Senior Patients, Tobacco Use and Your Practice

Tobacco use has been proven to be the leading cause of preventable death in the United States.  In response to the evidence, CMS decided in 2005 to consider smoking and tobacco use cessation counseling to be reasonable and necessary for a patient with a disease or an adverse health effect that has been found by the U.S. Surgeon General to be linked to tobacco use, or who is taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on FDA approved information.

This policy has since been extended to cover asymptomatic patients under CMS's encouragement of the use preventive service benefits extended to all Medicare beneficiaries.

Beginning in January 2006, Medicare’s prescription drug benefit covers smoking and tobacco use cessation agents prescribed by a physician.

Although minimal counseling is already covered at each evaluation and management (E&M) visit, Medicare will cover 2 cessation attempts per year.  Each attempt may include a maximum of 4 intermediate or intensive sessions, with the total annual benefit covering up to 8 sessions in a 12 month period.                               
 
The definitions of cessation counseling attempt and session are listed below:

Cessation counseling attempt occurs when a qualified physician or other Medicare-recognized practitioner determines that a beneficiary meets the eligibility requirements above and initiates treatment with a cessation counseling attempt. A cessation counseling attempt includes up to 4 cessation counseling sessions (1 attempt=up to 4 sessions). Two cessation counseling attempts (or up to 8 cessation counseling sessions) are allowed every 12 months. In calculating the 12-month period, it is necessary for at least 11 months to have passed following the month in which the first Medicare-covered cessation counseling attempt/session was performed.

Cessation counseling session means face-to-face patient contact of either the intermediate (greater than 3 minutes and up to 10 minutes) or the intensive (greater than 10 minutes) type performed either by or “incident to” the services of a qualified practitioner for the purpose of counseling the beneficiary to quit smoking or tobacco use. During a 12-month period, the practitioner and the beneficiary would have flexibility to choose between intermediate or intensive cessation strategies for each session.

The procedure codes that represent these sessions are:

99406 – Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

99407 - Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

G0436 - Smoking and tobacco use cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes up to 10 minutes

G0437 - Smoking and tobacco use cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes

The reimbursement for these procedures ranges from approximately $14.00 to $29.00 based upon the Medicare locality.  Your practice can also receive additional financial incentives by participating in the Physician Quality Reporting System (PQRS). Core Measure PQRS# 226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention.

 Information on this measure is detailed below:

Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

Numerator: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user

Definitions: Tobacco Use – Includes use of any type of tobacco

     Cessation Counseling Intervention – Includes brief 

     counseling (3 minutes or less), and/or pharmacotherapy

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.