Tuesday, November 15, 2011, 9:30 AM Scottish Rite Auditorium

Transcription

1 Practice Administrator Meeting Tuesday, November 15, 2011, 9:30 AM Scottish Rite Auditorium I PA Meeting Schedule 9:30 9:35 II. MOC Program Update 9:35 9:40 III. Coding 2012 and Beyond 9:40 10:40 Linda Edwards, RN, CPC IV. 1 st Physicians Resource 10:40 10:50 V. Medicaid 10:50 11:00 VI. Vaccine Program 11:00 11:05 VII. Quality Management Update 11:05 11:15 Strong 4 Life Chest Pain Study VIII Benchmarking 11:15 11:20 IX. Round Table Discussion 11:20 12:00 X. Payor Update (hand out) Next PA Meeting NO MEETING IN DECEMBER January 17, 2012, Scottish Rite Auditorium

2 Coding 2012 And Beyond Linda G. Edwards, RN, CPC Current Procedural Terminology (CPT ) International Classification of Diseases, 9 th Revision, Clinical Modifications (ICD-9-CM)

3 Our Discussion CPT 2012 changes January, 1, 2012 ICD-9-CM changes October 1, 2011 ICD-10-CM October 1, 2013 Medicare Physician Fee Schedule January 1, 2012

4 2012 CPT Changes Introduction Definition of other qualified healthcare professional Evaluation and management (E/M) services New vs. established patients Initial observation care Prolonged services

5 2012 CPT Changes Revisions to medicine section Immunization administration Vaccine codes Evoked otoacoustic emissions Pulmonary diagnostic testing Neonatal car seat testing Developmental screening and testing Modifier 33

6 Individual who by education, training, licensure/regulation, facility credentialing (when applicable) and payer policy is able to perform a professional service within their scope of practice and independently report a professional service. Distinct from clinical staff who are working under supervision of physician or other qualified healthcare professional Other policies may also affect who may report specific services. Definition of Qualified Healthcare Professional

7 Qualified Healthcare Professional When clinical staff (RNs, LPNs, MAs) perform service, physician cannot report 90460, Immunization Administration Non-direct prolonged services 99366, Medical team conference Education for patient selfmanagement Telephone care, nonphysician Does not include all codes in CPT codes

8 Revised Definition of New vs. Established Patient New patient: one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty in the same group practice, within the past 3 years. Established patient: one who has received professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.

9 Example One of your partners has additional training (or is board certified in a subspecialty) in treatment of asthma. If you transfer care of the patient to that partner, he/she may report service as a new patient visit (provided he/she has not provided service to that patient within last 3 years)

10 Decision Tree Reintroduced The Decision Tree (removed from the 2011 CPT), reinserted in the 2012 codebook. Used to help differentiate new and established patient

11 Hospital Observation Care Typical times added to the initial observation care codes ( ). Assigned times mirror those in the initial hospital care codes Care may be reported based on time when more than 50% of the total faceto-face encounter (eg, time on floor/unit) is spent in counseling and/or

12 Initial Observation Care Initial observation care, per day, for the E/M of a patient (detailed H&P, straightforward or low complexity medical decisionmaking) 30 minutes at bedside and on hospital floor or unit (comprehensive H&P, moderate complexity medical decision-making) 50 minutes (comprehensive H&P, high complexity medical decisionmaking) 70 minutes

13 Revisions to Prolonged Services Codes Descriptions no longer include the terms physician or face-to-face Introductory guidelines Definition of direct patient contact is..face-to- face and includes additional non face-to-face services on the patient s floor or unit in the hospital or nursing facility during the same session

14 Inpatient Prolonged Services Codes Report prolonged service inpatient add-on code(s) and with initial/subsequent observation codes ( , ) and initial/subsequent inpatient services ( ). Intraservice times for codes 99356/ are based on unit/floor time not face-to-face time as required in the office/outpatient setting. Office/outpatient prolonged services codes (99354 and 99355) continue to be reported with consultations performed in observation setting ( ) if appropriate Based on face-to-face time

15 Prolonged Services Codes Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour each additional 30 minutes (List separately in addition to code for prolonged service.) Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (Use in conjunction with , , , , , , 90822, 90829) each additional 30 minutes (List separately in addition to code for prolonged service.)

16 Example 2-month-old is admitted for hydration and observation; detailed history and physical examination is performed. Physician spends 65 minutes on the floor with the patient: 10 minutes of which is spent in counseling the parents. Time is spent on the unit reviewing laboratory reports, previous admission records, discussing care with the nurses and documenting in the medical record

17 Non Direct Prolonged Services Codes and used when non face-to-face or additional floor/unit time beyond the usual physician or other qualified health care professional service time performed and documented Reported in relation to other physician or other qualified health care professional services, including E/M services at any level.

18 Non Direct Prolonged Services Prolonged E/M service before and/or after direct (face-toface) patient care; first hour each additional 30 minutes

19 Immunization Administration A component refers to each antigen in a vaccine that prevents disease(s) caused by one organism Conjugates or adjuvants contained in vaccines are not considered to be component parts of the vaccine as defined above. Multivalent antigens or multiple serotypes of antigens against a single organism are considered a single component of vaccines

20 Immunization Administration Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)

21 Example RN, as allowed under state scope of practice laws, performs vaccine counseling on a child receiving the influenza vaccine (immunization administration, first vaccine, IM, intradermal) or (immunization administration, first vaccine, intranasal) is reported

22 Revisions to Vaccine Codes Revised Anthrax vaccine, for subcutaneous or intramuscular use Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae B vaccine, tetanus toxoid conjugate (Hib-MenCY- TT), 4-dose schedule, when administered to children 2 15 months of age, for intramuscular use Deleted Influenza virus vaccine, pandemic formulation, H1N1 New Influenza virus vaccine, split virus, preservative-free, for intradermal use

23 Evoked Otoacoustic Emissions New Code for automated evoked otoacoustic emissions and revised to be more descriptive

24 Evoked Otoacoustic Emissions Evoked otoacoustic emissions; screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis Distortion product evoked otoacoustic emissions; limited evaluation to confirm the presence or absence of hearing disorder, 3 6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report Comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report

25 Pulmonary Diagnostic Testing New section Instructions for reporting spirometry When spirometry (94010) performed before and after administration of a bronchodilator, report (bronchodilation responsiveness, spirometry as in 94010, preand post- bronchodilator administration) Measurement of vital capacity (94150) is a component of spirometry (94010, 94060) Spirometry (94010, 94060) includes maximal breathing capacity (94200) and flow-volume loop (94375)

26 Car Seat/Bed Testing Car seat/bed testing for airway integrity, neonate, with continual nursing observation and continuous recording of pulse oximetry, heart rate, and respiratory rate, with interpretation and report; 60 minutes (Do not report for less than 60 minutes.) each additional full 30 minutes

27 Car Seat/Bed Testing Requires continual nursing observation w/ continuous recording of pulse oximetry, heart rate, and respiratory rate; documentation of vital signs and observations; reviewed and interpreted w/ a written report by the physician. May be reported with discharge day management, subsequent hospital care, hourly critical care, pediatric critical transport services or office/outpatient visit when performed on same calendar day. Bundled with global critical care and intensive care codes Total time spent must be documented. Code cannot be reported if less than 60 minutes is spent; code cannot be reported if less than 90 minutes is spent

28 Example A neonate born at 34 weeks gestation did not receive car seat testing when discharged and was sent home in a car bed. Car seat testing is performed at the pediatrician s office

29 Developmental Screening and Testing Code revised - developmental screening Stipulates that the service is reported per interpretation and report of each standardized instrument form. Code is revised to delete the word extended and to reflect that service is testing

30 Developmental Screening and Testing Developmental screening, with interpretation and report, per standardized instrument form Developmental testing,(includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments) with interpretation and report

31 Modifier 33 Preventive Service Effective January 1, 2011 in CPT 2012 Result of Patient Protection and Affordable Care Act All health care plans must cover preventive services without any cost sharing When primary purpose of service is delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending modifier 33 It is not appended to separately reported services specifically identified as preventive

32 Modifier 33 Check with payer before reporting Do not report on codes

33 2012 ICD-9-CM Codes New/revised codes effective with services provided on October 1, 2012 and after Last comprehensive update before conversion to ICD-10-CM (October 1, 2013) Limited 2013 code updates to both code sets to recognize new technologies and diagnoses

34 Highlights ICD-9-CM Expansion of the codes for reporting E. coli (041.4x) Expansion of codes for thalassemia (282.4x) More specific codes for pancytopenia (284.1x) Expansion of the novel influenza A virus codes (488.8x)

35 Highlights ICD-9-CM Expansion of the novel influenza A virus codes (488.8x) Influenza due to identified novel influenza A virus with pneumonia Influenza due to identified novel influenza A virus with other respiratory manifestations Influenza due to identified novel influenza A virus with other manifestations

36 Highlights ICD-9-CM New codes to report nonspecific reactions to tuberculin skin tests (795.5x) Nonspecific reaction to tuberculin skin test without active tuberculosis Nonspecific reaction to cell mediated immunity measurement of gamma interferon antigen response without active tuberculosis

37 Highlights ICD-9-CM New codes for reporting anaphylactic reactions or other serum reactions due to vaccinations (999.4x and 999.5x) Anaphylactic reaction due to vaccination Other serum reaction due to vaccination New personal history codes (V12.2x and V13.8x)

38 Highlights ICD-9-CM Other V codes V40.31 Wandering in diseases classified elsewhere V40.39 Other specified behavioral problem

39 ICD-9 Why ICD-10-CM? Outdated Out of space Does not meet code set requirements under HIPAA of 1996 Does not allow reporting of specific terminology

40 ICD-10-CM More Flexible - can easily incorporate emerging diagnoses More specificity Improves ability to measure health care services Supports improved public health surveillance Reflects advances in medicine and medical technology Uses current medical terminology

41 ICD-10-CM Number of codes increase from ±13,500 to ± 68,000 Uses alphanumeric codes 3-7 characters Two additional chapters Eye and Ear/Mastoid External Causes of Morbidity and Mortality" and "Factors Influencing Health Status and Contact with Health Services" chapters are part of the chapter classifications Includes combination codes reducing number of codes required for reporting certain conditions

42 ICD-10-CM Chapters divided into blocks (subchapters) to identify conditions that are closely related 3-character categories = basic or general condition 4-character categories = site, etiology, manifestation, or state of the disease or condition 5 to 7-character categories = most precise and specific

43 Will Require Better Documentation J45 Asthma J45.2 Mild intermittent asthma J45.20 Mild intermittent asthma, uncomplicated J45.21 Mild intermittent with (acute) exacerbation J45.22 Mild intermittent with status asthmaticus J45.3 Mild persistent asthma J45.30 J45.32 J45.4 Moderate persistent asthma J45.40 J45.42 J45.5 Severe persistent asthma

44 ICD-10-CM Codes for Asthma J45.9 Other and unspecified asthma J45.90 Unspecified asthma, uncomplicated J45.91 Unspecified with (acute) exacerbation J45.92 Unspecified with status asthmaticus J45.99 Other asthma J Exercise induced bronchospasm J Cough variant asthma

45 Transitioning General Equivalence Mapping Translation reference for ICD-9 to and from ICD-10 codes May not include exact matching Example: Exercise induced bronchospasm J Exercise induced bronchospasm

46 Medicare Physician Fee Schedule 2012 Effective on January 1, 2012 Medicare CF reduced by > 27% Cut may be decreased or eliminated by legislation as in years prior Increase in RVUs for preventive medicine ( ) codes and normal newborn care (99460, and 99463)

47 CPT Code 2011 Medicare RVU 2012 Medicare RVU No code No code & & 0.15 Unchanged

48 CPT Errata Websites corrections.pdf ICD-10-CM _GEMs.asp Modifier 33

49 Thank You! Questions???

50 2012 Practice Administrator Meeting Schedule TENTATIVE Location to be determined Tuesday, 1/17/2012 9:30 12:00 Tuesday, 2/21/2012-9:30am 12:00 Tuesday, 3/20/2012-9:30am 12:00 Tuesday, 4/17/2012-9:30am 10:30am - Teleconference Tuesday, 5/15/2012-9:30am 12:00 NO MEETING IN JUNE NO MEETING IN JULY Tuesday, 8/21/2012-9:30am 12:00 NO MEETING IN SEPTEMBER Tuesday, 10/16/2012-9:30am 12:00 Tuesday, 11/20/2012-9:30am 12:00 NO MEETING IN DECEMBER

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52 Kids Health First (KHF) Performed an initial evaluation of KHF data & telecom services Under 3 year Cbeyond contract with 1 year auto renewals Evaluated organization s IT and business needs and recommended a better solution: KHF is now on a similar data/telecom product with an annual savings of $1,900 Solution provides better technology with a faster network at a much lower price New contract is for 3 years then month-to-month auto renewals 1PR leverages technical knowledge and long-standing relationships with multiple voice and data providers to benefit their clients November st Physicians Resource, LLC 2

53 Kids Health First (KHF) 1PR created a customized & unique technology plan for KHF 1PR provided a discount to KHF on both hardware and software purchases averaging additional 15% discounts Evaluated KHF s teleconferencing services and offered a much broader product at a lower price $0.05 per minute, 56% less per minute than prior contract Web conferencing service added under agreement for 30% less than prior teleconferencing rate. Not previously available under old contract. 1PR updated the KHF phone system to optimize for future business needs and at a lower cost than what was considered Includes enhanced features Additional lines and bandwidth November st Physicians Resource, LLC 3

54 Kids Health First (KHF) Consolidated anti-virus/spyware protection for KHF Single product with better coverage Improved computer performance Save approximately $45 per computer per year 1PR identified an improved anti-spam provider for KHF New provider is the industry leader Save approximately $800 annually Improving the backup and data retention plan Online backup process through a practice group discount Critical data backed up online and with a local copy Non-critical data stored at an offsite secure location November st Physicians Resource, LLC 4

55 Kids Health First (KHF) Reconfigured the wireless network Improved performance and levels of access Improved security Acquired and installed a projector for KHF conference room 1PR is currently working with KHF to: Improve the technology platform of custom application Provide advanced reporting capabilities within custom application Allow future growth and add stability within the custom application Entered monthly maintenance agreement saving 20% and no additional hourly charges KHF Staff has much greater customer satisfaction as a result of the change in service providers November st Physicians Resource, LLC 5

56 1PR Team Composition 1 st Physicians Resource (1PR) is a physician owned medical services cooperative based in Atlanta. Key Leadership Norman Chip Harbaugh, MD, Chairman, CEO and Majority Owner Paul Wilson, President Marc McGrath, Chief Information Officer Sean Austin, Information Technology Manager Medical Directors Geoffrey Simon, MD, Pediatrics Suzanne Lowry, MD, OB/GYN John Muse, DDS, Oral Surgery November 2011 CONFIDENTIAL 6

57 1PR Corporate Services Network Monitoring Card Processing PC and Server Support Services for Medical and Dental Clients Financial Controls Data and Telecom Reviews Primarily Technology and Financial Based Services Equipment Purchasing Hosted Exchange Information Security Solutions Online Backup and Recovery Focused on Cost Reduction and Improving Practice Efficiency November st Physicians Resource, LLC 7

58 Case Study #1 Two Site Practice with PM/EMR software running from the primary office Practice administrator wanted to resolve a restriction limiting the number of people accessing the Internet at any one time 1PR reviewed the Internet configuration 1PR identified practice was sending ALL patient data as plain text over the Internet when second office accessed the system 1PR implemented hardware firewalls and properly configured a private network between the sites to encrypt patient data 1PR solution dramatically improved the Internet access as desired 1PR solution also protects patients from identity theft and ensures HIPAA compliance for the practice November st Physicians Resource, LLC 8

59 Case Study #2 Multi-site practice with minimal backup protection Using only tape backups to secure copies of data Practice was reliant on employees taking the tapes home at night adding potential risk Potential for human error Potential theft of data if tapes are lost or stolen 1PR improved backup reliability at a lower cost Backup tapes cost $65 to $75 each with a useful life of 30 uses Online automatic backup solution eliminated need for tapes Solution saved practice approximately $500/year in hard costs as well as significant soft costs November st Physicians Resource, LLC 9

60 Next Steps Take advantage of our FREE data and telecom review by providing us with your contact information Provide most recent data and telecom statements 1PR will provide you with a summary report outlining: Savings opportunities Technical enhancements and additional services Right-sizing data and telecom cost and capacity November st Physicians Resource, LLC 10

61 1PR Contact Information Paul Wilson, President (866) Marc McGrath, EVP/Chief Information Officer (866) st Physicians Resource, LLC 2002 Summit Blvd, Suite 300 Atlanta, Georgia November st Physicians Resource, LLC 11

62 Sanofi Pasteur Vaccine Program Requirements Effective Qualifying Product Categories Polio, Pertussis, HIB (Pediatric products) Tetanus, Diphtheria, acellular Pertussis (TdaP) Meninge 2011 Program Requirements > 90%: > 90%: > 90% Market Share > 90% of prior 12 months sales > 80% of prior 12 months sales 2012 Program Requirements > 90%: > 90%: > 90% Market Share > 90% Market Share > 90% Market Share Effective January 1, 2012, the requirement for all products is > 90% of Market Share. Contract period runs January 1 st December 31 st Administration Service Fee is applied towards practice dues. o 3.25% directly offset practice dues o 1.75% KHF Overhead contribution Practices are required to provide log-in information to KHF. As practice may choose to provide their reporting on a monthly basis for all vaccine manufactures. If a practice elects to supply monthly reports to KHF, they must be received by KHF no later than the 5 th of each month. KHF monitors purchasing to makes sure all practice adhere to the terms of the contract. If a practice is non-compliant with the terms of the contract they will be removed to the contract. Practices can also participate in the KHF Flu Contract.

63 Strong4Life Program Kids Health First has partnered with Children s Healthcare of Atlanta in an effort to combat childhood obesity! The Stong4Life Program along with other obesity initiatives will be our major quality improvement focus in We believe that addressing and caring for obesity and other disease states is the future of primary care pediatrics. You and your practice have a tremendous opportunity to lead the charge! Children s Healthcare of Atlanta has created a program called Strong4Life. This program offers motivational interviewing training that aims to improve how you interact with patients to help them make healthily nutritional choices and activity changes in their life. This is the first of many steps to improve child wellness and address childhood obesity. Participation Requirement The KHF Board of Directors is requiring 50% of providers in a practice to become Strong4Life certified by March 15, The intent is to have all providers (100%) certified within 1 year (September 2012). The Board will reevaluate the 1 year requirement in March of In order to become Strong4Life Certified you must complete a 1½ to 2 hour training session with Children s. See details below. Training Schedule Children s offers many convenient training opportunities. If your practice has 7 or more providers, training can be completed at your office. For a complete list, or to schedule your training, contact Wendy Palmer at or wendy.palmer@choa.org. Notify Elizabeth Hogan at KHF (ehogan@khfirst.com) when your practice or physicians complete training to ensure you will receive credit. Certified Physician Once a physician has completed training, they will be Strong4Life Certified. We feel this is a huge Marketing opportunity for your practice and we are looking into ways for practices to capitalize even more on this opportunity. Physician Resources Kids Health First is working with Children s to create additional physician resources by region including nutritionists, dietitians, educational materials, educational programs, FAQ s, recipes, list serves, etc. MOC Program for 2012 Kids Health First along with Children s Healthcare of Atlanta will be creating an American Board of Pediatrics Maintenance of Certification (MOC) Program in The program will be similar to the recent DDH program and will allow all physicians to capture additional MOC Part 4 points through participation in a clinically integrated initiative. Point of Contact Any questions? Contact Elizabeth Hogan at Kids Health First x205 or ehogan@khfirst.com Be Sure to Check Websites for Additional Information Visit the Kids Health First Website at Then login into the member only site for up-to-date information. Visit Children s Strong4Life website at

64 Strong4Life Program Kids Health First has partnered with Children s Healthcare of Atlanta in an effort to combat childhood obesity! The Stong4Life Program along with other obesity initiatives will be our major quality improvement focus in We believe that addressing and caring for obesity and other disease states is the future of primary care pediatrics. You and your practice have a tremendous opportunity to lead the charge! Children s Healthcare of Atlanta has created a program called Strong4Life. The Strong4Life Provider Program offers motivational interviewing training that aims to improve how you interact with patients to help them make healthy nutritional choices and activity changes in their life. This is the first of many steps to improve child wellness and address childhood obesity. Participation Requirement The KHF Board of Directors is requiring 50% of providers in a practice to become Strong4Life certified by May 15, The intent is to have all providers (100%) certified within 1 year (November 2012). The Board will reevaluate the 1 year requirement in May In order to become Strong4Life Certified you must complete the 2 hour training session with Children s. Children s offers many training options, see details below. Training Schedule Children s offers many convenient training opportunities. If your practice has 7 or more providers, training can be completed at your office. For a complete list of dates to attend training, or to schedule your practice for training, contact Wendy Palmer at or wendy.palmer@choa.org. Participants must register in advance to attend training! Notify Elizabeth Hogan at KHF (ehogan@khfirst.com) when your practice or physicians complete training to ensure you will receive credit. Certified Physician Once a physician has completed training, they will be Strong4Life Certified Physician. We feel this is a huge Marketing opportunity for your practice and we are looking into ways for practices to capitalize even more on this opportunity. All Strong4Life Certified Physicians will be listed on the Strong4life website in the near future. Physician Resources Kids Health First is working with Children s to create additional physician resources by region including nutritionists, dietitians, educational materials, educational programs, FAQ s, recipes, list serves, etc. MOC Program for 2012 Kids Health First along with Children s Healthcare of Atlanta will be creating an American Board of Pediatrics Maintenance of Certification (MOC) Program in The program will be similar to the recent DDH program and will allow all physicians to capture additional MOC Part 4 points through participation in a clinically integrated initiative. Point of Contact Any questions? Contact Elizabeth Hogan at Kids Health First x205 or ehogan@khfirst.com Be Sure to Check Websites for Additional Information Visit the Kids Health First Website at Then login into the member only site for up-to-date information. Coming soon! Visit Children s Strong4Life website at