2013 ESRD Payments and Incentives

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule for 2013 that updates Medicare policies and payment rates for dialysis facilities paid under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS).  CMS estimated a 4.6 percent growth in fee-for-service Medicare dialysis beneficiary enrollment between 2012 and 2013.   

In August 2012, CMS released an analysis of patient claims in the new ESRD prospective payment system, which showed that this payment system has had no negative effects on patients’ health.

The ESRD PPS, first implemented in 2011, expands renal dialysis services included in the single bundled payment to the dialysis facilities and provides for patient case-mix adjustments, facility level adjustments, and outlier payments.  It is intended to improve efficiency. 

CY 2013 will be the third year of a four-year transition to the new payment system.  The overall impact of the CY 2013 changes is projected to be a 3.0 percent increase in payments. Hospital-based ESRD facilities have an estimated 3.6 percent increase in payments compared with freestanding facilities with an estimated 2.9 percent increase. Urban facilities are expected to receive an estimated payment increase of 3.0 percent compared to an estimated 2.9 percent increase for rural facilities.

The ESRD QIP aims to promote continued improvement in the quality of care provided to patients with ESRD. The final rule focuses on clinical measures and has added the following QIP reporting measures to cover a broader range of patients who receive dialysis care:

                                                                                            

• To evaluate anemia management                           

Anemia Management, a reporting measure.                 

• To evaluate dialysis adequacy                                             

A clinical Kt/V measure for adult hemodialysis patients.

A clinical Kt/V measure for adult peritoneal dialysis patients.

A clinical Kt/V measure for pediatric in-center hemodialysis patients.  

The overall economic impact of the ESRD QIP is an estimated $24.6 million for PY 2015. The total expected payment reductions will be approximately $12.1 million, and the costs associated with the collection of information requirements for certain measures to be approximately $12.4 million.

The estimated payment reduction will continue to incentivize facilities to provide higher quality care to beneficiaries. The reporting measures that result in costs associated with the collection of information are critical to better understanding the quality of care beneficiaries receive, particularly a patient's experience of care, and will be used to incentivize improvements in the quality of care provided.

For more information on the final rule, see: 

http://ofr.gov/OFRUpload/OFRData/2012-26903_PI.pdf

For more information about the ESRD PPS and ESRD QIP, please see: 

https://www.cms.gov/Center/Special-Topic/End-Stage-Renal-Disease-ESRD-Center.html

2013 Increased Claims Reimbursement

Due to recent legislative changes, many providers will see increased claims reimbursement in 2013. Below are the details of three areas that will be effected.

• Increased Medicaid Payments to Primary Care Physicians:

The National Quality Strategy, required by The Affordable Care Act of 2010, is a   national plan to improve the delivery of health care services, patient health outcomes, and population health. Three goals are used to guide and assess local, state, and national efforts to improve health and the health care delivery system: better care, healthy people/healthy communities, and affordable care.

Medicaid and CHIP currently provide health coverage to nearly 60 million Americans, including children, pregnant women, parents, seniors and individuals with disabilities. Medicaid payment increases are planned for certain primary care services provided to Medicaid beneficiaries in 2013 and 2014. This is an attempt to draw more primary care providers into the program in order to handle the inevitable increase in demand as enrollment is expected to expand by somewhere between 10-16 million individuals starting at the beginning of 2014.

Reimbursement will be raised to payment rates that match Medicare for specific services provided by a physician with a primary specialty designation of family medicine, general internal medicine, or pediatric medicine. The services subject to the increase are evaluation and management services represented by procedure codes in the category designated Evaluation and Management in the Healthcare Common Procedure Coding System and services related to immunization administration for vaccines and toxoids for CPT codes 90465, 90466, 90467, 90468, 90471, 90472, 90473, and 90474.

Higher payments and increased provider participation are key factors in implementing the National Quality Strategy.

•  Increased Medicare payments to Primary Care Physicians:

The Centers for Medicare & Medicaid Services (CMS) issued a final rule with comment period on November 1, 2012 for Medicare’s payments for physician fees for 2013.  It includes a new policy to pay a patient’s physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled nursing facility stay.  The changes in care coordination payment and other changes in the rule are expected to increase payment to family practitioners by seven percent—and other primary care practitioners between three and five percent—if Congress averts the statutorily required reduction in Medicare’s physician fee schedule.

This new physician fee rule is part of the drive to reward savings and foster collaboration amongst primary care providers.

The final rule with comment period can be viewed at:

http://www.ofr.gov/OFRUpload/OFRData/2012-26902_PI.pdf

The rule will be published on November 16, 2012.  It will take effect January 1, 2013 with a comment period that closes on December 31, 2012.

• Increased Medicare Payments for Outpatient Hospital Services:

The Centers for Medicare & Medicaid Services (CMS) finalized the Hospital Outpatient Prospective Payment System (OPPS) rule on November 1, 2012, updating Medicare payment policies and rates for hospital outpatient services beginning January 1, 2013.

The final OPPS/ASC rule with comment period affects hospital outpatient departments in more than 4,000 hospitals, including general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children’s hospitals, and cancer hospitals, and approximately 5,000 Medicare-participating ASCs.

Rates and policies set in the calendar year (CY) 2013 final rule with comment period will increase payment rates for hospital outpatient departments by 1.8 percent. The increase is based on the projected hospital market basket—an inflation rate for goods and services used by hospitals—of 2.6 percent, minus 0.8 percent in statutory reductions, including a 0.7 percent adjustment for economy-wide productivity and a 0.1 percentage point adjustment required by statute.

Total payments to hospitals under the OPPS in CY 2013 will be approximately $48.1 billion.

To view the CY 2013 OPPS and ASC payment system final rule with comment period and changes to the QIO program, please see:

http://www.ofr.gov/OFRUpload/OFRData/2012-26902_PI.pdf

The rule will be published on November 15, 2012.  It will take effect January 1, 2013 with a comment period that closes on December 31, 2012.

URGENT: Avoid Incorrect Place of Service for Outpatient Hospital Services

Physicians providing services in the outpatient department of a hospital need to urgently review their place of service (POS) coding practices. As of October 1, 2012, CMS has implemented it's new place of service coding instructions per CR7631.

Billing for outpatient hospital procedures have come under the scrutiny of the Office of the Inspector General (OIG). The OIG has determined one of the most common POS coding errors is represented by the incorrect use of code 11,“office”, for services provided in the outpatient department of a hospital.

The CMS ruling instructs providers to use the place of service that represents the setting in which the beneficiary received the face-to-face service. Unless a provider has a separately maintained office space in the hospital or medical campus where the services was rendered, the POS is considered “outpatient hospital” and must show POS code 22.

You may wonder why using POS code 11 instead of 22 makes a difference. For services paid under the MPFS, there is a reduced reimbursement of procedures billed by providers in the outpatient hospital department. This reduction is based upon the facillity bearing the costs, such as support staff and equipment, that are required for the services to be rendered instead of the provider. Therefore, providers that incorrectly submit POS code 11 are being overpaid for their outpatient hospital procedures, and if audited, are subject to paying refunds to Medicare.

                                                

Take the time now to review the configuration of your medical billing system to ensure the POS codes that are being submitted for all of your service locations are set up correctly. Iridium Suite medical billing software is designed to contain a comprehensive table of all your practice service locations with built-in POS coding tied to each one. This is just one of the many ways in which Iridium Suite enables you and your staff to submit the most accurate and complete billing as possible.

Always Code the Most Specific Diagnosis

Inaccurate or non-specific diagnosis coding can adversely affect your reimbursement of medical claims. Many categories of the ICD-9 contain codes that represent the non-specified site of a certain neoplasm. The are typically indicated with a “9” as the last digit of the code.

Even though all of these codes are viable, accepted diagnoses, many payers, especially Medicare, highly encourage the use of the more “site specific” codes. Failure to be specific can in some instances cause Medical Necessity denials as the non-specific codes may not be listed as acceptable in the payers' Medical Policies. Also, if audited, a discrepancy between the treating diagnosis in the medical chart and the diagnosis submitted on a claim, could cause payment reversals and money due back to the payer.

In all medical specialties, the patient medical record should dictate what services are billed and the diagnoses used.

One specialty example is Radiation Oncology. The prescriptions for Radiation Therapy Treatment Courses are very site specific, so this information is one of the most helpful tools in proper diagnosis coding when used in conjunction with patient data the medical staff has entered into the medical record.

In any specialty, but quite frequently in Radiation Oncology, a patient can have numerous diagnoses that require treatment. In these instances, it is especially important to indicate the proper diagnosis priority on your services. The priority one diagnosis should always be the current treating diagnosis for the service you are billing.

Another frequent situation in Radiation Oncology billing arises when treating a patient for metastatic disease. The metastatic treatment site will be listed as the priority one diagnosis with the primary original site diagnosis listed as the second.

Other specialties would follow a similar scenario if they were treating a complication diagnosis, billed as priority one, from an initial diagnosis, billed as priority two.

A medical billing system with comprehensive ICD -9 and ICD-10 code files, such as Iridium Suite can assist your office in accurately billing the most specific diagnoses for the patients in your practice.

Electronic Health Record (EHR) and Medical Billing Systems

An EHR must not only record your patient data electronically, but should be certified for meaningful use by CMS. Once you select a certified system, this gives you the potential to earn financial incentives from CMS by providing the required proof of meaningful use.

Integrating multiple systems can enhance your work environment and improve efficiency. Your medical billing system should be able to directly import medical data such as patient demographics from your EHR. This type of integration will eliminate the need for re-entry of patient data into the billing system by office staff.

Iridium Suite medical billing software now comes with the Connectivity Clearinghouse enabling connections to multiple EHR systems. You can connect to your EHR as often as your office work flow dictates. With accurate and complete data entry in your EHR, you are able to bring in all the necessary information to bill and file your patient claims. 

The Connectivity Clearinghouse can use multiple protocols such as: LLP, HTTPS, and SFTP. It can also be extended to use multiple data formats such as: multiple versions of HL7, any well formed XML and delimited text.

The versatility of the Connectivity Clearinghouse in Iridium Suite medical billing software provides the foundation to integrate with your existing Electronic Health Record, saving your practice time and money.

Optimize Use of Electronic Data Interchange In Medical Billing

Electronic data interchange (EDI) is the structured transmission of data between organizations by electronic means. It is used to transfer electronic documents or business data from one computer system to another computer system, i.e. from a medical practice to an insurance payer.

                                                

Medical billing software should utilize the following three common EDI functions: submission of Electronic Claims, utilization of Real Time Eligibility (RTE) and receipt of Electronic Remittance Advices (ERA's). Lets look at each one of these further.

• Electronic Claims replace the standard HCFA 1500 paper claim forms that are printed and mailed to the payer. The claims are batched in the medical billing software and then transmitted in an electronic format directly to the payer or to a clearinghouse. If a clearinghouse is used, they serve as the middle man for all the EDI transactions. Unlike with paper claims where you have no way to verify receipt by the payer, electronic claims can be tracked through each stage of the process, from receipt by the clearinghouse to the acknowledgement and acceptance by the payer. Additionally, electronic claims are pre-screened for certain errors with notices being sent back to the medical practice within days for quick correction and resubmittal. Due to their formatting, electronic claims are much more quickly processed by the payer, reducing the wait for reimbursement in some cases from weeks to days.
• The Real Time Eligibility function in the medical billing software allows the medical practice to verify patient insurance coverage before services are rendered. The details provided in the RTE response also confirm or provide other valuable data such as, patient address, health insurance identification number and group number, and effective dates of coverage. All of this information eliminates denials for lack of coverage and provides great assistance in submitting clean claims that will be processed quickly.
• Electronic Remittance Advices are the electronic equivalent of a paper Explanation of Benefits (EOB). The medical billing software imports the ERA from the payer or clearinghouse and often can adjudicate the payments automatically in the indicated patient's accounts. Amounts that are designated Contractual Obligations are written off, patient responsibilities such as co-pays and deductibles are allocated to the patient balance, and other open balances are applied to any appropriate additional payers. Even information regarding denials is attached to the designated services with complete details allowing medical office staff to research and choose the best action in order to resolve the denial with the payer.

If your medical billing software is not utilizing all of these functions, it may be time to look for a better solution, Iridium Suite by Medical Business Systems.