel

6/30/2012

On June 29, 2012 the California Supreme Court upheld California Governor Arnold Schwarzenegger's 2009 decision to opt out of federal regulations that require a CRNA to be supervised by the operating practitioner or an immediately available supervising anesthesiologist.  To date, the list of opt out states includes Kentucky (April 2012), Iowa, Idaho, Nebraska, Minnesota, New Hampshire, New Mexico, Kansas, North Dakota, Washington, Alaska, Oregon, Montana, South Dakota, Wisconsin, Colorado and California.  The decision to opt out is often very controversial with the debate focusing on patient safety and the ability to control health care costs, particularly in rural areas.

The Supreme Court Upholds the PPACA’s Individual Mandate
By: Christine Locay, JD, RHIA, CPC
Vice President, Corporate Compliance Counsel

6/28/2012

Today, the Supreme Court upheld President Obama’s health care reform law, the Patient Protection and Affordable Care Act (the Act), in a 5-4 decision.  The direct issue before the Court was the constitutionality of the individual mandate which requires all Americans (with certain exceptions) to obtain health insurance by 2014 or to pay a penalty that would be phased in by 2016.  The Court held that the mandate was a proper use of Congress’ authority to tax.  After further review of the opinion and the statute, a detailed analysis of the major provisions of the Act and the implications for providers will be provided in a future client alert to be issued in the next few days.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Ultrasound Guidance For Two Blocks During Same Patient Encounter: Billable or Non-Billable?
By Bellinger P. Moody, RHIA, CPC, CPC-I, CCP
Executive Vice President of Compliance

6/4/2012

Can you bill ultrasound twice if you perform 2 blocks on the same patient and use ultrasound for both blocks during the same patient encounter?

This question has surfaced several times over the last two months.  I thought it pertinent to set the record straight on this issue once and for all.  The simple answer is NO YOU CANNOT BILL THE ULTRASOUND TWICE. . . and here’s why:

Per Chapter 9 of the NCCI Manual: CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.

Per the NCCI, ultrasound needle guidance, CPT 76942 would only be billed once per patient encounter.   

In addition, the MUEs support only reporting 1 unit for code 76942, 77002, 77003 and so forth. 

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

OIG Rules on Management Fees & the Company Model
By Christine M. Locay, JD, RHIA, CPC
Vice President, Corporate Compliance Counsel

6/5/2012

On June 1, 2012, the Office of the Inspector General (OIG) issued an advisory opinion to an anesthesia group that concluded that two proposed arrangements potentially violated the federal anti-kickback statute which prohibits remuneration (i.e., anything of value) in return for referrals for federal health care program beneficiaries.  The first arrangement is the payment of management service fees by an anesthesia group to an ASC, and the second arrangement is known as the controversial “company model.” 

Management Service Fees
Under the first arrangement, the anesthesia group would continue to provide anesthesia services to the ASCs and bill for their own services, but the anesthesia group would begin paying the ASCs a management service fee on a per patient basis (excluding all federal health care program patients).

The OIG determined that the anti-kickback statute was still applicable despite the “carve out” of federal patients because “there is risk that the [anesthesia group] would be paying the Management Services fees with regard to non-Federal health care program patients to induce the [ASCs’] referral of all of its patients, including Federal health care program beneficiaries.” The OIG noted that the additional fees “could unduly influence the [ASCs] to select the [anesthesia group] as the [ASCs’] exclusive provider of anesthesia services” and concluded that the arrangement potentially violated the anti-kickback statute. 

Company Model
Under the second arrangement, often described as the “company model,” the ASCs’ physician owners would establish separate companies to provide anesthesia services to the ASCs. The new companies (subsidiaries) would then engage the anesthesia group as independent contractors to provide exclusive anesthesia services at the ASCs.

The OIG first concluded that no safe harbor protected the distribution of profits from the subsidiaries to the ASCs’ physician owners.  Although failure to satisfy a safe harbor is not fatal, the OIG also concluded that the proposed arrangement presented more than a minimal risk of fraud.  The OIG identified several factors, such as minimal business risk for the physician owners, in determining the risk for fraud. Ultimately, the OIG determined that proposed arrangement is “designed to permit the [ASCs’] physician-owners to do indirectly what they cannot do directly; that is, to receive compensation, in the form of a portion of the [anesthesia group’s] anesthesia services revenues, in return for their referrals to the [anesthesia group].”

Conclusion
Although the OIG’s opinion only applies to the requesting parties, it provides guidance on the OIG’s interpretation of the anti-kickback statute.  Therefore, providers should avoid arrangements that involve the payment of management service fees and the company model.  Violations of the anti-kickback statute could result in fines up to $25,000 or five years in prison, or both. 
For providers already in such arrangements, providers should terminate their contracts immediately.  Most contracts have provisions that allow for immediate termination in the event of a change in law or opinion.  Even without such a provision, providers should not continue practicing in such arrangements due to the risk of anti-kickback violations.  Some federal courts have held that contracts for arrangements that violate the anti-kickback statute are void and unenforceable.

There are many implications that cannot be addressed in a short alert; therefore, a detailed memo with an analysis of the opinion is attached along with the OIG’s advisory opinion.  Included in the memo is a discussion of common questions regarding variations on the proposed arrangements as well as a discussion of the risks of other models.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

2012 eRx Deadline Approaches
By Justin Vaughn, M.Div, CPC
Director of Compliance

5/31/2012

As a final reminder to our chronic pain physicians, June 30, 2012 is a key date in the Medicare E-Prescribing (eRx) Incentive Program.  It acts as a dual deadline for avoiding the 1.5% reduction in your total Medicare allowable payment for 2013, since by this date you must have either:

• Successfully reported at least 10 eRx events on applicable Medicare claims (via G-code G8553); or

• Submitted a hardship exemption request, if applicable.

Again, you are not subject to the 2013 eRx penalty if your Medicare allowable for office/outpatient E/M services (codes 99201-99215) accounts for less than 10% of your TOTAL Medicare allowable for DOS Jan 1-Jun 30, 2012.  If such is the case, then you would not have to submit any eRx, G-code or hardship request to avoid the 2013 penalty.  Your exemption from the penalty is automatic.  The problem is that you won’t officially know whether you’ve met the 10% threshold until later this year when the official CMS calculation is conducted, making it difficult to determine where you stand by the June 30 deadline. 

If you believe that you will be eligible for the program (and penalty), and you have a certified eRx system in place, make sure that you have submitted to Medac at least 10 Medicare cases where at least 1 eRx was submitted and documented (DOS Jan 1-Jun 30, 2012), so that our coders can ensure the claims are correctly identified and processed.  If you do not have such a system, and you believe you will be deemed eligible for the program (based on the 10% E/M threshold discussed above), then you can attempt to avoid the 2013 penalty by filing a hardship exemption by the aforementioned deadline.

If you need more information on avoiding the 2013 eRx penalty, please visit the following CMS link.  To submit a hardship exemption, go to the following link. 

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

OIG Zeros-In on Physicians with History of High-Level E/M Claims
By Justn Vaughn, M.Div, CPC
Director of Compliance

5/17/2012

The Office of Inspector General (OIG), the “watchdog” agency of the U.S. Dept. of Health and Human Services, has released a report indicating that physicians are reporting high-level evaluation and management (E/M) codes more frequently for all types of patient encounters.  As a result, Medicare payments for E/M services increased 48% during the decade ending in 2010.

In its analysis of the 2001-2010 period, the OIG identified 1,700 providers “who consistently billed higher-level E/M codes,” in contrast to their colleagues who treated similar patients but with lower-level E/M claim submissions.  The “outlier” physicians billed the two highest codes within a code set at least 95% of the time.

Though the OIG “did not determine whether the services billed by physicians who consistently billed higher level E/M codes were inappropriate or fraudulent,” there is nevertheless an implication within the OIG report that the shift in E/M coding patterns may, in part, be due to fraud or abuse.  In response to the OIG’s report and recommendations, CMS has advised that it will take the following actions:

DHHS Proposes One-Year Delay in ICD-10 Implementation
By Justin Vaughn, M.Div, CPC
Director of Compliance

4/9/2012

Today, the secretary of the U.S. Department of Health and Human Services (DHHS), Kathleen Sebelius, announced a proposed rule that would effectuate a one-year delay in the transition from “ICD-9” to “ICD-10.”  For some time, health plans, healthcare providers, IT staffs, and medical billing firms have been gearing up for a massive change in the way diagnoses are documented on the record and ultimately submitted on the claim.  October 1, 2013 had been the looming deadline for making the switch from the current version (9th “revision”) of International Classification of Diseases, ICD-9, to a far more complex version, ICD-10.  For many in the healthcare industry, the proposed delay represents a badly needed reprieve.

As many of you know, the ICD manual is recognized across the medical specialty spectrum, and by all payors, as the authoritative tool for translating a diagnosis described in a medical record into a particular code that appears on a claim.  Because of the enormous changes found in the 10th revision of ICD, it was feared that many healthcare entities would still be unprepared for the “big switch” in 2013.  Accordingly, DHHS is proposing that the inauguration of the ICD-10 era be moved to Oct 1, 2014.  Medac will keep you updated on this proposed postponement as new information is received.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Avoiding the 2013 eRx Penalty:
Hardship Website Now Available

By: Justin Vaughn, M.Div, CPC
Director of Compliance

3/23/12

CMS has published a Medicare Learning Network (MLN) article informing providers what they can do to avoid the 2013 “payment adjustment” (read, “payment penalty”) relative to the E-Prescribing (eRx) Incentive Program.  You will recall that physicians who are deemed eligible to participate in the eRx program, but who fail to successfully do so in 2012, will have their total Medicare allowable for the year reduced by 1.5% in 2013.

To avoid this penalty, CMS reminds you of the following criteria that they will consider:

CMS Proposes 10-Year Lookback for Potential Overpayments
By: Justin Vaughn, M.Div, CPC
Director of Compliance

2/27/2012

On February 16, 2012, the Center for Medicare and Medicaid Services (CMS) promulgated a proposed rule that would continue the recent trend of growing government pressure on physician practices.  Specifically, the proposed regulations would mean the following:

• Extend the current “lookback” period, relative to Medicare claim audits, from 4 years to 10 years. That is, Medicare auditors would be able to examine provider claims with dates of service that are up to a decade old.  The purpose of these audits is to identify and recover overpayments that were incorrectly made to healthcare providers during that time period.

• Where a refund is determined to be due the government, the provider would be forced to perform a self-audit, going back 10 years, to see if any other Medicare overpayments had been received during that period. The provider would have to report and return any such overpayments.  Should the government, upon audit, determine that the provider did not return an overpayment occurring within the 10-year lookback period, each unremitted overpayment would be subject to the False Claims Act penalty of $10,000, in addition to having to return the amount of the overpayment.  The new rule would mean providers would have to retain patient records for at least 10 years in the event they became subject to the self-audit provision.

To sum up, this new lookback period is another example of recent government actions that are putting the squeeze on healthcare workers.  If you find this proposal ominous and overreaching, you may want to consider urging your medical society (eg, ASA, ASIPP) to give voice to your views in Washington.  In the meantime, Medac will continue to watch for further developments on these proposed regulations, and keep you informed on any changes.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

HIPAA Version 5010 Issues Impacting Client Cash Flow
By Bellinger P. Moody, RHIA, CPC, CPC-I, CCP
Executive Vice President of Compliance

2/2/2012

There are a number of 5010 issues that are impacting client cash flow, many of which are beyond Medac’s control. The issues are as follows:

1. Due to the uncertainty of 2012 payment schedule CMS had a moratorium on processing 2012 dates of service for the first ten days of January. Now, all Medicare claims are filed and processed electronically, so the cash flow lag associated with this issue should recover quickly.
2. The new 5010 claims specs are creating difficulties in a number of areas. We are working through specific issues with a number of carriers but even when there are no specific issues, we have noticed a general slowdown in processing with certain insurance companies.
3. Also related to 5010, Medicare stopped sending Response Notices at the end of December. When we follow up on unpaid claims, we are being informed that there is no claim on file. Rather than wait for a resolution, we have re-filed all unpaid claims.
4. We have recently uncovered another 5010 error. A number of carriers that still process paper claims (mostly Workers Comp and Commercial) are sending payments to the facility. We are working with our clearinghouse to resolve this problem. In the meantime, the facilities should be alerted that they may be receiving checks that belong to your group.
5. Lastly, claims are subject to deductibles at the beginning of each year. In the past, this was primarily Medicare. Now, there are plans with high deductibles (even with in network services) that are the patients’ responsibility. As you know, it always takes longer to collect from the patients.

This is a national issue as evidenced by a recent letter from MGMA to HHS regarding payment disruptions caused by HIPAA Version 5010 implementation. Medac will keep you apprised of this situation as these issues are resolved. If you have any further questions, or wish to discuss in greater detail, please contact your Medac Practice Management representative.

The information presented herein reflects general information that is current as of the date it was first published. In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

RAC Expands to Medicaid: What Providers Can Expect
By: Justin Vaughn, M.Div, CPC
Director of Compliance

1/20/2012

Most of you have heard quite a bit about the “RACs”—recovery audit contractors.  These are independent entities that have been empowered by the federal government to review provider claims in an effort to identify over- and underpayments in connection with Medicare cases. 

Pursuant to federal statute and regulatory rule (“final rule,” as found in 42 CFR 455), the RAC program is now being expanded to Medicaid cases.  With that in mind, we would like to provide you with a brief overview of how the Medicaid RAC program will work:

CCI Medical Director Clarifies Bundling of Post-Op Blocks
By: Justin Vaughn, M.Div, CPC
Director of Compliance

1/4/2012

Many of you have voiced concerns over a recent submission found on the Anesthesia Administration Assembly (AAA) “listserv” concerning post-op pain procedures.  Specifically, the submission asserted that preoperatively or intraoperatively placed epidurals and nerve blocks may no longer be separately reimbursed, even where they are used primarily for postoperative pain control and not for the main anesthesia service.  This assertion was based on new language in CMS’s Correct Coding Initiative (CCI)—the document that addresses and defines bundling rules. 

Since this new language was vague, but nonetheless troubling, anesthesia compliance attorney David Vaughn recently wrote the CCI medical director, Dr. Niles Rosen, asking for clarification. Dr. Rosen’s response, which Mr. Vaughn was kind enough to share with me, can be summarized as follows:

• The new CCI language should not be assigned a “sinister” intent.

• Even though a pre- or intraoperatively placed nerve block will provide “some intraoperative analgesia,” one should not interpret the new CCI language to mean that the block cannot be separately reimbursed where the main anesthesia for the case was a general anesthetic.

• Unless and until CMS provides further clarification on this topic, anesthesia providers should continue to practice and bill as they have with regard to post-op pain services.

Accordingly, our clients will see no change in the submission of their post-op pain claims.  I want to thank attorney David Vaughn for eliciting and passing on this clarification.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

2012 Medicare Physician Pay Cut Update
By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

12/21/2011

This past Saturday (December 17th) the Senate voted 89-10 to extend the payroll tax cut by two months – which would have postposed the 26.2% Medicare payment cut to the “National Average Anesthesia conversion factor” until March 1, 2012. However, the measure has not yet passed the House – which means that the pay cut is still pending.  House leaders have stated that they intend to defeat the bill.  We anticipate that the situation in Washington will remain in limbo, as the 2012 elections and politics are fueling this showdown between the Senate and the House.  We will keep you updated on the outcome of this critical Bill as negotiations continue. In the meantime, we strongly recommend that you continue to call your congressional representatives and voice your concerns about a permanent solution to this pending pay cut and repeal of the SGR (Sustainable Growth Rate) formula.

MEDAC will continue to update you on all news related to the Medicare physician payment cuts in future alerts.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

CMS RELEASES INFORMATION ON HOLDING 2012 CLAIMS
By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

12/21/2011

This past Monday (December 19th) the Centers for Medicare & Medicaid Services (CMS) instructed all of the Medicare Carriers (Contractors) to hold all 2012 claims for the first 10 business days of January (i.e., January 2, 2012, through January 13, 2012). This claims hold will impact provider cash flow – but it should be minimal – because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt.

Those Medicare claims for services rendered on or before December 31, 2011, will not be affected by the 2012 claims hold and will be processed and paid under normal procedures and time frames.

According to CMS, they will notify you on or before January 11, 2012, with more information about the status of Congressional action to avert the Medicare pay cut, as well as next steps regarding the claims hold.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

2012 Anesthesia Pain Management & Critical Care Changes
By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

12/12/2011

Each New Year brings a number of changes for documentation, coding, compliance, billing and reimbursement.  This coming year (2012) is no different.  From the Medicare payment cut of 24.6% t to new CPT codes, to increased government scrutiny – the business side of medicine becomes more complex next year.

The best way to ensure that you do not become the subject of an audit or experience an unexpected loss of revenue is to be informed about these changes that impact  your practice.  Below you will find a summary of changes that will impact your practice in 2012.  It is my hope that you will find this information useful in complying with all of the new rules and regulations for 2012.  I wish you all Happy Holidays and a very prosperous, healthy and Happy New Year.

CMS Finalizes 2012 Medicare Physician Fee Schedule
By: Justin Vaughn, M.Div, CPC
Director of Compliance

11/17/2011

CMS published in November its “final rule” relative to the 2012 Medicare physician fee schedule (MPFS).  Some of the highlights of this rule are as follows:

E-Prescribing Exemption Deadline Approaching
By Justin Vaughn, M.Div, CPC
Director of Compliance

10/26/2011

This is a reminder for those of you who are deemed eligible for participation in CMS’s E-Prescribing (eRx) Incentive Program that you have until Nov 1 to file for an exemption from the penalty for unsuccessful participation (1% reduction in your Medicare allowable), to be imposed in 2012.  You do not have to file for an exemption if even one of the following criteria is/has been met:

SIJ Bundles Fluoro in 2012
By Justin Vaughn, M.Div, CPC
Director of Compliance

10/17/2011

Beginning in 2012, pain physicians will no longer be able to bill for fluoroscopy when submitting claims for sacroiliac joint (SIJ) injections. According to the 2012 edition of the CPT coding manual, fluoroscopy (or other imaging guidance) will now be deemed an inherent part of the SIJ procedure, and thus no longer separately payable.
This latest move to roll back reimbursement for fluoroscopy comes on the heels of similar bundling of the radiological service in the recent past.  You may recall that the AMA bundled fluoroscopy with facet joint injections in 2010, and did the same with transforaminal injections in 2011.

Deadline for Filing E-Prescribing Hardship Exemption Extended
by Justin Vaughn, M.Div, CPC
Director of Complaince

11/2/2011

CMS announced today that it will extend its deadline for program-eligible providers to request hardship exemptions relative to the 2012 E-Prescribing (eRx) penalty to Nov 8.

As you’ll recall, per program requirements, eligible providers who failed to successfully submit 10 eRx claims by Jun 30, 2011 are subject to the 1 percent payment reduction in 2012—UNLESS one of the following hardship exemptions applies:

Template Language Targeted:
Documentation Just Got Harder
By Justin Vaughn, M.Div, CPC
Director of Complaince

10/17/2011

According to one Medicare Part B contractor, doctors will have to be very careful to differentiate their procedure descriptions from patient to patient.  That is, the use of template language, i.e., the same wording for the same procedure, but for different patients, will be scrutinized and possibly used as a  basis to deny the claim. 

Palmetto GBA, the Medicare Part B contractor for WV, VA, NC & SC, has this month issued the following advisory to documenting providers:

Moderate Sedation Time:
New Clarification Raises Concern
By Justin Vaughn, M.Div, CPC
Director of Compliance

10/14/2011

The American Medical Association (AMA) has responded to an inquiry from healthcare attorney David Vaughn regarding the threshold that must be met—in minutes—for billing the moderate sedation codes (99143-99150).  In an official and binding response from its research division, CPT Knowledge Base, the AMA advised that:

The eRx Hardship Exemption:
Who Can Submit the Request?
By Justin Vaughn, M.Div, CPC

10/4/2011

As you know from our previous alerts, providers who fail this year to successfully participate in the E-prescribing (eRx) Incentive Program have certain options available to avoid the financial penalty scheduled for 2012.  Among these options are 2 previous, as well as 4 new, “hardship exemptions.”  However, to be considered for one of these 6 exemptions, one must request it by November 1. 

It had been thought that it would be possible for ancillary staff, such as billing agents or practice administrators, to undertake the filing of such a request on behalf of the provider.  However, an FAQ published recently by CMS has dashed such hopes.  The relevant portion of the FAQ reads as follows:

Q:  Can I submit a significant electronic prescribing (eRx) hardship exemption request on behalf of a provider in my office? 

A:  No, you may not. Billing managers, office managers, receptionists, and other office staff cannot submit an eRx hardship exemption request on behalf of their eligible professionals for the 2012 eRx payment adjustment.  The Tax Identification Number/National Provider Identifier (TIN/NPI) requesting the significant hardship exemption must be the one who enters the request by November 1, 2011.

Accordingly, if you intend to seek a hardship exemption, you will personally need to follow the steps outlined in the most recent version of the final rule for the eRx Incentive Program.  That rule, in pertinent part, states:

Specifically, to request a significant hardship exemption . . . an eligible professional . . .  [must] provide to us, via a Web-based tool . . . (or by mail, if it is not technically feasible . . .) the following:

• Identifying information such as the TIN, NPI, name, mailing address, and e-mail address of [the] affected eligible [professional].

• The significant hardship exemption category(ies) . . . that apply.

• A justification statement describing how compliance with the requirement for being a successful electronic prescriber for the 2012 eRx payment adjustment during the reporting period would result in a significant hardship to the eligible professional . . . . The justification statement should be specific to the category under which the eligible professional . . . is submitting its request and must explain how the exemption applies to the professional . . . . For example, if the eligible professional is requesting a significant hardship exemption due to Federal, State, or local law or regulation, he or she must cite the applicable law and how the law restricts the eligible professional's ability to electronically prescribe. Similarly, if the eligible professional is requesting a significant hardship due to lack of prescribing activity, the eligible professional must provide the number of prescriptions generated during the 2012 eRx payment adjustment reporting period.

• An attestation of the accuracy of the information provided.

Due to the lack of perfect clarity in several sections of the final rule that deal with how exemption requests must be submitted, I can only assert that CMS intends that individual providers use the web-based tool to submit their request.  (However, there may be an exception to this requirement if it is not technologically feasible for the provider to use the web-based tool.  In such a case, the implication is that the provider may submit the request by U.S. mail—which must be postmarked by November 1, 2011.  In no case can requests be submitted via email or fax.  Due to the gray language found on this point, I strongly urge you to submit your exemption request only through the web-based tool if at all possible.)  To access the web-based tool, a recent CMS FAQ has stated:

Submission will be completed using a new CMS provider website, called the Quality Reporting Communication Support Page. It will be available at http://www.qualitynet.org/pqrs, so please continue checking the website for updates and additional information. The Quality Reporting Communication Support Page is where the eligible professional will be instructed to enter the hardship exemption request and supporting rationale.

Providers interested in additional information on the eRx program should continue to monitor the CMS eRx website at https://www.cms.gov/ERxIncentive for more information, or contact your Medac compliance representative.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Government Targets “Office-Based” Claims
By Justin Vaughn, M.Div, CPC
Director of Compliance

9/29/2011

The Office of the Inspector General (OIG), working under the U.S. Department of Health and Human Services (DHHS), recently announced that 83% of sample claims were incorrectly coded and ultimately overpaid in 2009.  Remarkably, the claims’ deficiency was tied to an incorrect place of service (POS) code.  While the claims were listed with POS 11 (office), the services were actually performed in a facility, such as a surgery center (POS 24), resulting in inappropriate overpayments to physicians.

Due to such a high incidence of incorrect POS coding uncovered in its review, and a determination via extrapolation that this miscoding error is occurring on a vast scale, the OIG has recently recommended that CMS undertake the following actions:

• Immediately reopen and review claims associated with nearly a half-million services not yet sampled, and work with providers to recover any identified overpayments (which the OIG estimates to be in the neighborhood of $9.5 million).

• Strengthen educational processes to re-emphasize to physicians and their billing agents the importance of correctly coding the POS.

The lesson providers should take away from this article is to ensure you are consistently identifying the correct place of service (office, outpatient hospital, inpatient hospital, ASC, etc.) when submitting documentation of services to Medac.  You should also make sure that Medac has on record the correct place of service as it concerns your main practice locations.  For example, if you have informed us that your “clinic,” which may be located within an ASC or outpatient hospital, is an “office” setting (POS 11), you may want to confirm the accuracy of that information.  Is it really an office?  Are you leasing the space?  Are there sufficient walls of separation between the leased space and the rest of the facility?  Getting the place of service right is the first step to surviving the government’s newest effort at recouping a portion of your payments.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Avoiding the E-Prescribing Penalty Just Got Easier
By: Justin Vaughn, M.Div, CPC
Director of Compliance

9/1/2011

Well, sort of. CMS has published a final rule outlining a few additional escape routes for providers who are currently staring down the barrel of a 1% reduction in their Medicare reimbursement for 2012, as authorized by the E-Prescribing (eRx) Incentive Program.  As you know, eligible providers were to have submitted at least 10 prescriptions electronically by June 30th of this year in order to avoid the 1% penalty in CY 2012.  For those who were unable to meet this requirement, CMS had previously published a list of exemptions—any one of which would allow providers to avoid this penalty.  Those initial exemptions involve 2011 claims, and are reiterated below:

New ABN Form Now Available
Mandatory by November 1, 2011
By: Justin Vaughn, M.Div, CPC, Director of Compliance

8/15/2011

CMS has published a new Advanced Beneficiary Notice of Non-Coverage (ABN) meant to replace the current ABN-G (Form CMS-R-131G), dated 03/08, as well as ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20007).  The new ABN can be identified, in part, by the date designation “(03/11)” on the bottom left-hand corner of the form.  Either the current or the new form may be used through October 31 of this year.  However, beginning on November 1, the new form (03/11) will become the only ABN recognized by Medicare for most physician and laboratory services.

As you may know, Medicare requires that the provider submit to the beneficiary an ABN in situations where Medicare payment is expected to be denied.  The provider must go over the form with the patient, and ensure the form is completed and signed.  Many anesthesiologists rely on the surgeon to provide them with information pertinent to potential non-coverage of a particular procedure, along with the actual ABN form in such cases.  However, if you would like to learn more about the purpose and proper usage of these forms, you should review the instructions provided by CMS at http://www.cms.gov/BNI/02_ABN.asp#TopOfPage, where a copy of the new form may also be obtained.  Alternatively, you can contact the Medac compliance advisor for your group.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Major Financial Penalties Assessed Against HIPAA Violators
By: Justin Vaughn, M.Div, CPC, Director of Compliance

7/21/2011

The Office of Civil Rights (OCR), the enforcement agency for the U. S. Dept. of Health and Human Services concerning the HIPAA privacy rule, has announced the assessment of the following fine and financial settlements in response to corporate violations of specific HIPAA provisions:

CMS to Audit Drug Screening Services for Medical Necessity
By: Justin Vaughn, M.Div, CPC, Director of Compliance

5/26/2011

As you know, you may submit code G0434 (at 1 unit only) for Medicare patients when performing an “in-house” urine drug screening service that does not involve an on-site high complexity lab.  However, even though Medicare will certainly pay you for such screenings, that does not mean you will get to retain these reimbursements.

A handful of Medicare carriers have recently published guidance stating that they will not pay for urine drug screening when it is deemed to be a routine service.  Rather, they expect there to be medical necessity attached to these tests, and have developed documentation standards that providers must meet in this regard.  For example, National Government Services (NGS), the Medicare carrier for New York, among other states, has issued a Local Coverage Determination (LCD) outlining two prerequisites for withstanding a CMS audit for drug screen services.  Your documentation must indicate one of the following two situational conditions:

• You “suspect” a drug overdose as having occurred.  In such a case, you can perform urine drug screens during “active treatment for substance abuse or dependence.” Obviously, this scenario will not apply to most patients; OR

• You “suspect” that the patient is involved in “other illicit drug use.”

The NGS LCD advises providers that if their urine drug screening does not meet either of the above conditions, they will need to obtain a signed Advance Beneficiary Notice (ABN) from the patient, advising the patient that Medicare will not pay for the drug screen, and therefore the patient will have to pay for it him/herself.  In such a situation, the provider would need to inform Medac that a signed ABN is in place so that we will know to submit G0434 with the appropriate modifier (GA), indicating the presence of a signed ABN.

While only a few carriers have published such specific guidance, it may be wise for your practice—regardless of the state—to abide by the above documentation criteria.  You do not want to find yourself years later owing Medicare money        should they ultimately determine that such tests were routine rather than necessary. 

I want to acknowledge healthcare attorney David Vaughn as a source for this article.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

CMS to Automatically Deny Claims with GZ Modifier
by: Justin Vaughn, M.Div, CPC
Director of Compliance

5/16/2011

CMS has issued instructions to its carriers around the country to begin denying claims submitted with the GZ modifier, effective July 1, 2011.  When this modifier is appended to a Medicare claim form it indicates two things:

• The provider has reason to believe the service is not medically necessary, AND

• The provider did NOT secure from the patient a signed Advanced Beneficiary Notice (ABN).

An anesthesia provider would typically submit such a claim where (a) he or she provided anesthesia for a GI case or a case involving an anesthesia service covering a chronic pain injection, AND (b) there is no qualifying diagnosis based on that particular Medicare carrier’s MAC LCD (or no physical status of P3 or higher for those carriers without a MAC LCD). 

CMS was unaware until recently that there was an issue with these claims.  As it happens, use of the GZ modifier has been under the microscope lately due to its being on the OIG’s work plan for 2011.  CMS’s new policy of automatically denying a “GZ case” is simply an attempt to correct the error on the part of its carriers, which had heretofore often paid such claims. 
According to healthcare attorney David Vaughn:

“The net effect of this new rule on anesthesia practices is two-fold: (1) you need to redouble your efforts to secure patient co-morbid conditions in the pre-anesthesia exam that support either a qualifying dx under your Medicare MAC LCD (regardless of whether the case is MAC or a GA), or if you are in a state with no MAC LCD, to document patient co-morbid conditions which warrant P3 and higher; and (2) if you cannot document a patient condition warranting a qualifying dx or P3 and above, that you try to secure an ABN from the patient.  If you do neither, then, GZ must be billed to Medicare, and the claim will be denied, and monies will be reduced.”

Based on the above, we want to encourage our clients to be particularly mindful of the special documentation requirements inherent in these types of cases.  Should you have any questions about this issue, please contact your Medac compliance representative.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

CMS E-Prescribing Penalty:  Less Than 2 Months to Avoid
By: Justin Vaughn, M.Div, CPC
Director of Compliance

5/7/2011

With less than 60 days available to avoid the government’s e-prescribing penalty, pain practices should seriously consider whether or not they will participate in the “incentive” program.

In order to avoid the penalty—to be assessed in 2012, and which amounts to a 1% reduction in one’s total annual Medicare “allowable”—an eligible provider (EP) must electronically and successfully prescribe 10 times, on behalf of Medicare patients, before June 30, 2011, indicating such via claims-based reporting. 

The only way EPs can avoid the e-prescribing penalty is if they fall under one or more of the following exceptions:

Physician Convicted of Medicaid Fraud in Drug Vial Scheme

By: Justin Vaughn, M.Div, CPC
Director of Compliance
4/15/2011

The Telegraph newspaper in Macon, Ga. has reported the guilty plea of Dr. Kathy Mansfield relating to charges of Medicaid fraud.  Representatives of Georgia’s attorney general stated that from 2003 to 2007 Mansfield was routinely administering a single-dose drug to a patient, and then instructing her staff to administer the remaining portion in the vial to a subsequent patient.  She then billed Medicaid as if she had used a second vial. 

This practice runs counter to the FDA’s instructions regarding single-use vials, which mandate that providers are to discard any remaining portion in a vial after removing the patient’s dose.

Georgia officials also revealed that Dr. Mansfield was billing Medicaid for large vials, though she was actually using smaller, cheaper vials.

Mansfield was sentenced to 10 years of probation, restitution of $537,428, fines of $10,000, and investigative costs of $5,000.  Accordingly, pain management physicians should be exceedingly careful to abide by the drug wastage rules.  After all, the government is watching!

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Is a Post-Op Pain Block Placement Allowed During Medical Direction?

By: Justin Vaugh, M.Div, CPC
Director of Compliance
4/14/2011

A recent article published by the ASA has created a stir among some anesthesiologists (MDAs) who have been working under the belief that they can place a postoperative pain epidural or nerve block while medically directing.  In the April  2011 edition of the ASA Newsletter (Volume 75, Volume 4), Dr. Jean-Louis Horn writes:

CMS MEDICAL RECORDS SIGNATURE REQUIREMENTS
By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

4/6/2011

One of the more frequent questions I have been asked over the last few months is:  What are CMS’ requirements – acceptable and unacceptable practices – for medical records signatures?  I researched this question and found my answer in the following Medicare documents:

1. The Medicare Program Integrity Manual, Pub. 100-08, Chapter 3, Section 3.4.1.1 B: http://www.cms.hhs.gov/manuals/downloads/pim83c03.pdf
2. MLN Matters Article #: MM5971: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5971.pdfMLN Matters Article #: MM5971: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5971.pdf

Additionally, for your reference, I was able to locate a very detailed account of acceptable and unacceptable practices on the Palmetto GBA Medicare website – posted below. Palmetto GBA is the Medicare contractor for California, Nevada, Ohio, West Virginia, Hawaii and South Carolina. I also thought you might find this information helpful in answering your questions:

Deducting Time for Lines & Blocks
A Key Clarification of the Rule
By: Justin Vaugn, MDiv, CPC
Director of Compliance

March 21, 2011

As you know, the American Medical Association (AMA) in 2007 rendered an opinion that was later ratified by the American Society of Anesthesiologists (ASA) regarding the billing of anesthesia time in conjunction with an invasive line or post-op pain block placement.  The rule made it clear that the person providing anesthesia service could not bill for time placing such a line or block if the placement occurred prior to induction of the primary anesthetic—even if in the OR.  However, this rule raised questions among many in the anesthesia community as to how one would bill such time when two providers are involved.  These questions have now been answered.

In a March 17, 2011 letter to healthcare attorney David Vaughn, the AMA (in consultation with the ASA) advised that there are two circumstances in which time spent placing invasive lines or post-op pain blocks while in the OR, but prior to induction of the primary anesthetic, would NOT need to be deducted from total anesthesia time.  Those circumstances are as follows:

• Where a medically directing anesthesiologist places the line or post-op pain block, the time does not need to be deducted since the CRNA is providing ongoing anesthesia service during such placement.

• Where an anesthesiologist is providing ongoing anesthesia care, and one of his/her partners (a separate anesthesiologist) comes into the OR only to place the line or post-op pain block, no anesthesia time needs to be deducted since the patient has uninterrupted anesthesia care from the anesthesiologist who is handling the case.  (The AMA noted that it expected such a case involving 2 anesthesiologists to be rare.)

Though the AMA’s official notification to attorney David Vaughn does not overturn any previously published provision of the 2007 rule concerning time for lines and blocks, and though it remains subject to any payor policy to the contrary, this clarification does provide a very welcome answer to the questions many of you have posed in the last couple of years regarding the above contingencies.  I want to thank David for seeking this clarification from the AMA and for forwarding their positive answer.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

FTC Red Flag Regulations:
U.S. Circuit Court Issues Ruling
By: Justin Vaughn, MDiv, CPC
Director of Compliance

March 18, 2011

The United States Court of Appeals, District of Columbia Circuit, has invalidated the Federal Trade Commission’s (FTC’s) definition of a creditor, as contained in the so-called Red Flags Rule (hereinafter, “Rule”).  Congress had already clarified the meaning of “creditor” in December, and the Court’s opinion acted to underscore that change. 

The FTC’s position had been that any entity that offers a deferred payment plan –including physician groups—is a creditor, and therefore would be subject to another layer of government regulation.  Specifically, the Rule requires creditors to draft and adopt an identity theft prevention program that would include a set of specified policies and procedures. 

While the D.C. Circuit Court’s ruling did not definitively state that physician groups could never fall within the parameters of the Red Flags Rule, the FTC will have to go through a formal rulemaking process if it elects to continue in its attempts to impose the Rule upon physicians.  Therefore, we have not heard the last on this issue.  For now, medical groups do not fall under the Rule, but there may be further battles to fight on this front.  As always, we will keep you informed of future developments.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

E Prescribing Incentive Program
Can a Penalty Be Avoided?
By: Justin Vaughn, MDiv, CPC
Director of Compliance

March 11, 2011

CMS recently promulgated a Medicare Learning Network (MLN) article concerning the penalties associated with a prescribing physician’s failure to successfully participate in the electronic prescribing (eRx) program.  Though we have sent previous alerts on this topic in the last few months, we want to take this opportunity to remind our pain management physicians that the government is serious about getting you on board with this program.  The recent MLN article reinforces the following facts concerning what CMS euphemistically calls the “payment adjustment,” i.e., reimbursement penalty:

• The 2012 payment adjustment for not being a successful electronic prescriber in 2011 will result in an eligible professional (EP) receiving 99% of his/her Medicare Part B PFS amount that would otherwise apply to such services.

• In 2013, an EP will receive 98.5% of his/her Medicare Part B PFS amount for covered services for not being a successful electronic prescriber in 2011 or as defined in future rulemaking.

• In 2014, the payment adjustment for an EP’s failure to meet the eRx program requirements will mean receiving only 98% of his/her Medicare Part B PFS reimbursement.

CMS Clarifies Drug Screen Codes
By: Justin Vaughn, M.Div, CPC
Director of Compliance

2/25/2011

Pain physicians who perform urine toxicology tests are often bewildered by the seemingly endless changes in Medicare and CPT coding protocols, as well as the continuing lack of clarity in official guidance concerning these codes.  In a recently released MLN Matters article (# SE1105), CMS has attempted to shed a little more light on the appropriate circumstances under which two of the key drug screen codes would be submitted to Medicare.  The pertinent points arising from the article are as follows:

Code G0434

This code “will be used to report very simple testing methods, such as dipsticks, cups, cassettes, and cards, that are interpreted visually, with the assistance of a scanner, or are read utilizing a moderately complex reader device outside the instrumented laboratory setting (i.e., non-instrumented devices). This code is also used to report any other type of drug screen testing using test(s) that are classified as Clinical Laboratory Improvement Amendments (CLIA) moderate complexity test(s), keeping the following points in mind:

• “G0434 includes qualitative drug screen tests that are waived under CLIA as well as dipsticks, cups cards, cassettes, etc., that are not CLIA waived.

• “Laboratories with a CLIA certificate of waiver may perform only those tests cleared by the Food and Drug Administration (FDA) as waived tests.

• “Laboratories with a CLIA certificate of waiver shall bill using the QW modifier.

• “Laboratories with a CLIA certificate of compliance or accreditation may perform non-waived tests. Laboratories with a CLIA certificate of compliance or accreditation do not append the QW modifier to claim lines.

• “Only one unit of service for code G0434 can be billed per patient encounter regardless of the number of drug classes tested and irrespective of the use or presence of the QW modifier on claim lines.”

Code G0431

This code “will be used to report more complex testing methods, such as multi-channel chemistry analyzers, where a more complex instrumented device is required to perform some or all of the screening tests for the patient. Note that the descriptor has been revised for CY 2011. This code may only be reported if the drug screen test(s) is classified as CLIA high complexity test(s) with the following restrictions:

• “G0431 may only be reported when tests are performed using instrumented systems (i.e., durable systems capable of withstanding repeated use).

• “CLIA waived tests and comparable non-waived tests may not be reported under test code G0431; they must be reported under test code G0434.

• “CLIA moderate complexity tests should be reported under test code G0434 with one (1) Unit of Service (UOS).

• “G0431 may only be reported once per patient encounter.

• “Laboratories billing G0431 must not append the QW modifier to claim lines.”

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Entity Hit with $4.3 Million Fine for HIPAA Violations
By: Justin Vaughn, M.Div, CPC
Director of Compliance

2/24/2011

For the first time ever, a civil monetary penalty has been assessed against a “covered entity” for violations of the HIPAA privacy rule.  The Office for Civil Rights (OCR), the enforcement agency for the Department of Health and Human Services as it concerns the HIPAA privacy standards, levied a fine of $4.3 million against Cignet Health of Prince George’s County, Md.  The fine was based on the entity’s failure to provide its patients access to their own medical records, as required by HIPAA regulations.

According to the OCR’s press release, 41 patients requested copies of their medical records, but were denied.  This resulted in the filing of patient complaints against Cignet with the OCR.  In its investigation, the government determined that Cignet not only rejected patient requests during a 13-month period, but refused to sufficiently cooperate with the ensuing OCR investigation.  As a result, the government utilized new powers granted under the Health Information Technology for Economic and Clinical Health (HITECH) Act to impose a $1.3 million fine for failure to provide medical records, as well as a $3 million fine for delaying a federal investigation. 

This latest federal action is yet another reminder that we are in a new era of enforcement.  Physician practices will have no choice but to ratchet up their compliance efforts in response.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Historic Medicare Fraud Bust
Over 100 Charged in Multi-State Sweep
By: Justin Vaughn, M.Div, CPC
Director of Compliance

February 18, 2011

According to an Associated Press (AP) story released yesterday, more than 700 federal officials in several states moved in concert on Thursday to indict 111 physicians and other providers on charges of Medicare fraud—making it the largest healthcare-related round-up in history.  The medical providers were said to have bilked the government out of $250 million in false claims.  Significantly, this bust comes just 2 days after another federal action arrested 21 providers on charges of $200 million in fraudulent Medicare claims.

The AP story asserted that such busts are a key component in the government’s strategy to pay for President Obama’s healthcare overhaul.  Toward that end, Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder have worked in tandem to target what they believe to be “fraud hot spots.” These include Miami, Los Angeles, Dallas, Houston, Detroit, Chicago, Brooklyn, Tampa, and Baton Rouge—with Dallas and Chicago said to receive even greater scrutiny in the months ahead.

Though the AP story did not specify whether or not anesthesiology providers were part of the government sweep, our clients and partners should certainly be sobered by these latest developments.  It’s clear that we find ourselves in a new era of enforcement; and while we all want to see true criminal activity prevented and prosecuted, there is some concern that a potentially over-zealous, overreaching government may ensnare the good with the bad.  The FBI agent in charge of Thursday’s action has called for criminal background checks and fingerprinting of all healthcare providers, and Secretary Sebelius has promised “more decisive action” by aggressively screening providers and “stopping payment to suspicious ones, under greater authority granted by the Affordable Care Act.”

While greater government action to avert fraud is no doubt needed, there is the potential for government abuse in this process.  Accordingly, I strongly recommend that your group implement policies to prevent the inspector’s magnifying glass from being turned in your direction.  Make sure you have a compliance plan that is current and that contains strong measures addressing compliance risk areas in your practice.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

CMS Not Prepared for Third Party EHR Registration
By: Christine  Locay, JD, RHIA, CPC
Vice President, Compliance Counsel

February 16, 2011

The Centers for Medicare and Medicaid Services (CMS) recently issued the following update regarding third party registration:

At this time there is no method available for a third party to register multiple eligible professionals for the Medicare and Medicaid EHR Incentive Programs. Beginning in May 2011, CMS plans to implement functionality that will allow an eligible professional to designate a third party to register and attest on his or her behalf. We will release detailed information about that process when it is available. States will not necessarily offer the same functionality. Eligible professionals should contact their state to see if there is additional information they will need to provide.

Please be aware that eligible professionals currently are not permitted to allow a practice manager or any other person to register in their place. Sharing your National Plan and Provider Enumeration System (NPPES) user ID and password with third parties can place your information at risk. Until CMS implements new functionality in May 2011, each EP should register himself or herself separately for the Medicare and Medicaid HER Incentive Programs.

Due to this update, Medac will not register groups at this time; however, we will continue to gather information for registration from those providers who plan to begin using an electronic health record in January 2012.  Medac will begin registering groups as soon as CMS permits.

The information presented herein reflects general information that is current as of the date it was first published. In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Retraction Language for UH Policy
By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

February 14, 2011

On February 11, 2011, an alert was sent announcing that Medac would no longer bill anesthesia for pain procedures to United Healthcare due to a recent change in United Healthcare’s anesthesia reimbursement policy.  After a careful review of United Healthcare’s policy terms, it has been determined that anesthesia services for pain procedures should be separately paid by United Healthcare.

Based on the policy language and definitions, the only instance where United Healthcare should deny anesthesia for pain procedures is when the anesthesiologist and pain physician are the same physician.  Where the anesthesiologist and pain physician have different tax identification numbers, United Healthcare should not deny the claims; however, United Healthcare may incorrectly deny claims where the anesthesiologist and pain physician are two different providers but share the same tax identification number.  In this situation, we will appeal all denials using United Healthcare’s own policy language to argue for reimbursement.

We will keep you updated on any issues or changes with the United Healthcare policy.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

UHC Bundles Anesthesia for Chronic Pain Injections Clarification: Chronic Pain CPT Code Procedure Descriptions
By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

February 11, 2011

I have received a number of requests from Medac Clients asking for further clarification as well as the descriptions of the procedure codes listed in my alert sent out yesterday – “United Healthcare Bundles Anesthesia for Pain Injections”. First and foremost, let me clarify that the intent of this alert was to inform you that you may not submit to UHC an anesthesia claim where the main surgical procedure is nothing more than a pain injection performed by a pain management physician. You may still bill UHC for post-op pain procedures, as well as the rounding on such procedures.  

The Chronic Pain CPT procedure descriptions listed in yesterday’s alert are as follows:

January 2011 Labor Epidural Interpretive Guideline Revisions: Is Physician Supervision Required or NOT?
By: Bellinger P. Moody, RHIA, CPC, CPC-I, CCP
Executive Vice President of Compliance

February 21, 2011

As stated in a previous Medac Billing & Compliance Alert (sent February 2, 2011) from Medac Corporate Compliance Counsel, Christine Locay, CMS has removed language specifically exempting labor epidurals from the physician supervision requirements. Hospitals are now required to “establish policies and procedures, based on nationally recognized guidelines that address whether specific clinical situations involved anesthesia versus analgesia,” as well as, “the minimum qualifications and supervision requirements for each category of practitioner who is permitted to provide analgesia services.”

So what does this mean? Is physician supervision now required as it previously was before the change in May 2010? The answer to this question is up to your hospital! The revised Interpretive Guidelines allow each hospital to determine whether Labor & Delivery is analgesia versus anesthesia.

Under the most recent revision of the Interpretive Guidelines (January 2011), as so eloquently stated by prominent Healthcare Compliance Attorney David Vaughn in his recent Reading Room Article entitled “Interpretive Guidelines Revised Yet Again”,  dated 2/8/11:

“ It is critical to understand that if a particular sedation is characterized as “anesthesia,” and if a CRNA is involved in providing that anesthesia, then an anesthesiologist must be physically in the area to supervise that CRNA, and cannot be involved at the same time in supervising other CRNA’s who are not in the L&D suite. On the other hand, if the particular sedation is characterized as “analgesia,” then the CRNA does not have to be supervised, and the anesthesiologist does not have to be in the immediate area. Why? Because the federal regulation requiring MD supervision of CRNA’s, 42 CFR 482.52(a)(4), only applies to the administration of “anesthesia,” not analgesia. The January 2011 IG revisions acknowledge this, wherein CMS states, “Consequently, each hospital that provides anesthesia services must establish policies and procedures . . . that address whether specific clinical situations involve anesthesia versus analgesia.” (Article from Vaughn & Associates, LLC, Reading Room, 2/8/2011, “Interpretive Guidelines Revised Yet Again”)

These newly revised (January 2011) Interpretive Guidelines now allow each hospital to determine whether Labor & Delivery services are analgesia versus anestheisia. So, if you work with CRNAs and don’t want to have to hire additional anesthesiologists – that will be solely confined to the Labor & Delivery Suite – you should begin lobbying immediately with your hospital administration for a hospital policy that defines labor epidurals as analgesia,  and you will not have to satisfy the supervision requirement.

However, if your hospital defines labor epidurals as “anesthesia,” then CRNA supervision is required. Additionally, if your hospital defines your labor epidurals as “anesthesia”, CRNA supervision will be required regardless of whether you perform services in a non-medically directed practice (QZ), and regardless of the fact that the labor epidural cases aren’t Medicare. Remember, these are not billing rules. These are hospital conditions of participation (CoP’s) rules, and the hospital must apply the CRNA supervision rules to all cases –if it wants to continue participating with Medicare.

If you are in an opt-out state, you do not have to be concerned about this because your state has opted out of any CRNA Supervision requirements. However, if you are NOT in an opt-out state, you should immediately begin lobbying your hospital administration to define labor epidurals as “ANALGESIA”– that is, if you don’t want to incur the hassles and additional expenses that come along with the supervision requirement as a result of defining the Labor Epidural services as “ANESTHESIA”.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

United Health Care Bundles Anesthesia for Pain Injections
By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

February 10, 2011

Effective Immediately, United Health Care (UHC) uses the CMS National Correct Coding Initiative (NCCI) edits when considering procedural or pain management services that are an integral part of anesthesia management services (CPT codes 00100 – 01999 excluding 01996 and 01953) and anesthesia management services that are an integral part of the procedural or pain management services.  The CMS NCCI edits are managed under the United Healthcare “CCI Editing Policy.”

The policy addresses the following procedural or pain management services that are not separately payable to the same physician or other healthcare professional on the same date of service with anesthesia management services:

EHR Incentive Program Bonus for Anesthesiologists:  Q & A

By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

February 4, 2011

Under the initial provisions of the new Electronic Health Records (EHR) Incentive Program brought about by the American Recovery & Reinvestment Act (ARRA), “eligible professionals (EPs)” – physicians only – are eligible to receive incentive payments for the “meaningful use” of EHRs.  The total incentive payments are $44,000 per physician – if they meet meaningful use requirements beginning in 2011 or 2012.  Also stated in the Act are provisions for penalties beginning in 2015 – if the physician has not yet begun meaningfully using and EHR.

There are two categories of professional under the EHR Program:  (1) “eligible professionals” (EPs); and (2) hospital-based eligible professionals (HBEPs).   According to a December 22, 2010 posting on the ASA website: 

Coding and Billing Coronary Sinus Catheters
By: Christine M. Locay, JD, RHIA, CPC
Vice President, Corporate Compliance Counsel

February 4, 2011

Recently, I have received several questions about the correct code for placement of a coronary sinus catheter.  The CPT Assistant addressed this issue in the following April 2009 article (Volume 19, Issue 4, pages 8-10):

Question: What is the correct coding for placement of a coronary sinus catheter? The documentation is as follows: 11 Frx10cm introducer sheath inserted into right internal jugular vein using sterile, modified, Seldinger technique after 1 attempt. Central venous pressure verified. Side-port flushes and aspirates easily. Sheath sutured in place. Coronary sinus catheter placed via sheath and positioned using TEE guidance. Ventricularized waveform obtained at 36 cm using 2 cc saline in balloon. Sterile dressing applied. No hematoma noted.

Revision to Interpretive Guidelines for Anesthesia
By: Christine M. Locay, JD, RHIA, CPC
Vice President, Corporate Compliance Counsel

Februrary 2, 2011

In late 2009, the Centers for Medicare & Medicaid Services (CMS) revised its Medicare hospital conditions of participation (COPs) interpretative guidelines for anesthesia services.  The guidelines specifically exempted labor epidural analgesia from the physician supervision requirement; thus, CRNAs, even in states that had not opted-out from the Medicare supervision requirement, could administer analgesia via epidurals/spinals without physician supervision.

Shortly after issuance of the 2009 guidelines, the ASA began voicing its concerns to CMS.  The ASA argued for removal of the labor exemption citing a variety of reasons including “compromise of safety net for mother and baby” and “non-reliable distinction between the effect of analgesic doses of epidural drugs and anesthetic doses on the sympathetic nervous system and its cardiovascular effects.”

EHR Registration & Attestation:  Proxy Allowed or Not Allowed?
By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

February 1, 2011

There has been quite a bit of confusion over whether CMS will allow someone besides the provider - a proxy - (e.g. billing office staff, practice manager, etc.) to register and attest for the EHR Incentive bonus payment.

Initially, CMS stated that only providers themselves could register & attest for the EHR Incentive bonus payment. However, according to Medicare Part B News, Vol. 25, Issue 25, January 31, 2011:  “. . . according to a CMS email [written by Jennifer Kahn, technical director for health information technology (HIT) to a practice manager] obtained by Part B News . . . ,” “Proxy registration is allowed . . . proxy attestation is not allowed”.

Corporate Officer Liability: Federal Ruling Causes Concern
By: Justin Vaughn, CPC, M.Div
Director of Compliance

January 19, 2011

If you’ve ever wondered whether your position as a group president or practice administrator or compliance officer could subject you to a greater risk of negative consequences in the event of a federal action for fraud, you can stop wondering.  The answer is a resounding “yes.”

According to a recent federal court ruling in Washington, D.C., Friedman, et al. v. Sebelius, et al., No. 09-2028 (ESH) (D.D.C. Dec. 13, 2010), corporate officers, who did not directly perform the illegal actions, were nevertheless deemed “responsible corporate officers,” and were held to have been in a position to stop the wrongful conduct, but did not.  As a result, the court ruled that these officers would be excluded from working in the healthcare industry for 12 years.

AMA RETRACTS BUNDLING OF FLUORO WITH TRANSLAMINAR EPIDURALS
By: Bellinger P. Moody, RHIA, CCP, CPC, CPC-I, Executive Vice President of Compliance
1/12/2011

In the November edition of the AMA CPT Assistant, the AMA posted an opinion statement that it considered fluoroscopy bundled with Translaminar Epidural procedures (CPT codes 62310 – 62319), which would have meant that you could no longer bill fluoroscopy separately in addition to these procedures.

Thanks to Dr. Norm Cohen and the ASA’s diligent efforts with AMA officials, the AMA promptly recognized the mistake and changed course – retracting its previous opinion statement.  Therefore, you may continue to bill fluoroscopy separately, in addition to Translaminar Epidurals and be reimbursed for both services.

However, keep in mind that fluoroscopy is still bundled with the Transforaminal Epidural services in accordance with the revised 2011 CPT code descriptors.

The information presented herein reflects general information that is current as of the date it was first published. In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

CMS Releases Revised Fee Schedule RVU Files & Conversion Factors
By: Bellinger P. Moody, RHIA, CPC, CPC-I, CCP, Executive Vice President of Compliance
1/6/2011

On December 8, 2011, Congress passed the Medicare and Medicaid Extenders Act of 2010, which blocked the Sustainable Growth Rate (SGR) cut and froze Medicare payments at 2010 levels throughout 2011 – with the exception of changes resulting from the PPACA (Patient Protection and Affordable Care Act) and the MEI (Medicare Economic Index).  According to a recent MGMA Washington Connexion newsletter issued on Wednesday, January 5, 2011, CMS has released updated Relative Value Unit (RVU) files, anesthesia conversion factors, non-anesthesia (general) conversion factor and the updated Medicare physician fee schedule on its website: http://www.cms.gov/PhysicianFeeSched/PFSRVF/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=2&sortOrder=descending&itemID=CMS1242727&intNumPerPage=10

In this update, CMS lists the 2011 anesthesia conversion factors (attached) and the non-anesthesia (general)   conversion factor of $33.9764. This is a decrease of approximately $2.90 from last year’s general conversion factor of $36.88. According to the MGMA Washington Connexion alert, the anesthesia conversion factor and the general conversion factor were modified as a result of changes to the Medicare Economic Index (MEI) as outlined in the 2011 final Medicare physician fee schedule database and as result of adjustments required by the Affordable Care Act: http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

These modifications resulted in a decreased general conversion factor, increased practice expense RVU, increased malpractice RVUs, and lower work values for chronic pain services and critical care services that will result in decreases to fees for many of these services.  The negative impact of these decreases for pain practices and critical care services is about 8%.  

Additionally, the anesthesia conversion factors for all localities (except Miami, Florida – which will remain the same and Queens, NY locality – which actually increased by 12 cents) have decreased slightly from 2010 to 2011. The average decrease in anesthesia conversion factors for those localities with decreases is approximately $0.54.

What does all of this mean for your practice?

Although, the big 25% Medicare fee schedule reduction was averted, calendar year 2011 will bring lower Medicare payments (although very minor) for anesthesia services as well as chronic pain and critical care services.  Due to the PPACA (Patient Protection and Affordable Care Act) and the Medical Economic Index, you will experience a minor decrease in the anesthesia conversion factor that will result in small reductions in reimbursement, but nowhere near the magnitude of what was expected earlier last year.  We will keep you informed of any additional changes to the fee schedule that may impact your revenues.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

2011 Anesthesia and Pain Changes
By: Bellinger Moody, RHIA, CPC, CCP, CPC-I, Executive Vice President of Compliance

12/23/2010

Below is a summary of changes that will impact anesthesia and pain management in calendar year 2011:

Toxicology Testing: New Codes for 2011
By: Justin Vaughn, CPC, M.Div
Director of Compliance
12/20/2012

For those of you who have added, or are planning to add, a drug screening component to your pain practice, there are new rules for 2011 you will want to note.  The AMA and CMS have implemented important changes in the urine toxicology code sets that are meant, in part, to clear up uncertainties in the 2010 code descriptors and in appropriate billing protocols. 

A summation of these changes is provided as follows:

•    CMS has deleted code G0430, “Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure,” from the fee schedule.

•    CMS has revised the descriptor for G0431 to now read, “Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter.”  Because this is a “per patient encounter” code, you may only bill one unit for this screening procedure regardless of the number of dipsticks employed during the session.  However, CMS has set the reimbursement for this code at five times the rate for the deleted code, G0430.  This is due to CMS research revealing that “a multiplier of five (5) accurately represents the average number of confirmatory tests that might be required from one specimen.”  Finally, unless you have a “complex lab” (as implied by the “high complexity” requirement in the code descriptor), you should not submit this code to Medicare. 

•    CMS has created a new code, G0434, “Drug screen, other than chromatographic; any number of drug classes by CLIA waived test or moderate complexity test, per patient encounter.”  This code is essentially meant to replace deleted code G0430, and will be paid at a similar rate.  Again, due to the “per patient encounter” part of the descriptor, you may not bill multiple units when submitting G0434 on the claim form.   

•    The AMA has created a new code, 80104, “Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure.” 

•    Medicare will not recognize 80100 or 80104.  Instead, providers would use G0431 or G0434.

We anticipate that further clarification in the use of these codes will be released by the AMA, CPT and/or CMS in the weeks ahead.  We will continue to keep you updated as more information become available.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Final Rule for PQRS 2011: What Pain Physicians Can Expect
By: Justin Vaughn, CPC, M.Div
Director of Compliance

12/16/2010

As with all things “healthcare” these days, changes are in store for the Physician Quality Reporting System, or PQRS.  For example, physicians can no longer expect a 2% bonus for successfully reporting their applicable “quality measures.”  The final rule, as found in 42 CFR 414.90, stipulates that successful reporting during the 2011 reporting period will instead yield a 1% bonus—that is, an amount equal to 1% of a physician’s total allowed charges relative to all his/her Medicare claims for that period. 

It gets worse.  Beginning with the 2012 reporting period, the bonus will only be 0.5% of a doctor’s Medicare allowable charges; and starting in 2015, it appears there will be no bonus at all.  Instead, a 1.5% penalty will be assessed for failure to successfully report!

However, it’s not all doom and gloom.  One of the positive changes for the 2011 reporting period is that the 80% reporting threshold doctors have had to meet over the years has been lowered to 50% in the final rule.  In other words, a participating physician need only successfully report on 50% of the cases where his/her PQRS measures would apply.  This obviously increases physicians’ chances for earning the bonus—though that bonus will be half the amount made available for 2010 reporting.

Other elements of interest in the 2011 version of PQRS include:

•    The reporting periods will be the same as in 2010, i.e., Jan-Dec or Jul-Dec.
•    The reporting mechanisms will be the same as in 2010, i.e., via claims, registry or EHR.
•    Claims must be in by Feb 28, 2012.
•    13 of the “measures groups” will be retained from 2010, including the “back pain” measures group.

If you wish to participate in the 2011 PQRS reporting period, you may want to consider reporting on the following measures:

Back Pain Measures Group
Measure 148 – Back Pain: Initial Visit
Measure 149 – Back Pain: Physical Exam
Measure 150 – Back Pain: Advice for Normal Activities
Measure 151 – Back Pain: Advice Against Bed Rest

NOTE:  If you choose to report on any of the four measures found in the Back Pain Measures Group, you must report on all four measures in that group for each applicable patient.

Cluster 32 - Falls
Measure 154 – Falls: Risk Assessment
Measure 155 – Falls: Plan of Care

NOTE:  If either one of the above measures is reported, the provider is required to also report the other, as providers must report every measure within the verification cluster that contains any measure reported.  Measure 154 and 155 are part of Cluster 32, “Falls.”

More information regarding PQRS participation can be found by reviewing the links and downloads at: http://www.cms.gov/PQRI/15_MeasuresCodes.asp#TopOfPage. 

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

E-Prescribing Incentive Program: Either Play . . . or Pay
By: Justin Vaughn, CPC, M.Div
Director of Compliance
12/16/2010

In my last alert concerning the e-prescribing incentive program, I stated that among the stipulations found in the proposed rule for 2011 was a possible penalty for those prescribing providers who do not successfully participate in the program.  Based on a review of the recently released final rule, it is clear that a financial penalty will indeed be assessed in 2012 and 2013 against providers who are not “successful” prescribers in 2011.

The Centers for Medicare & Medicaid Services (CMS) is requiring providers with “prescribing authority” to report via the normal claims process at least 10 eligible e-prescribing encounters from Jan 1 through June 30, 2011.  Failure to do so will mean a 1% reduction in a provider’s overall Medicare reimbursement in 2012.  To avoid an even higher penalty in 2013 (1.5% reduction in Medicare reimbursement), the provider must successfully report 25 e-prescribing encounters from January 1 to December 31, 2011.  Therefore, you will have 6 months to obtain and successfully use (for at least 10 patient encounters) an e-prescribing system to avoid the 2012 penalty; and you will have a year to successfully report e-prescriptions (for 25 patient encounters) to avoid the 2013 penalty.

Though healthcare-related societies have issued strong opposition to the penalty mandates found in the final rule, CMS seems to be set on this carrot-and-stick approach.  If you successfully report in 2011, a 1% bonus will be added to your total Medicare reimbursement; if you do not, your reimbursement will be reduced.  With this in mind, providers who issue prescriptions as part of their patient care should move with urgency to determine if participation in the e-prescribing program is right for them.  Those wishing to learn more about the e-prescribing incentive (and penalty) program, should download the “Electronic Prescribing Measure,” which can be accessed by visiting: http://www.cms.gov/ERxIncentive/06_E-Prescribing_Measure.asp#TopOfPage.

While there are limited circumstances that may exempt certain providers from the penalties discussed above, it is my belief that those “safe harbors” will not apply to most of our clients.  We will continue to keep you updated regarding any changes CMS may elect to seek in the current structure of this program.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Congress One Step Closer to Physician Pay Cut Solution
By: Justin Vaughn, CPC, M.Div
Director of Compliance

**UPDATE as of 12/9/2010**The U.S. House of Representatives has followed the Senate in passing H.R. 4944 (as discussed below), and the president is expected to sign the measure into law.

Late yesterday, the United States Senate passed  a bill that would postpone a 24.9% cut in Medicare reimbursement to physicians for at least one year.  Known as the Medicare and Medicaid Extenders Act of 2010 (H.R. 4944), the bill would extend the current Medicare payment rates through Dec. 31, 2011.  The legislation will now move to the House of Representatives for its consideration.  This is, therefore, not yet a “done deal;” however, the House is expected to take up H.R. 4944 quickly.   

Accordingly, we encourage our clients to immediately contact their elected representatives regarding full passage of this legislation.  The stakes could not be higher, and your active participation may be critical in pushing this bill across the goal line.  Please visit the ASA’s website for ways to contact Congress in this regard.  Thank you!

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Congress Postpones Massive Medicare Pay Cut
By: Justin Vaughn, CPC, M.Div
Director of Compliance

According to the Associated Press (AP), the US House of Representatives has, today, followed the lead of the Senate in providing a one-month “fix” to the planned cut in Medicare physician fee schedule payments that was due to begin December 1.  The proposed legislation, which the president is expected to sign without delay, will push back the 23% reduction in physician reimbursement to January 1.

While we are thankful for this last-minute reprieve, Medac continues to urge our friends in the healthcare industry to press Congress for a long-term solution to this continuing source of concern.  The ASA website provides some helpful guidance in contacting your elected officials. 

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Medicare Identifies Top Errors in Provider Documentation
By: Justin Vaughn, CPC, M.Div
Director of Compliance

It is no secret that the Federal Government regularly reviews physician claims in an effort to minimize errant billing and overt fraud.  We have alerted you to the fact that Recovery Audit Contractors (RACs) are now utilized by CMS to conduct such reviews in all 50 states, but Medicare carriers continue to conduct their own audits, as well.  Known as Comprehensive Error Rate Testing (CERT) audits, these reviews serve as a supplement to the RAC program. 

One Medicare carrier, Trailblazer, recently published a list of key deficiencies uncovered in its CERT audit of Part B claims in Texas, Oklahoma, New Mexico and Colorado.   Among other items, these deficiencies included several errors commonly found in medical record documentation, which can be summarized as follows:

Medicare Fee Schedule Freeze for 31 Days
By: Christine Locay, JD, RHIA, CPC
Vice President, Corporate Compliance Counsel

Today the Senate unanimously approved a 31-day freeze of the sustainable growth rate formula.  This freeze prevents the 23% reduction in physician reimbursement from becoming effective on  December 1, 2010.  The House of Representatives is scheduled to vote on the matter in approximately one week.  While this is good news, it is only a temporary fix; physicians still face a 25% reduction in reimbursement on January 1, 2011 unless Congress acts.

We will keep you updated as this matter is addressed by Congress.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

PQRI Update
By: Christine Locay, JD, RHIA, CPC
Vice President, Corporate Compliance Counsel

In 2007, the Centers for Medicare and Medicaid Services (CMS) implemented the Physician Quality Reporting System or PQRS (formerly, the Physician Quality Reporting Initiative or PQRI), a voluntary claims-based reporting system.

Under the program, group practices or eligible providers that satisfactorily report data on PQRI measures for a particular reporting period are eligible to earn a PQRI incentive payment. The incentive payment is equal to a specified percentage of the group practice’s or provider’s total estimated Medicare Part B allowed charges for covered professional services furnished during the reporting period. In 2010, group practices or eligible providers were required to report quality data codes (QDCs) on eighty percent (80%) of eligible claims in order to receive the two percent (2%) incentive payment.

Under CMS’ 2011 final rule, two important changes were made to incentive payments. First, group practices or eligible providers must report QDCs on fifty percent (50%), instead of eighty percent (80%), of eligible claims to receive the incentive payment. Second, the incentive payment for calendar year 2011 is equal to one percent (1%), instead of two percent (2%), of the group practice’s or provider’s total estimated Medicare Part B allowed charges for covered professional services furnished during the 2011 reporting period.

In addition to the CMS final rule, the Affordable Care Act (ACA) implemented the following changes to the PQRI program:

Massive Medicare Reductions in Physician Reimbursement Loom
By: Justin Vaugh, CPC, M.Div
Director of Compliance

The Medical Group Management Association (MGMA) published the following statement today:

The newly-released 2011 Medicare final physician fee schedule indicates that physician payments will be reduced by approximately 23 percent on Dec. 1.  Additional cuts effective Jan. 1 will result in a cumulative cut of approximately 25 percent from current levels unless Congress intervenes.

Medac will continue to keep you updated on the status of these scheduled cuts.  Hopefully, Congress will intercede once more to prevent such draconian reductions from ever taking place.  However, Medac continues to urge you to contact your elected representatives in Washington and express your views on this issue.  The ASA website contains additional information on how you may get involved in the advocacy process.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

E-Prescribing Incentive Program Proposed Rule for 2011
By: Justin Vaughn, CPC, M.Div, Director of Compliance

The U.S. Congress has authorized a continuation of the Electronic Prescribing (eRx) incentive program for 2011.  As in the past, eligible providers (EPs) will have the opportunity to earn a financial bonus based on successful participation in the program.  However, the bonus for the 2011 reporting period will be only 1% of the total Medicare allowed charges for the year, as compared with 2% relative to the 2010 reporting period. 

To avoid any confusion, you should be aware that the eRx incentive program is separate and apart from the PQRI program.  Participation in one of these programs does not disqualify you from participating in the other.  However, you will not be eligible for the eRx bonus relative to the 2011 reporting period if you earn a bonus via participation in the 2011 EHR incentive program—yet another program that is distinct from PQRI and eRx (though the EHR program will be rolled into the PQRI program beginning in 2012).

In order to ensure successful participation in the eRx incentive program, the rule proposes that you meet the following criteria:

PCA:  CASH COW OR COURTESY CALL?
By Bellinger Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

One recurrent question that I receive on a regular basis:  “Is it worth it to provide and bill for IV PCA services?  The answer to this question for 99% of the anesthesia groups that perform this service is a resounding NO!!!  The below survey of payer billing rules and regulations overwhelmingly support this response:

MEDICARE & MEDICAID

Medicare does not allow PCA as a procedure.  PCA is generally considered a component of an E&M service for pain management.  As per the Federal Register, it is included in the surgeon’s global unless a special situation exists such as:  (1) A patient has addiction issues and the surgeon transfers pain care to a specialist trained in addiction medicine/Opiod management; (2) Pain is so severe a specialist is called. 

BCBS OF FLORIDA & MOST OTHER STATE BCBS PAYERS

Quality Data Capture Solution for P4P!!!  Are you ready for pay for performance?

By: Bellinger P. Moody, RHIA CPC-I CPC CCP
Executive Vice President, Compliance

One of my most frequently asked questions is: What can my practice do to make more money?  Well, as you know, there are the more commonly recognized areas of improvement, such as better documentation for more accurate coding and increased OR utilization and efficiency.  However, the one most unfamiliar, yet increasingly popular method of improving your bottom line is the collection and reporting of quality measures data. Capturing and reporting quality measure data is key in preparing your practice for one of the most critical elements in the future of provider reimbursement – “pay for performance”.

New CMS Notices Target Pain Management Services
By: Justin Vaughn, M.Div, CPC, Director of Compliance

7/20/2011

CMS has begun issuing notices to pain management goups across the country that address government concerns of non-compliant claims submission.  The first of these notices involves audits, known as “Specialty Medical Reviews,” that will specifically target transforaminal epidural injections.  CMS has contracted with Strategic Health Solutions, LLC as the auditing entity relative to these procedures.  The genesis of these audits was the OIG’s prior determination that a significant number of transforaminal claims did not meet the LCD requirements of Medicare contractors, were miscoded, or were otherwise medically unnecessary.

Compliance attorney David Vaughn advises:  “If you get one of these audit requests, make sure to send both the H&P and/or progress note documenting the medical necessity rationale for initiating these injections, as well as the follow-up notes showing the efficacy of the injections.”

On another front, CMS has begun issuing CBRs (Comparative Billing Reports) to pain practices that prescribe back braces.  These CBRs provide the physicians with a comparison of their prescriptions of back braces with those of their peers—both in their state and in the nation as a whole.  CMS has identified orthotics as an area of increased utilization, and this is the government’s way of warning you that they will be auditing those who have a high incidence of orthotic prescriptions.

Attorney Vaughn notes that there must be (a) a signed order and, (b) a statement of the medical necessity, relative to each brace prescribed.

The information presented herein reflects general information that is current as of the date it was first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Medicare Delays Physician Pay Cut Until December

By: Justin Vaughn, MDiv, CPC
Director of Compliance

On June 25, 2010, President Obama signed into law the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act, which provides for a six-month extension of the physician pay update.  The effect of this legislation is that, instead of a significant pay cut, Medicare physicians will now receive a modest 2.2% pay increase—to run through November 30, 2010.  

Previously, a scheduled 21% cut in Medicare physician payments went into effect on June 1.  The new law provides a rate update retroactive to that date.  On June 25, CMS instructed its contractors to hold all claims for services rendered after May 31 until the new 2.2% updated rates can be tested and loaded into the Medicare contractors’ claims processing systems.  CMS revealed that it expects to begin processing claims at the new rate no later than July 1.  Claims that had been paid at the reduced rates will be re-processed "as soon as possible," according to CMS officials.

This is good news for now, but continued vigilance is warranted.  We continue to urge our clients to make your views known to your representatives in Congress.  Thank you, and have a great week!

The information presented herein reflects general information that is current as of the date it is first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information and any general advice previously published might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Medicare To Hold Claims Through June 14th

By: Bellinger P. Moody, RHIA, CPC, CCP, CPC-I
Executive Vice President of Compliance

Yesterday, June 1, 2010 was the proposed date that the 2010 Medicare physician pay cut (21.2 %) was to go into effect.  This pay cut will not go into effect as Congress in looking to pass legislation that will give providers a 1.3% increase for now and put off solving the Sustainable Growth Rate (SGR) problem until some time in 2014. 

In light of this recent development, CMS has announced that it will hold claims for services provided on June 1 through June 10th  so as to provide Congress time to pass legislation that would put off the SGR cut.  THEREFORE, CMS WILL HOLD CLAIMS PROCESSING THROUGH JUNE 14TH FOR ALL DATES OF SERVICE BETWEEN June 1 and June 10, 2010.  The Senate will return on June 7th and hopefully this issue will be resolved during the next session.

The information presented herein reflects general information that is current as of the date it is first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information and any general advice previously published might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

FTC “Red Flags” Regulations:
Implementation Delayed Again

By: Justin Vaughn, M.Div, CPC
Director of Compliance

The Medical Group Management Association (MGMA) has announced today that the Federal Trade Commission (FTC) is delaying yet again the implementation date of the “Red Flags” rule.  Slated to become effective on June 1, 2010, the FTC has, at the request of Congress, pushed back the effective date of the rule until Jan 1, 2011.

This is the latest in a series of implementation delays that are due in part to the continuing debate over whether or not a medical practice falls under the regulatory definition of “creditor.”  According to the FTC, entities so designated must follow the Red Flags rule, which among other requirements mandates the creation of policies and procedures aimed at limiting identity theft.

So, once more, anesthesia groups can breathe a temporary sigh of relief.  Thank you, and have a wonderful Memorial Day weekend!

The information presented herein reflects general information that is current as of the date it is first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information and any general advice previously published might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

Post-Anesthesia Assessment:
CMS Revises its Recent Rule

By: Justin Vaughn, M.Div, CPC
Director of Compliance

As many of you know, CMS released at the end of 2009 an advanced copy of “Interpretive Guidelines” (IGs) pertaining to rules for hospital surveyors, as found in Appendix A of the Medicare State Operations Manual.  Among other items, the IGs addressed time limitations for completing the post-anesthesia assessment.  Of some concern to many anesthesia providers was the stipulation that, for outpatient cases, the assessment would have to be completed before the patient was discharged from the facility.  That instruction has now been revised.  

According to the May 21, 2010 version of the IGs, the following sentence has been deleted:  

“For outpatients, the post-anesthesia evaluation must be completed prior to the patient’s discharge.”  

This means that outpatient cases will default to the same requirements as outlined for inpatient cases; that is, you will have 48 hours from the moment the patient is transported to the recovery area to complete the post-anesthesia assessment.  Naturally, you will need to begin the assessment long before this time period has elapsed, as the IGs also advise that the patient must participate in the applicable portions of the assessment (and thus must be sufficiently recovered to be able to answer questions, perform simple tasks, etc.).

In addition to your fellow anesthesia providers, you may want to bring this revision to the attention of appropriate hospital officials in the event facility policies and protocols are at issue.  Thank you, and have a great week!

The information presented herein reflects general information that is current as of the date it is first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information and any general advice previously published might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

MEDAC BILLING & COMPLIANCE ALERT
February 26, 2010

By: Bellinger P. Moody RHIA,CPC, CCP
Executive Vice President of Compliance

Failure to Act By Senate Means 21% Medicare Cut Effective March 1

According  the most recent MGMA Washington Connexion alert sent out at 2:53pm EST today -- the Senate failed to act on legislation  that would extend Medicare’s current physician payment rates and therapy cap exception process through March 31st due to Senator Jim Bunning’s, R-Ky., objections as to how to pay for the bill – which means that by law, the 21.2% payment cut will take effect March 1.  The senate will return on Tuesday and will most likely try to address the issue again.  However, regardless of whether congress acts, by law, Medicare carriers must hold all claims payments for at least 13 business days after receipt.  CMS states that it will also hold all processing of claims at the reduced rate for the first 10 business days of March – which will give the Senate a window to act.

In accordance with MGMA recommendations, you should contact your Senators and urge them to permanently address this issue by repealing the sustainable growth rate formula. You can contact your senators by calling the American Medical Association Grassroots Hotline, 800.833.6354

The information presented herein reflects general information that is current as of the date it is first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information and any general advice previously published might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

MEDAC BILLING & COMPLIANCE ALERT
February 2, 2010

By: Bellinger P. Moody RHIA,CPC, CCP
Executive Vice President of Compliance

ASA Confers with CMS on New Interpretive Guidelines

In a recent letter to CMS dated January 18, 2010, Dr. Alexander Hannenberg, President of the ASA, stated the ASA’s concerns and perspective in reference to the new revisions to the hospital interpretive guidelines that will affect anesthesia service provision.

MEDAC BILLING & COMPLIANCE ALERT
December 30, 2009

By: Bellinger P. Moody RHIA,CPC, CCP
Executive Vice President of Compliance

New Facet  Injection Codes:  Base Unit Assignments

As you may or may not know, there are new CPT codes for facet injections.  The old codes were 64470, 64472 (Cervical or Thoracic) and 64475, 64475 (Lumbar or Sacral).  The base unit assignments for these codes previously were:

MEDAC BILLING & COMPLIANCE ALERT
November 25, 2009

By: Bellinger P. Moody RHIA,CPC, CCP
Executive Vice President of Compliance

New PQRI Measure in 2010 for Anesthesia

As part of the final rule, CMS has approved another quality measure for anesthesia reporting in 2010.  You will be able to report on a third measure:  Perioperative Temperature Management.   Currently there are two reportable measures for anesthesia:  (1) Measure #30 – Administration of prophylactic antibiotics; and (2) Measure #76 – Central Line Sterile Technique measure.

MEDAC BILLING & COMPLIANCE ALERT
November 24, 2009

By: Bellinger P. Moody, RHIA, CPC, CCP
Executive Vice President of Compliance

New 2010 CPT Codes for Facet Blocks

The old Facet injection block codes, 64470-64476, have been deleted and replaced by codes 64490-64495. Now, there are 6 facet block codes, instead of four.  Additionally, fluoroscopy is now bundled into these codes for all payers. Consequently, the Facet Radiofrequency codes (64622, 64623, 64626, and 64627) have not changed. Therefore, fluoroscopy can still be billed with the facet Radiofrequency codes, and the number of levels of RF has not been restricted, as is the case with the new 2010 facet block codes.

MEDAC BILLING & COMPLIANCE ALERT
November 18, 2009

By: Bellinger P. Moody, RHIA, CPC, CCP
Executive Vice President of Compliance

Clarification & Update:  2010 SRNA Medical Direction Rule

On November 9, 2009 I issued a “Medac Billing & Compliance Alert” entitled “New Teaching Rules for Anesthesiologists”.  In this alert I addressed my interpretation of the 2010 Medicare Physician Fee Schedule Final rule as it pertains to rules for teaching anesthesiologists in reference to Residents and SRNAs. 

As you may or may not know, there has been a great deal of discussion (and alarm) about the “CORRECT” interpretation of the 2010 SRNA teaching rule.  Currently, the anesthesia administrative community is split in its interpretation of the 2010 SRNA teaching rule:

MEDAC HEALTHCARE REFORM ALERT & UPDATE
November 11, 2009

By: Bellinger P. Moody, RHIA, CPC, CCP
Executive Vice President of Compliance

ASA Tele-Town Hall:  Wednesday, November 11, 7pm EST

I strongly urge all Medac Clients that are ASA members to participate in a Tele-Town Hall meeting to be held tonight at 7pm EST.  The Tele-Town Hall meeting will be hosted by ASA President Alex Hannenberg, M.D.  This meeting will focus on the recent bill -- H.R. 3962 “Affordable Health Care for America Act” – and will provide great insight into the history of  the healthcare reform debate and what you must do as the legislative process moves into the U.S Senate and House-Senate conference committee.  

This event is open to all ASA members and Component Society staff and it will provide detailed information and legislative analysis based on the facts relative to healthcare reform.  It is sure to clear up a lot of speculation about what is currently happening and what may happen with healthcare reform.  I encourage all of you to become informed about the provisions included in H.R. 3962 and its effects on the specialty of Anesthesia.  This meeting will also help you to better understand the ASA’s strategy throughout the legislative process.

There are H.R. 3962 materials on the ASA website at www.ASAhq.org that you may review prior to the Tele-Town Hall meeting tonight.  You may register for the Tele-Town Hall meeting online at www.directeventreg.com/registration/event/41033095 or by phone:  (888) 869-1189, Conference ID 41033095.

The information presented herein reflects general information that is current as of the date it is first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information and any general advice previously published might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

MEDAC BILLING & COMPLIANCE ALERT
November 9, 2009

New Teaching Rules for Anesthesiologists
By: Bellinger P. Moody, RHIA, CPC, CCP
Executive Vice President of Compliance

The 2010 Medicare Physician Fee Schedule Final Rule has new rules for teaching anesthesiologists in reference to residents and SRNA’s.  I will address both rules and the impact they may potentially have on your anesthesia practice.

MEDAC BILLING & COMPLIANCE ALERT
November 6, 2009

CMS Eliminates Consults
By: Bellinger P. Moody, RHIA, CPC, CCP
Executive Vice President of Compliance

For decades, coding professionals and consultants alike have tried to educate physicians about the proper use of the consult codes.  The fact is, many healthcare providers, across all specialties have not properly utilized these codes and as a result, they have been a significant cost burden for CMS.  As reported on Wednesday, November 4 in the MGMA Washington Connection, in an effort to curtail its cost, “in the 2010 Medicare Physician Fee Schedule, CMS has eliminated the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for tele-health consultation G-codes)”.  

In an effort to calm providers on the elimination of consults, CMS has increased the work RVUs for new and established patient visits.  They have also increased the work RVUs on initial hospital and nursing facility visits, and have made adjustments for the increased use of these codes into the practice expense and malpractice RVU calculations.

Will this decrease your revenues?

MEDAC BILLING & COMPLIANCE ALERT
November 2, 2009

Red Flags Rule Delayed Once Again

By: Bellinger P. Moody, RHIA, CPC, CCP,
Executive Vice President of Compliance

According to a recent posting on the Federal Trade Commission’s website:  www.ftc.gov/opa/2009/10/redflags.shtm, at the request of Members of Congress, enforcement of the Red Flags Rule has been delayed again – this time until June 1, 2010. 

The delay was posted on the FTC site on Friday, October 30, 2009 at approximately 3:37 pm.  Therefore, those physician practices with greater than 20 members now have until June 1, 2010 to fully develop and implement identity theft prevention programs.

The information presented herein reflects general information that is current as of the date it is first published.  In light of changes that may occur in the health care regulatory and compliance environments, the author's presentation of this information and any general advice previously published might become outdated.  Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

MEDAC BILLING & COMPLIANCE ALERT
October 30, 2009

By: Bellinger P. Moody, RHIA, CPC, CPC-I, CCP
Executive Vice President of Compliance

Red Flag Identity Theft Rules

Effective November 1, 2009, the FTC mandated Red Flag Rules for health care providers become enforceable.

In compliance with these rules, Medac, Inc. has adopted new policies and procedures to identify and avoid risk factors in patient accounts.  One significant risk factor is patient identity theft – specifically in the processing of patient credit card information.

MEDAC BILLING & COMPLIANCE ALERT
October 23, 2009

By Bellinger P. Moody, RHIA, CPC, CCP
Executive Vice President of Compliance

NC Medicare Bundles Fluoroscopy Service With Facet Joint Injections/Denervations & SI Joint Injections:  Other Medicare Contractors Likely To Follow

Effective for dates of service performed on or after September 15, 2009, NC Medicare will no longer separately pay for Fluoroscopy (CPT code 77003-26) when performed in addition to Paravertebral Facet Joint Nerve Blocks/Denervation and Sacroiliac Joint Injections.

MEDAC BILLING & COMPLIANCE ALERT
PA Catheter Rebill Potential for Additional Revenues

By: Bellinger P. Moody, RHIA, CPC, CCP
Executive Vice President of Compliance

Due to a recent increase in the Practice Expense Relative Value Units (PE RVUs) assigned to CPT code 93503 -- Insertion and placement of flow directed catheter (e.g., Swan-Ganz) -- when performed in the facility setting, you may be able to get additional reimbursement for all PA catheters billed in the facility setting, effective October 5, 2009.