Moving Forward: The Bundled Payments for Care Improvement Initiative

CMS has announced the participants for Models 2 through 4 of the Bundled Payments for Care Improvement Initiative (BPCI). 

Models 2 and 3 involve a retrospective bundled payment arrangement where actual expenditures are reconciled against a target price for an episode of care.   Model 4 involves a prospective bundled payment arrangement, where a lump sum payment is made to a provider for the entire episode of care. 

Over the course of the three-year initiative, CMS will work with participating organizations to assess whether the models being tested result in improved patient care and lower costs to Medicare. 

The implementation of these models has been broken down into two distinct phases:

Phase I:   Referred to as the “no-risk” preparation period has just begun and will continue until July 2013.  During this time, CMS and participants prepare for implementation and assumption of financial risk based on the provider’s final submitted list of their episodes.  Participants can select up to 48 different clinical condition episodes. 

Phase II:   Beginning in July 2013, the “risk-bearing” performance period starts for those participants from Phase I that are ultimately approved by CMS and decide to move forward with implementation and assumption of financial risk.

	Model 2	Model 3	Model 4
Episode of Care	Inpatient stay at acute care hospital plus post-acute period for selected DRGs.	Selected DRG’s for an acute care hospital stay will trigger the episode to begin at initiation of post-acute care services with a participating skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health agency	Inpatient stay at acute care hospital plus readmissions for selected DRGs.
Bundled Services	The bundle will include physicians’ services, care by post-acute providers, related readmissions, and other related Medicare Part B services included in the episode definition such as clinical laboratory services; durable medical equipment, prosthetics, orthotics and supplies; and Part B drugs.	The bundle will include physicians’ services, care by post-acute providers, related readmissions, and other related Medicare Part B services included in the episode definition such as clinical laboratory services; durable medical equipment, prosthetics, orthotics and supplies; and Part B drugs.	All Part non-hospice A and B services (including the hospital and physician) during initial inpatient stay and readmissions
Service Timeline	The episode will end either 30, 60, or 90 days after hospital discharge.	The post-acute care services included in the episode must begin within 30 days of discharge from the inpatient stay and will end   either a minimum of 30, 60, or 90 days after the initiation of the episode.	Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount.
Payment Calculation	Retrospective: A target price will be set that will be based on historical fee-for-service payments for the participant’s Medicare beneficiaries in the episode and will include a discount. Payments will be made at the usual fee-for-service payment rates, after which the aggregate Medicare payment for the episode will be reconciled against the target price. Any reduction in expenditures beyond the discount reflected in the target price will be paid to the participant and may be shared among their provider partners. Expenditures that are above the target price will be repaid to Medicare by the participant.	Retrospective: A target price will be set that will be based on historical fee-for-service payments for the participant’s Medicare beneficiaries in the episode and will include a discount. Payments will be made at the usual fee-for-service payment rates, after which the aggregate Medicare payment for the episode will be reconciled against the target price. Any reduction in expenditures beyond the discount reflected in the target price will be paid to the participant and may be shared among their provider partners. Expenditures that are above the target price will be repaid to Medicare by the participant.	Prospective: A single, prospectively determined bundled payment to the hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit “no-pay” claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount.

Research has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners– allowing them to work closely together across all specialties and settings.

The Bundled Payments for Care Improvement initiative will test innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) expenditures while preserving or enhancing the quality of care for beneficiaries.

2013 Orthopedic Surgery CPT Code Changes and Additions

These are the highlights of the seven CPT code changes and a listing of numerous CPT code additions affecting Orthopedic Surgery billing in 2013.  Make sure you review the full CPT manual for complete details of all coding changes to insure you receive your optimum claim reimbursements.
                                                         
Spine CPT

Guideline Change: CPT codes 22633 and 22634 may be appropriately related as primary or index codes for spine bone grafts (20930–20938), instrumentation (22840–22844, 22848, 22845–22847), and intervertebral device (22851) codes. 

 Bone marrow aspirate

Clarification: Use of bone graft codes (20930–20938) related to bone marrow aspiration. CPT code 38220 defines the work associated with the harvest of bone marrow for bone grafting only. (Billing Note: Category III code 0232T should be used when bone marrow aspiration is performed for platelet-rich stem cell.)

Cervical Spinal Arthrodesis Guideline

Guidelines Added:  CPT codes 22554, 22585, 63075, and 63076; if the work associated with these procedures is performed during the same surgery by the same surgeon or by two separate surgeons/individuals during the same session, the correct codes are 22551 and 22552. (Billing Note: CPT codes 63075 and 22554 may not be unbundled and reported for the same patient, same session.)

Cast application

Guideline Change:  Refer to the section “Application and Strapping” for specific changes regarding the application of the first cast, its removal, coding by the individual who performs the initial service, and restorative management. (Billing Note: CPT code 29590 (Denis-Browne bar (splint) with manipulation and casting (eg, for metatarsus adductus, clubfoot) was deleted.)

Hip arthroscopy

Clarification: CPT code 29916 (Arthroscopic labral repair of a torn labrum) is considered inherent to CPT codes 29915, 29862, and 29863. (Billing Note:  CPT code 29916 should not be reported in addition to CPT codes 29915, 29862, or 29863 because the repair is already included in these codes, whether as a takedown and repair or a repair of an already torn labrum.)

Chemodenervation

Guideline Change:   CPT code 64614 (Chemodenervation of muscle(s); extremity and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, multiple sclerosis) may only be reported once per extremity. The parenthetical (s) was removed from extremity. (Billing Note:  CPT code 64614 states that modifier 50 should not be appended to this code. Check with your payers to determine specific rules to code submission.)

Intraoperative nerve monitoring

Clarification: Intraoperative nerve monitoring by the operating surgeon is included in the primary surgical service and is not separately reportable.

Update your medical billing system with the following new CPT codes for 2013:
Spine

22586—Arthrodesis, pre-sacral inter-body technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace

0309T—Arthrodesis, pre-sacral inter-body technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (Billing Note: List 0309T separately in addition to code for the primary procedure 22586)

Shoulder Arthroplasty

23473 - Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component.

23474 - Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component.

Elbow Arthroplasty

24370 - Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component.

24371 - Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component.

Nerve Conduction

(Billing Note:  Guideline instructions related to the reporting of electromyograms (EMGs) and nerve conduction studies (NCS) are found in the beginning of their respective CPT sections.)

 CPT codes 95900–95904 were deleted and replaced by the following CPT codes: 

95907—Nerve conduction studies; 1–2 studies

95908—Nerve conduction studies; 3–4 studies

95909—Nerve conduction studies; 5–6 studies

95910—Nerve conduction studies; 7–8 studies

95911—Nerve conduction studies; 9–10 studies

95912—Nerve conduction studies; 11–12 studies

95913—Nerve conduction studies; 13 or more studies

Extracorporeal Shock Wave: Wound Healing

Two new Category III codes for extracorporeal shock wave for wound healing were introduced:

0299T—Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound

0300T—Each additional wound (Billing Note:  List separately in addition to code for primary procedure.)

With Iridium Suite practice management software, you can take the worry away from all of these changes.   This medical billing software is loaded with all current CPT I, II, III and HCPCS Level II codes as well as the NCCI edits.  It also has the Claim Scrubber function, allowing you to create special billing rules so you don’t forget to bill those “companion” codes.

                                                                                      

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 billing and coding software 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 practice billing software provides the foundation to integrate with your existing Electronic Health Record, saving your practice time and money.

Check the Vital Signs of Your Medical Practice-Part 2

A Medical Practice is a unique business in many ways, but it is still a business and must be treated as such.  Checking the health of your practice is similar to checking the health of your patients.  In this three part series, we will look at these Vital Signs, pulse, blood pressure and temperature, to help you assess the financial well-being of your medical practice.

In Part 1, we addressed the pulse of your practice: trends in new patient statistics and physician referrals.  If you missed Part 1, please select this link: Check the Vital Signs of Your Medical Practice-Part 1

For Part 2, let’s check that Blood Pressure-   

Are the numbers of services you bill increasing, decreasing, or staying the same?

Depending on your type of medical practice, you could expect to see one or two procedure codes billed per patient visit or for some specialties like Radiation Oncology, you may bill 10 procedure codes per visit.  In either case, reviewing reports that show month-to-month statistics can allow you to recognize anomalies in your billing patterns.  Sharp declines in a certain procedure may indicate forgotten or missed coding opportunities and therefore missed revenue.  Many payers have time filing limits from the date of service.  They can range from 60 days to one year.  A regular review for missed charges will enable to meet those filing limits and collect on all of your rendered services.  If your report showed an unexpected procedure or an unusually high number of a certain procedure was billed, you will be able to audit the medical record(s) for appropriate documentation.  If billing errors are discovered, you can get ahead of an insurance audit by quickly refunding any payments received for these non-provided services.  Keeping yourself in the good graces of your payers is always important.

Is your claim reimbursement in line with your contracted fees?

This type of analysis is invaluable to any medical practice.  Once you have signed on that dotted line with the payer, you are wise to ensure that you are receiving the proper reimbursement based on the agreed upon contractual rates.  In the daily whirlwind of activity in the medical office, office staff seldom has the time to comb over the detail of every paid line item.  A monthly report that compares the payments received to the payer’s fee schedule will indicate payments that are below (as well as above) the payers contracted fees.  Payments that are below should immediately prompt a call the Provider Relations Department.  For payments above the contracted fees, research has to be done on the accuracy of the fee schedule you are using, for instance, perhaps the payer has updated its schedule and you have not.  This type of report could also make you aware of overpayments. If those are pre-emptively refunded to the payer, it will show your practice to be following proper procedures in the eyes of the payer.

These two reports are just a small sampling of the extensive selection of practice management reporting options built into the Report Center module of Iridium Suite Medical Billing Software.

Be sure to watch for the upcoming publication of Part 3:  Temperature.