Medicare 2010 Hot Topics. About This Manual. Mary Jean Sage The Sage Associates 1/13/ Oak Park Blvd.

Transcription

1 Medicare 2010 Hot Topics Alameda Contra Costa Medical Association January 13, 2010 About This Manual Copyrighted 2010, The Sage Associates, Pismo Beach, California All rights reserved. All material contained in this manual is protected by copyright. Participants who receive this book as part of a workshop presented by The Sage Associates have permission to reproduce any forms contain herein, solely for their own uses within their medical practices. Any other reproduction or use of material in this book without the permission of the author is strictly prohibited. The material in this manual was written by practice management consultants. Any advice or information contained in this manual should not be construed as legal advice. When a legal question arises, consult your attorney for appropriate advice. The information presented in this manual is extracted from official government and industry publications. We make every attempt to assure that information is accurate; however, no warranty or guarantee is given that this information is error-free and we accept no responsibility or liability should an error occur. CPT codes used in this manual are excerpts from the current edition of the CPT (Current Procedural Terminology) book, are not intended to be used to code from and are for instructional purposes only. It is strongly advised that all providers purchase and maintain up to date copies of CPT. CPT is copyrighted property of the American Medical Association. Mary Jean Sage The Sage Associates Oak Park Blvd. Pismo Beach, CA Tel: (805) Fax (805) MaryJean@thesageassociates.com 1

2 Today s Agenda: Medicare no longer considers consultation codes valid How do I bill for those services? Outpatient Inpatient What does this mean for my practice? What about other carriers? Also on the Agenda: Today s Conversion Factor Part B Claims Being Held Until 1/15/2010 Medicare Participation vs. Non- Participation Deciding What s Best for YOUR Practice Medicare Opt Out What Does it Mean? How Does it Work? CONSULTATIONS 1/1/ Medicare will no longer pay for consultation codes Considered invalid CPT codes by Medicare (only) Bill those services with another E/M CPT code 2

3 Consultations..... Medicare has revalued other E/M service codes to accommodate the discontinuation of payment for consultation services Outpatient new & established Work RVUs increased by 6% Inpatient initial & subsequent Work RVUs increased by 2% Also Increased: Physician payment for interventional and surgical procedures with a 10 day or 90 day global assignment, includes a bundled payment for the related post-operative ti visits it There is increased payment for 10 day and 90 day services to recognize the increased payment in the office visits that are incorporated into these services. What do I bill????? A Comparison of the CPT Service Codes 3

4 Outpatient Consults Consult Code Consult New Patient (3 of 3) Problem Focused History Problem Focused Exam Established Patient (2 of 3) Minimal Problem May not require presence of physician Typical Time: 15 minutes Straightforward Decision Making Typical Time: 10 minutes Typical Time: 5 minutes. Consult Code Consult New Patient (3 of 3) Typical Time: 30 min. Expanded Problem Focused History Expanded Problem Focused Exam Straightforward Decision Making Typical Time: 20 min. Established Patient (2 of 3) Problem Focused History Problem Focused Exam Straightforward Decision Making Typical Time: 10 min. 4

5 Consult Code Consult New Patient (3 of 3) Typical Time: 40 min. Detailed History Detailed Exam Low Complexity Decision Making Typical Time: 30 min. Established Patient (2 of 3) Expanded Problem Focused History Expanded Problem Focused Exam Low Complexity Decision Making Typical Time: 15 min. Consult Code Consult New Patient (3 of 3) Comprehensive History Comprehensive Exam Established Patient (2 of 3) Detailed History Detailed Exam Typical Time: 60 min. Moderate Complexity Decision Making Typical Time: 45 min. Moderate Complexity Decision Making Typical Time: 25 min. Consult Code Consult New Patient (3 of 3) Comprehensive History Comprehensive Exam Established Patient (2 of 3) Comprehensive History Comprehensive Exam Typical Time: 80 min. High Complexity Decision Making Typical Time: 60 min. High Complexity Decision Making Typical Time: 40 min. 5

6 Prolonged Services (outpatient) Office or other outpatient setting requiring direct (face-to-face) patient contact t beyond the usual service, first hour each additional 30 minutes Inpatient Consults Code History Exam Decision Making Problem Focused Problem Focused Straightforward Typical Time 20 min Expanded Problem Focused Expanded Problem Focused Straightforward 40 min Detailed Detailed Low Complexity 55 min Comprehensive Comprehensive Moderate Complexity 80 min Comprehensive Comprehensive High Complexity 110 min. 6

7 Initial Hospital Care Code History Exam Decision Making Detailed or Detailed or Comprehensive Comprehensive Straightforward or Low Time 30 min Comprehensive Comprehensive Moderate 50 min Comprehensive Comprehensive High 70 min. Modifier AI Identifies Admitting Physician of record Appended to initial hospital service or initial nursing facility service ONE physician ONLY uses Initial Nursing Facility Care Code History Exam Decision Making Detailed or Detailed or Comprehensive Comprehensive Straightforward or Low Time 25 min Comprehensive Comprehensive Moderate 35 min Comprehensive Comprehensive High 45 min. 7

8 Code These Scenarios Patient #1 Cardiologist is asked to see a patient unknown to him/her to evaluate congestive heart failure: Code: New Patient Visit ( ) Patient #2 Orthopedic Surgeon is asked to see a patient to evaluate the need for open treatment of a femur fracture. The patient has been seen by the physician the previous year for a Colles fracture Code: Established Patient ( ) Consider adding Prolonged Service Code if appropriate (99354) 8

9 Patient #3 Ophthalmologist is asked to see a patient to evaluate cataracts. The patient was seen by the ophthalmologist l t four years prior to extract a foreign body from the eye Code: New patient visit ( ) Patient #4 Family Physician is asked to see patient he/she is treating for diabetes to provide pre-operative clearance for surgery. Code: Established Patient ( ) Patient #5 Hospitalist admits patient to hospital and requests consult by neurologist. Code: Hospitalist AI Neurologist

10 Patient #6 Family Physician admits patient for upper abdominal pain. Next day he/she requests a general surgery to evaluate the patient for cholecystitis and possible cholecystectomy y Code: Day 1 (FP) AI Day 2 (FP) Surgeon Patient #7 A patient who has been seen in your office is admitted to the hospital by another physician for an unrelated illness/injury. The physician i who admitted the patient then asks you to see the patient. Code: What do the Consultation Changes Mean For MY Practice?? 10

11 Projected Changes: Ophthalmology +5% Family Practice +4% General Practice +3% Geriatrics +3% Internal Medicine +2% Projected Changes: Interventional Radiology -3% Urology -4% Radiology -5% Cardiology -8% Nuclear Medicine -18% Here s the Bottom Line! Reimbursement will increase for some services New Patient Visits Established Patient Visits Initial Hospital Care Initial Nursing Facility Care Some Surgical Procedures (because of post op care) 11

12 Bottom Line: Reimbursement will decrease for some services Inpatient Consults Outpatient Consults who return with new injury/illness within three years of a previous visit Bottom Line: This change is for Medicare ONLY continue to bill consultation services to other carriers! The Conversion Factor 12/21/09 Department of Defense appropriations bill freezes the Medicare conversion factor for 60 days (2/28/10) All other 2010 policy changes to the Medicare program became effective 1/1/

13 Conversion Factor Q&A If the conversion factor is the same, why are my office visits a little higher? The new and established patient visits have been re-valued to accommodate the elimination of payment for consultations Conversion Factor Q&A If the conversion factor is the same, why are some of my procedures paid less? The RVUs may have been re-worked as part of a five year review and may be valued lower in This could be either work, practice expense or malpractice RVUs. Conversion Factor Q&A What will happen to the conversion factor at the end of the 60 extension? HOPEFULLY Congress will adopt a longer term solution to the unfair Medicare payment formula known as the Sustainable Growth Rate (SGR). Do your part in advocating for this change!! 13

14 Medicare holding claims for two weeks Applies to 2010 dates of service only Should have minimal effect on your practice, because claims are held for 14 calendar days after receipt anyway Claims for dates of service 12/31/09 and before are paid as usual Participation vs. Non-Participation Participation Period Extended Participation Enrollment period has been extended until 3/17/10 Any changes in participation status will be effective as of 1/1/

15 Participation Must accept assignment on EVERY claim to Medicare Allowed Participating (PAR) Rate Medicare pays 80% Directly to Provider Patient pays 20% Secondary Insurance may cover Non-Participation Not required to accept assignment May accept assignment on a case by case basis Accept Non Par rate =95% of PAR fee Non-accept - may collect Limiting Charge = 115% of PAR Fee directly from patient Considerations for Non-Participation What percentage of your practice is Medicare? What percent of your Medicare population will pay in full at the time of service? How difficult will it be to collect from the patient if they don t pay at the time of service and Medicare sends the check to them? What percentage of the time would you accept assignment for your services? 15

16 What Should I Do Now? Crunch the numbers Excel spreadsheets work well Survey yyour patients How many would you lose if you change status? Review your other contracts Do any require you be Medicare participating? Then What? If you don t wish to make any changes DO NOTHING! If you wish to change From Participating to Non-Participating Notify the MAC (carrier) in writing that you wish to terminate your participation agreement From Non-Participating to Participating Submit a CMS 460 (Participating Agreement) before 3/17/09 Medicare Opt Out Program 16

17 What Does Opt Out Mean? Opting out, also known as private contracting, allows private contracts with Medicare patients if the contracts meet certain conditions specified in the law, most notably that the physician agrees not to submit any Medicare claims nor receive any payment form Medicare for items or services provided to any Medicare beneficiary for two years. Consider: Financial Impact Patient Loss Overhead reduction Cost of contracting with patients Contractual Obligations Hospitals Health Plans Other Entities Other Considerations Steps for Opting Out Notify patients, colleagues and others File affidavit with Medicare Privately contract with Medicare patients Initiate office procedures Mark your calendar to renew opt out status every 2 years 17

18 Other Considerations You must remain in compliance with opt out conditions, otherwise your private contracts are null and void Have 90 days after effective date to change your mind Notify carriers to whom you sent affidavit Refund any money you received from private contracts QUESTIONS???