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CMS says it's not too late to avoid payment adjustments

Mon, 17 Jun 2013 05:00:00 GMT

by Jaclyn Fitzgerald, Online editor

Eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) that cannot demonstrate meaningful use of electronic health records (EHRs) could soon face Medicare payment adjustments. But CMS has an important message for providers: there’s still time to prove meaningful use and avoid adjustments.

“Some providers are under the impression that it’s too late, but there’s certainly time this year and there’s time next year,” says Robert Anthony, deputy director of the Health IT Initiatives group in the Office of E-Health Standards and Services at CMS. “It’s not too late for them to select an EHR that’s right for them, to implement that EHR, and to become meaningful users.”

Beginning January 1, 2015, CMS will apply payment adjustments to Medicare physician fee schedule rates of EPs who do not demonstrate meaningful use before October 1, 2014. EPs will face a cumulative 1% decrease for each year that they do not meet meaningful use standards. If CMS deems the number of Medicare EPs demonstrating meaningful use in 2018 to be favorable, it may places a 5% cap on the cumulative adjustments.

Beginning October 1, 2014, eligible hospitals that have not proved to be meaningful users will see adjustments applied to the percentage increase to the Inpatient Prospective Payment Systems (IPPS) payment rate, while CMS would apply CAH adjustments to the cost reporting period in which the CAH was unable to demonstrate meaningful use.

EPs and eligible hospitals that have demonstrated meaningful use in 2011 or 2012 can avoid the 2015 payment adjustments by demonstrating meaningful use throughout 2013. Those who have not yet proved meaningful use can avoid the 2015 adjustments by reporting meaningful use for a 90-day period in 2013 or in 2014 before beginning of fiscal year 2015. Providers must continues to demonstrate meaningful use to avoid payment adjustments in subsequent years. CAHs must demonstrate meaningful use by fiscal year 2015 and will need to continue to be meaningful users thereafter.

“That’s really why we’re trying to get people going now. There’s still time for people to participate and receive incentive monies and we’d really love to see those people participate,” says Anthony. “We’re hoping as we talk more about it this year that more people will get involved and receive some incentives and avoid payment adjustments overall.”

Anthony says that the best way to demonstrate meaningful use is to look at the big picture, rather than focusing on each incentive program objective individually. In his experience, the providers that are successful at demonstrating meaningful use are the ones that incorporate the objectives into their overall workflow and standards because aiming to meet just the minimum can often be more of a challenge.

While it may seem as if the payment adjustments are a means of penalizing Medicare providers who fail to exhibit meaningful use, Anthony says that “the goal here is to drive people to participate.” He describes it as “a second stage in moving people towards meaningful use,” with the first stage being payment incentives. According to Anthony, CMS hopes that providers will be compelled to display meaningful use not only because it can improve the quality of healthcare but because they want to receive payment incentives and avoid negative payment adjustments.

“Incentive payments are great. Avoiding payment adjustments is fantastic. But I think the real payout for people in healthcare is going to be improving the quality of care for patients,” says Anthony.

For more information on EHR Incentive Program payment adjustments, please visit http://tinyurl.com/mmccxgc.

OCR's new all-inclusive HIPAA doc

Mon, 17 Jun 2013 05:00:00 GMT

Want all things HIPAA all in one document?

OCR has provided it in its HIPAA Administrative Simplification document via its website.

The complete suite of regulations outlined in this document can be found at 45 CFR Parts 160, 162, and 164, and includes:

Transactions and code set standards
Identifier standards
Privacy rule
Security rule
Enforcement rule
Breach notification rule

Now, it’s all in a convenient combined regulation text (as of March 2013). This is an unofficial version that presents all the regulatory standards in one document, OCR states on its website. The official version of all federal regulations is published in the Code of Federal Regulations (CFR).

This article originally appeared on HCPro, Inc.’s HIPAA Update blog.

Eyes see more ICD-10-CM codes because of laterality

Mon, 17 Jun 2013 05:00:00 GMT

In ICD-10-CM, the eyes get their own chapter of codes. No more sharing with the ears, hear that?

One of the first things you’ll notice in the chapter on diseases of the eyes is the significant increase in the number of codes. We see that everywhere in ICD-10-CM, so it’s really not a surprise.

The increased number of codes isn’t as scary as you might think. In many cases, the increase is simply due to the addition of laterality.

For example, a patient comes in with dacryops (excess tears). In ICD-9-CM, we have one code: 375.11.

In ICD-10-CM, we’ll choose from these four codes:

H04.111, dacryops of right lacrimal gland
H04.112, dacryops of left lacrimal gland
H04.113, dacryops of bilateral lacrimal glands
H04.119, dacryops of unspecified lacrimal gland

The only difference is laterality—which eye is affected. Hopefully, our physicians are documenting that information now. Pull some records and find out. If they are, great, that’s one less thing to worry about when we transition to ICD-10-CM.

If they aren’t, start querying for it now. If the physician answers the query, great, it’s more information in the patient’s record. If the physician doesn’t respond, you can still code the record and get the bill out the door. Either way, you’re training them for ICD-10-CM.

The same holds true for many of the conditions of the eye, such as blepharochalasis (inflammation of the eyelid). In ICD-9-CM, we again have only one code choice: 374.46.

The ICD-10-CM codes not only specify right and left eye, they also denote upper and lower eyelid:

H02.30, blepharochalasis unspecified eye, unspecified eyelid
H02.31, blepharochalasis right upper eyelid
H02.32, blepharochalasis right lower eyelid
H02.33, blepharochalasis right eye, unspecified eyelid
H02.34, blepharochalasis left upper eyelid
H02.35, blepharochalasis left lower eyelid
H02.36, blepharochalasis left eye, unspecified eyelid

So we’ve gone from one code to seven with the addition of one piece of information: the specific site of the inflammation.

As a side note, you should rarely, if ever, report H02.03 (unspecified eye, unspecified eyelid). Really, the physician should be documenting that information. If he or she isn’t, query. I doubt many payers are going to reimburse for H02.03 for long. After all, one reason to move to ICD-10-CM is the increased specificity.

Cataracts aren’t quite as clear a transition. In ICD-9-CM, we have numerous codes under the category cataracts (366) divided into these subcategories:

366.0, infantile juvenile and presenile cataract
366.1, senile cataract
366.2, traumatic cataract
366.3, cataract secondary to ocular disorders
366.4, cataract associated with other disorders
366.5, after-cataract
366.8, other cataract
366.9, unspecified cataract

Each subcategory includes multiple codes with more specificity.

However, ICD-10-CM breaks cataracts into two main categories:

H25, age-related cataract
H26, other cataract

Age-related cataracts further divide into:

H25.0, age-related incipient cataract
H25.1, age-related nuclear cataract
H25.2, age-related cataract, morgagnian type
H25.8, other age-related cataract

Under other cataracts, you’ll find these main subcategories:

H26.0, infantile and juvenile cataract
H26.1, traumatic cataract
H26.2, complicated cataract
H26.3, drug-induced cataract
H26.4, secondary cataract
H26.8, other specified cataract
H26.9, unspecified cataract

For both age-related and other cataracts, we need to know which eye is affected. Many of the other details are similar to ICD-9-CM, just organized in a slightly different fashion. For example, in both ICD-9-CM and ICD-10-CM, traumatic cataracts break down into:

Localized
Partially resolved
Total

ICD-10-CM adds laterality and an additional subcategory for unspecified (again, you should query for more specifics before you report an unspecified code).

Look at your current records to see whether you can code them in ICD-10-CM. As long as your physicians are documenting laterality, you should be good to go. You’ll just need to remember to look for that detail when you code in ICD-10-CM.

If they aren’t documenting laterality, start asking for it now. By the time we switch to ICD-10-CM, they’ll be used to documenting it.

By the way, you don’t need to tell them you’re asking for laterality because of ICD-10-CM. Just ask. You might be surprised by the response.

This article originally appeared on HCPro, Inc.’s ICD-10 Trainer blog.

Documentation of medical necessity drives successful RA appeals

Mon, 17 Jun 2013 05:00:00 GMT

Most hospitals have been overwhelmed by Recovery Auditor (RA) requests for documentation. So it's no surprise that the RAs themselves seem to be equally as burdened with the task of processing those records.

"There has been a great deal of overload and overburden on the system in general," says Marilyn S. Palmer, DO, vice president of audit, compliance, and education at Executive Health Resources in Newton Square, Pa. "This is part of the reason why CMS is addressing this Part A to B rebilling."

Qualified Independent Contractors, the entities responsible for processing level two appeals, have 60 days to make a determination. If they're unable to do this, they must provide hospitals with a process to escalate the denial directly to the Administrative Law Judge the third level of appeals. Palmer says the ALJ is increasingly remanding cases back to the QIC, which only increases the burden placed on it. Executive Health Resources, which assists hospitals in the appeals process, receives approximately 2,500 escalation notices per week, she adds.

Continue reading “Documentation of medical necessity drives successful RA appeals” on the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have free access to this article in the June issue.

HIPAA Q&A: Receiving faxed HEDIS requests

Mon, 17 Jun 2013 05:00:00 GMT

Q. Is it a HIPAA violation if a hospital receives a faxed Healthcare Effectiveness Data and Information Set (HEDIS) request and the hospital cannot identify the patient by full name, last name, or birth date?

These requests contain name, birthdates, provider, HEDIS measure (chlamydia screening, cervical cancer screening, cholesterol management, etc.), and last date of service of the patient. Typically, these faxed requests are from business associates of the patient's health insurance company, but occasionally they come directly from the insurance company.

A. Certainly, these HEDIS requests are time-consuming and administratively burdensome, and it is understandable that you want to classify those where the patient isn't easily identified as a HIPAA violation. However, remember that the patient has signed up with the health plan/business associate and that its notice of privacy practices states the health plan or business associate will obtain information for operational purposes (in this case, for quality review). Remember, too, that the health plan/business associate may only have a physician name and not the name of your organization/HIM department.

The best approach is to contact the originators of these incomplete requests to work with them to make the process as smooth as possible. It is also a good idea to let the providers in your organization know that these requests should go to your HIM department so that each individual provider isn't burdened by responding to these requests.

Editor’s note: Chris Simons, MS, RHIA, director of health information and privacy officer at Cheshire Medical Center/Dartmouth-Hitchcock in Keene, N.H., provided these answers for HCPro’sMedical Records Briefing newsletter.

The week in Medicare updates

Mon, 17 Jun 2013 05:00:00 GMT

Pass-through payments for CRNA anesthesia services and related care

On June 7, CMS issued a transmittal clarifying that effective January 1, 2013, qualifying critical access hospitals and rural hospitals are eligible to receive Certified Registered Nurse Anesthetists (CRNAs) pass-through payments for services that a CRNA is legally authorized to perform in the state in which the services are furnished.

Effective date: January 1, 2013

Implementation date: September 9, 2013

View transmittal R2719CP.

Revised Appendix A, Interpretive Guidelines for Hospitals, Appendix L, Interpretive Guidelines for Ambulatory Surgical Centers, and Appendix W, Interpretive Guidelines for Critical Access Hospitals

On June 7, CMS issued a transmittal to revise regulations adopted for hospitals in 42 CFR Part 482, ambulatory surgical centers in 42 CFR Part 416, and critical access hospitals in 42 CFR Part 485, Subpart F.

View transmittal R84SOMA.

Implementation of the Award for the Jurisdiction K (JK) Part A and Part B Medicare Administrative Contractor (A/B MAC) to National Government Services

On June 7, CMS issued a transmittal to implement the Jurisdiction K (JK) A/B MAC award to National Government Services.

Effective date: October 1, 2013

Implementation date: October 7, 2013

View transmittal R1246OTN.

July 2013 Update of the Hospital Outpatient Prospective Payment System (OPPS)

On June 7, CMS issued a transmittal to describe changes to and billing instructions for various payment policies implemented in the July 2013 OPPS update.

Effective date: July 1, 2013

Implementation date: July 1, 2013

View transmittal R2718CP.

Implementing the Recompetition Award for the Jurisdiction L (formerly Jurisdiction 12) Part A/Part B Medicare Administrative Contractor (A/B MAC) Workload

On June 7, CMS issued a transmittal stating that the Jurisdiction L A/B MAC recompetition procurement was awarded to the incumbent contractor, Novitas Solutions, Inc.

Effective date: July 1, 2013

Implementation date: July 1, 2013

View transmittal R1245OTN.

Removal of POR and PSOR instructions and the Glossary of Acronyms from the Internet Only Manual, Publication 100.06, Chapter 3

On June 7, CMS issued a change request to remove all instructions in the IOM Publication 100.06, Chapter 3 related to POR and PSOR systems and the Glossary of Acronyms. These systems are retired and the Glossary of Acronyms is outdated.

Effective date: July 9, 2013

Implementation date: July 9, 2013

View transmittal R220FM.

Implementation of the End Stage Renal Disease (ESRD) Prospective Payment System (PPS)

On June 7, CMS issued a transmittal to update and reorganize the ESRD chapter in the Medicare Benefit Policy Manual to reflect the ESRD PPS.

Effective date: January 1, 2011

Implementation date: September 9, 2013

View transmittal R171BP.

View MLN Matters article MM8261.

Revisions to Chapter 7–Risk Adjustment

On June 7, CMS issued a transmittal to revise Chapter 7 significantly by focusing it only on risk adjustment, retitling it accordingly, and moving the topic of payments to Medicare Advantage Organizations to Chapter 8. It now includes much more information on risk adjustment since the last revision, including background on the statutory and regulatory authority for risk adjustment, the history of risk adjustment, a schedule, and information on the Part D (RxHCC) model.

View transmittal R114MCM.

Changes to the Provider Reimbursement Manual

On June 7, CMS issued a transmittal to clarify existing instructions, incorporate statutory changes and comply with an Executive Order as it relates to Part 2, Provider Cost Reporting Forms and Instructions, Chapter 42, Form CMS-265-11.

View transmittal R2P242.

Autologous Platelet-rich Plasma (PRP) for Chronic Non-healing Wounds

On June 10, CMS issued a change request to include attachments that should have been included for previous transmittals.

View transmittal R2720CP.

Implementation of CMS Ruling 1455-R (Medicare Program; Part B Billing in Hospitals)

On June 10, CMS issued a change request to correct coding and remarks requirements for Part B claim in BR 8277.17 and BR8277.18.

View transmittal R1247OTN.

OIG releases Sequestration Operating Plan for FY2013

On June 6, the OIG released the Sequestration Operating Plan for FY2013.

View the release.

OIG issues report on comparing lab test payment rates

On June 10, OIG issued a report comparing lab test payment rates and found that in 2011, Medicare paid 18%-30% more than other insurers for 20 high-volume and/or high-expenditure lab tests, and could have saved $910 million (38%) on these lab tests if it had paid providers at the lowest established rate in each geographic area.

View the report.

Remind your workforce members to ’zip their lips’ when it comes to patient privacy

Mon, 17 Jun 2013 05:00:00 GMT

In a time when so much attention is focused on issues such as cyber security and the dangers posed from evolving technology, it's easy to forget the HIPAA basics such as the need for workforce members not to gossip or chitchat about patients with other staff members or people in the community.

One reminder of that recently came up on a HIPAA listserv with a lively exchange of comments about whether a hospital staff member created a HIPAA breach by talking about a patient with a neighbor. Opinions differed about whether the exact circumstances constituted a breach, but the lesson for Greg Young, information security officer at Mammoth Hospital in Mammoth Lakes, Calif., was clear: healthcare organizations need to keep up their efforts to provide staff with ongoing privacy education to prevent the kind of gossip that created the potential violation.

Continue reading “Remind your workforce members to 'zip their lips' when it comes to patient privacy” on the HCPro website. Subscribers to Briefings on HIPAA have free access to this article in the June issue.

Don't forget to submit your comments for the IPPS proposed rule

Mon, 10 Jun 2013 05:00:00 GMT

by Jaclyn Fitzgerald, Online editor

CMS proposed revisions to the Hospital Inpatient Quality Reporting (IQR) Program when it issued the Hospital Inpatient Prospective Payment System (IPPS) Notice of Proposed Rulemaking (NPRM) in April. CMS is currently accepting comments on the proposed rule but the deadline for submission is quickly approaching. All comments must be submitted by June 25 so that responses can be included in the final rule, which will be issued by August 1.

CMS included several policies that are expected to align the Medicare EHR Incentive Program and the Hospital IQR Program in the proposed rule. CMS is considering allowing providers to begin submitting electronic clinical quality measures (eCQMs) within the Medicare EHR Incentive Program January 2, 2014.

CMS also proposed allowing hospitals participating in the Hospital IQR Program to electronically submit one quarter's data for 16 quality measures from four measure sets (stroke, venous thromboembolism, emergency department and perinatal care) in 2014 for Fiscal Year 2016 Hospital IQR Program payment determination. The measures in three of these four measure sets—STK, VTE, ED—(15 measures) are already included in the Medicare EHR Incentive Program Electronic Reporting Pilot for Eligible Hospitals. CMS proposed adding one measure—PC-01 elective delivery—from fourth measure set (perinatal care) because the measure is burdensome to report using chart abstraction.

Electronic reporting in 2014 would be voluntary, but CMS proposed making it mandatory in 2015.

The proposed rules are intended to streamline hospital quality-reporting programs and make the best use of EHRs. It would also allow hospitals to satisfy the CQM and Medicare EHR Incentive Program reporting requirements by electronically submitting all four measure sets.

The proposed rule can be downloaded at http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1. You can submit your comments at http://www.regulations.gov/#!submitComment;D=CMS-2013-0084-0002.

Medical center alerts patients of lost PHI

Mon, 10 Jun 2013 05:00:00 GMT

The University of Rochester Medical Center (URMC) has sent letters to a group of former orthopaedic patients, alerting them to the loss of PHI, it announced on its website May 3.

URMC notified 537 patients that a resident physician misplaced a USB computer flash drive that contained PHI. The flash drive was used to transport information used to study and continuously improve surgical results. The information was copied from other files and so its loss will not affect follow-up care for any patients.

The flash drive included the patients’ names, gender, age, date of birth, weight, telephone number, medical record number (a number internal to URMC), orthopaedic physician’s name, date of service, diagnosis, diagnostic study, procedure, and complications, if any. No address, Social Security number, or insurance information of any patient was included.

The flash drive is believed to have been lost at a URMC outpatient orthopaedic facility, according to the URMC release. Hospital leaders believe that the drive likely was destroyed in the laundry. The laundry service, which works exclusively with hospital/medical facilities, also failed to locate the drive.

URMC is providing affected patients phone numbers to call for further information, the statement said. In addition, URMC is re-educating faculty and staff about its policy that requires the use of encrypted drives when transporting PHI on flash drives. Over the past year, URMC also has developed new rules for the use of smart phones, iPads, and other mobile devices to safeguard PHI. In addition, URMC encourages its physicians and staff to access sensitive patient information using its secure network rather than transfer information on portable devices.

This article originally appeared on HCPro, Inc.’s HIPAA Update blog.

Select your ICD-10-PCS principal procedure

Mon, 10 Jun 2013 05:00:00 GMT

Sometimes our patients are very sick, very injured, or undergo multiple procedures during their stay. So how do you pick your principal procedure code in ICD-10-PCS?

The ICD-10-PCS guidelines offer the following information to use when determining the principal procedure in different situations:

Procedure performed for definitive treatment of both principal diagnosis and secondary diagnosis. Sequence the procedure performed for definitive treatment most related to principal diagnosis as principal procedure.
Procedure performed for definitive treatment and diagnostic procedures performed for both principal diagnosis and secondary diagnosis. Again we are going to sequence the procedure performed for definitive treatment most related to principal diagnosis as principal procedure.
A diagnostic procedure was performed for the principal diagnosis and a procedure is performed for definitive treatment of a secondary diagnosis. Sequence the diagnostic procedure as the principal procedure, since the procedure most related to the principal diagnosis takes precedence.
No procedures performed that are related to principal diagnosis; procedures performed for definitive treatment and diagnostic procedures were performed for secondary diagnosis. Sequence procedure performed for definitive treatment of secondary diagnosis as principal procedure, since there are no procedures (definitive or nondefinitive treatment) related to principal diagnosis.

When you look at the guidelines, they’re not really different from what we currently do. We’re always going to list the procedure most related to the principal diagnosis first. The only time you wouldn’t is when the physician doesn’t perform a procedure related to the principal diagnosis.

That makes sense when you remember that the principal diagnosis is the main reason the patient came in. So we’re going to treat the main problem first, then deal with any procedures for secondary diagnoses.

This article originally appeared on HCPro, Inc.’s ICD-10 Trainer blog.

HIPAA Q&A: Sharing patient information between clinics in the same organization

Mon, 10 Jun 2013 05:00:00 GMT

Q. Can a dentist in our organization see and access the medical record of a patient who was seen by a medical provider in our organization?

We have three medical clinics and two dental clinics. All data for the patient is stored in one database. Recently a patient complained that the dentist had accessed his or her medical record in the course of the dental treatment.

A. Yes, the dentist is allowed to access the information if it is the minimum necessary he or she needs to know to provide treatment to the patient. Your Notice of Privacy Practices (NPP) should make clear what is being done with and without your patient’s written authorization. In this case, your NPP should spell out that information will be shared between the five clinics for patient care purposes (and for operations, if true).

Product of the week: Optimizing PEPPER in the Audit Environment

Mon, 10 Jun 2013 05:00:00 GMT

How do you use the information from PEPPER at your facility? Medicare’s quarterly PEPPER report helps to determine which discharges may be vulnerable to improper payments.

Join experts Ralph Wuebker, MD, MBA, and Yvonne Focke, RN, BSN, MBA, for this 90-minute webcast at 1 p.m. (Eastern) Friday, June 21. They will cover changes to the PEPPER data for 2013, as well as provide advanced PEPPER techniques and strategies for incorporating the data into a proactive revenue cycle to stay a step ahead of external auditors. A live question and answer session will follow the presentation.

For more information or to order, call 800/650-6787 and mention Source Code EZINEAD or visit the HCPro Healthcare Marketplace.

The week in Medicare updates

Mon, 10 Jun 2013 05:00:00 GMT

CMS issues transmittal to update Chapter 29, Independent Rural Health Clinic (RHC)/ Freestanding Qualified Health Center (FQHC) cost report

On May 24, CMS issued a transmittal to update Form CMS-222-92 to reflect clarifications and corrections to existing instructions, incorporate statutory changes, and comply with an Executive Order.

View transmittal R11P229.

Updates to Chapter 12 and Chapter 16 of the Medicare Claims Processing Manual

On May 24, CMS issued a change request to make revisions to the Physicians/Nonphysician Practitioners and laboratory services chapters of the Medicare Claims Processing Manual so that billing and claims processing instructions are up-to-date with regards to billing for the Technical Component (TC) of physician pathology services furnished to hospital patients.

Effective date: July 1, 2012

Implementation date: June 25, 2013

View transmittal R2714CP.

Claim Status Category and Claim Status Codes update

On May 24, CMS issued a transmittal announcing that the Accredited Standards Committee (ASC) has decided to allow the industry six months for implementation of newly added or changed codes that are updated three times per year at the ASC X12 meetings.

Effective date: October 1, 2013

Implementation date: October 7, 2013

View transmittal R2713CP.

View MLN Matters article MM8320.

Quarterly update for the DMEPOS Competitive Bidding Program (CBP) - October 2013

On May 24, CMS issued a transmittal to notify providers that the DMEPOS CBP files have been updated and applies to Chapter 23, section 100.

Effective date: October 1, 2013

Implementation date: October 7, 2013

View transmittal R2712CP.

View MLN Matters article MM8316.

Expedited determinations for provider service terminations

On May 24, CMS issued a transmittal providing new information to the Medicare Claims Processing manual in accordance with CMS-4004-FC to ensure consistency with provisions of the final rule and clarifies operating instructions.

Effective date: August 26, 2013

Implementation date: August 26, 2013

View transmittal R2711CP.

View MLN Matters article MM7903.

Internet Only Manual (IOM) update to payment for medical or surgical services furnished by CRNAs

On May 30, CMS issued a change request to rescind and replace CR 8027, and to clarify existing manual language to bring the manual in line with revisions to regulations at 410.69.

Effective date: January 1, 2013

Implementation date: February 12, 2013

View transmittal R2716CP.

Change in creation date for CMS standard edit/audit/reason code reports

On May 30, CMS issued a change request to change the execution and delivery time Medicare Administrative Contractors (MACs) and legacy contractors will follow in the creation of the CMS standard edit/audit/reason code report.

Effective date: October 1, 2012

Implementation date: October 15, 2012; June 21, 2013 for revised business requirements

View transmittal R1242OTN.

Quarterly average sales price for Medicare Part B drug pricing files and revisions to prior quarterly pricing files

On May 31, CMS issued a transmittal to notify providers of updates to the quarterly average sales price (ASP) and to prior quarterly pricing files.

Effective date: October 1, 2013

Implementation date: October 7, 2013

View transmittal R2715CP.

Implementation of CMS ruling 1455-R

On May 31, CMS issued a transmittal to set forth requirements for contractors to implement CMS ruling 1455-R until such time as the operating instructions and necessary system changes in CR 8185 can be fully implemented.

Effective date: March 13, 2013

Implementation date: July 1, 2013

View transmittal R1243OTN.

Common Working File (CWF) Informational Unsolicited Response (IUR) or Reject for a new patient visit billed by the same physician/physician group within the past three years

On May 31, CMS issued a transmittal to update the new and established patient CPT codes in BR 8165.1 and 8165.2.

Effective date: October 1, 2013

Implementation date: October 7, 2013

View transmittal R1244OTN.

View MLN Matters article MM8165.

Update of the Ambulatory Surgical Center (ASC) payment system

On May 31, CMS issued a transmittal to describe changes to and billing instructions for various payment policies implemented in the July 2013 ASC payment system update, applied to Chapter 14, section 10.

Effective date: July 1, 2013

Implementation date: July 1, 2013

View transmittal R2717CP.

View MLN Matters article MM8328.

Revision to surety bond collection process

On May 31, CMS issued a transmittal to update CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 15, section 15.21.7.1 to reflect an alteration to the surety bond collection process for suppliers of DMEPOS.

Effective date: July 1, 2013

Implementation date: July 1, 2013

View transmittal R470PI.

Enrollment denials when an existing or delinquent overpayment exists

On May 31, CMS issued a change request to revise section 15.13 of Pub. 100-08, Program Integrity Manual, Chapter 15 for provider enrollment, and to notify providers that this new section will offer guidance on denying newly enrolling or change of ownership applications when existing or delinquent overpayment exists for an owner of a current provider or supplier or for a physician/nonphysician.

Effective date: October 1, 2013

Implementation date: October 7, 2013

View transmittal R469PI.

Detailed written orders and face-to-face encounters

On May 31, CMS issued a change request to implement changes to Pub. 100-8, Medicare Program Integrity Manual to support 42 CFR 410.38(g).

Effective date: July 1, 2013

Implementation date: July 1, 2013

View transmittal R468PI.

Requirements for the closing of complaints after transfer to the PSCs and ZPICs in the OIG hotline complaint database

On May 31, CMS issued a transmittal to clarify the procedures by which the ACs and MACs (hereinafter referred to as contractors) should handle complaints that have been transferred to the PSCs and ZPICs on the OIG hotline database.

Effective date: December 1, 2012

Implementation date: July 1, 2013

View transmittal R467PI.

Updates to Chapter 32, Home Health Agency Cost Report

On May 31, CMS issued a transmittal to update Chapter 32, Form CMS-1728-94, to clarify and correct existing instructions, and to incorporate recent statutory changes and an executive order.

View transmittal R16P232.

View transmittal R16P232F.

CMS releases FY 2014 IPPS proposed rule

Mon, 10 Jun 2013 05:00:00 GMT

Consider the following: A beneficiary is admitted to a hospital pursuant to a physician order and receives medically necessary care spanning at least two midnights. CMS will consider this appropriate for payment under Medicare Part A, according to the FY 2014 IPPS proposed rule released April 26. Actuaries estimate that this proposal for what constitutes appropriate inpatient care would increase IPPS expenditures by $220 million due to an expected net increase in inpatient encounters. CMS proposes a 2% reduction to offset projected spending increases.

The concept of appropriate Part A payments centers around whether a physician expects the patient to require a stay that crosses at least two midnights and admits him or her based on that expectation. Medicare contractors will continue to focus on inpatient admissions with lengths of stay crossing only one midnight or less, according to CMS. Physician documentation of a patient's medical history and comorbidities, severity of signs and symptoms, current medical needs, and risk of an adverse event will be paramount.

Continue reading “CMS releases FY 2014 IPPS proposed rule” on the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have free access to this article in the June issue.

Make modifications to Notice of Privacy Practices to comply with final HIPAA rule

Mon, 10 Jun 2013 05:00:00 GMT

One task that almost every healthcare organization is going to have to tackle to comply with the HIPAA omnibus final rule is amending its Notice of Privacy Practices (NPP). The final rule-released by HHS January 17 and dubbed the "mega rule"-changes the requirements for what organizations must include in their NPP.

"The required modifications dictated by the final rule are very likely to require redrafting Notices of Privacy Practices," says Elizabeth H. Johnson, Esq., a partner at Poyner Spruill, LLP.

HHS states that covered entities (CE) do not have to update notices if they already made changes to implement HITECH, provided the provisions in their current notices are consistent with the final rule's requirements, Johnson says. However, organizations are unlikely to have anticipated several of the modifications described in the final rule and these may not have been taken into account in updated versions of notices, she cautions.

Continue reading “Make modifications to Notice of Privacy Practices to comply with final HIPAA rule” on the HCPro website. Subscribers to Briefings on HIPAA have free access to this article in the June issue.

Medicare Fraud Strike Force charges 89 in nationwide takedown

Mon, 03 Jun 2013 05:00:00 GMT

by Jaclyn Fitzgerald, Online Editor

The recent Medicare Fraud Strike Force takedowns should serve as a reminder for HIM professionals that not only is Medicare fraud still a major concern, but it is one that the Department of Justice (DOJ) and the Department of Health and Human Services (HHS) are not taking lightly.

To recap, Attorney General Eric Holder and HHS Secretary Kathleen Sebelius announced May 14 that as a result of the most recent sweep, 89 individuals were charged with allegedly taking part in acts that resulted in roughly $223 million in fraudulent Medicare charges. More than 1,500 defendants have been charged with falsely billing Medicare for more than $5 billion since the Strike Force began their work in 2007.

During this takedown, 25 Florida residents were charged with falsely billing Medicare for approximately $44 million. This included a former crime-series actor who got caught in a case of life imitating art when he and his wife were charged with allegedly submitting more than $20 million in false or fraudulent claims and receiving and paying kickbacks. This modern-day Medicare Bonnie and Clyde now face up to a 10 year sentence for healthcare fraud and up to five years for each kickback charge.

A physician, medical biller, and clinic manager were charged with conspiracy to commit healthcare fraud, conspiracy to pay healthcare kickbacks, and falsification of records at three clinics in New York. It’s been said that there’s a high price to pay for beauty and this trio proved that point when they racked up $13 million in fraudulent Medicare charges while allegedly offering spa services such as massages and facials to patients. In addition to billing Medicare for separate claims to cover the lavish services provided, they were also accused of falsifying patient records when Medicare auditors asked them to produce records in relation to specific claims.

Meanwhile in Detroit, 18 people were charged with submitting $49 million in false claims. This included a scheme where three individuals who posed as physicians allegedly charged $12 million to Medicare while providing phony prescriptions and unlicensed psychotherapy.

Others in California, Louisiana, Illinois, and Texas also face charges as a result of Strike Force initiatives.

The Medicare Fraud Strike Force is a joint venture between the DOJ and HHS consisting of multiple agencies of federal, state, and local investigators to battle Medicare fraud. A federal prosecutor leads each Strike Force team from his or her respective U.S. Attorney’s Office, in cooperation with agents from the FBI and the Office of Inspector General. The Medicare Fraud Strike Force was established in March 2007 and currently has nine teams in nine cities considered “hot spots" for Medicare fraud.

Inside the corrective action plan for Idaho State University

Mon, 03 Jun 2013 05:00:00 GMT

In the business of corrective action plans for HIPAA violations, OCR means business these days. Just take a look at some of the must-dos for Idaho State University (ISU), which agreed to pay HHS $400,000 for Security Rule violations involving the breach of unsecured electronic PHI of 17,500 individuals who were patients at an ISU clinic:

Hybridization: ISU shall provide HHS with documentation designating it a hybrid entity and identifying all of its components that have been designated covered healthcare components within 30 days of the effective date.
Risk management: ISU shall provide HHS with its most recent risk management plan that includes specific security measures to reduce the risks and vulnerabilities to a reasonable and appropriate level for all of its covered healthcare components. ISU shall provide the risk management plan to HHS within 30 days of the effective date for review and approval.
Information system activity review: ISU shall provide HHS with documentation of implementation of its policies and procedures regarding information system activity review across all of its covered healthcare component clinics. ISU shall provide the documentation to HHS within 60 days of the effective date for review and approval.
Compliance gap analysis: ISU shall provide documentation of its updated compliance gap analysis activity entitled Post Incident Risk Assessment, as specified by HHS, indicating changes in compliance status regarding each Security Rule provision. Such documentation shall include, but is not limited to, a copy of the contingency plan and the documents implementing the contingency plan, as well as a listing of all technical safeguards implemented and the documents implementing the technical safeguards, across its covered healthcare component clinics, within 30 days of the effective date.
Reportable events: For a period of two years ISU shall, upon receiving information that a workforce member may have failed to comply with its privacy and security policies and procedures, promptly investigate the matter. If ISU, after review and investigation, determines that a member of its workforce has failed to comply with its privacy and security policies and procedures, ISU shall notify HHS in writing within 30 days from the date ISU made its determination. Such violations shall be known as “Reportable Events.”

This article originally appeared on HCPro, Inc.’s HIPAA Update blog.

Congenital anomaly codes contain more information in ICD-10-CM

Mon, 03 Jun 2013 05:00:00 GMT

One of the advantages to coding in ICD-10-CM is how much information is packed into a single code. You’ll find combination codes throughout the ICD-10-CM Manual. In many cases, you are coding the same information, but instead of adding a fifth character or in some cases an additional code, everything you need is in one code.

Let’s look at some examples from the congenital abnormalities codes, starting with spina bifida.

In ICD-9-CM, we have two main codes for spina bifida:

741.0, spina bifida with hydrocephalus
741.1, spina bifida without hydrocephalus

Those codes each require a fifth digit to specify the location:

0, Unspecified region
1, Cervical region
2, Dorsal (thoracic) region
3, Lumbar region

In ICD-10-CM, the location is an integral part of the code:

Q05.0, cervical spina bifida with hydrocephalus
Q05.1, thoracic spina bifida with hydrocephalus
Q05.2, lumbar spina bifida with hydrocephalus
Q05.3, sacral spina bifida with hydrocephalus
Q05.4, unspecified spina bifida with hydrocephalus
Q05.5, cervical spina bifida without hydrocephalus
Q05.6, thoracic spina bifida without hydrocephalus
Q05.7, lumbar spina bifida without hydrocephalus
Q05.8, sacral spina bifida without hydrocephalus
Q05.9, spina bifida, unspecified

You’re still coding the same information, it’s just set up differently.

One difference to note however is Arnold-Chiari syndrome, which is a malformation of the brain. In ICD-9-CM, it is included under spina bifida with hydrocephalus. In ICD-10-CM, it has its own code series: (Arnold-Chiari syndrome, type II, Q07.0-), which provides additional details about the condition.

You’ll find some differences in the information required to code cleft lip, cleft palate, or both. In ICD-9-CM, the codes for cleft lip, cleft palate, and cleft palate with cleft lip are divided into:

Unilateral complete
Unilateral incomplete
Bilateral complete
Bilateral incomplete

The ICD-10-CM codes are more specific about where the anomaly is located. For example, for a cleft palate, you will choose from these codes:

Q35.1, cleft hard palate
Q35.3, cleft soft palate
Q35.5, cleft hard palate with cleft soft palate
Q35.7, cleft uvula
Q35.9, cleft palate, unspecified

For a cleft lip, you have these three choices:

Q36.0, cleft lip, bilateral
Q36.1, cleft lip, median
Q36.9, cleft lip, unilateral

As you can probably guess, the codes for cleft palate with cleft lip provide a wealth of detail about the patient’s particular problem. Those codes include:

Q37.0, cleft hard palate with bilateral cleft lip
Q37.1, cleft hard palate with unilateral cleft lip
Q37.2, cleft soft palate with bilateral cleft lip
Q37.3, cleft soft palate with unilateral cleft lip
Q37.4, cleft hard and soft palate with bilateral cleft lip
Q37.5, cleft hard and soft palate with unilateral cleft lip
Q37.8, unspecified cleft palate with bilateral cleft lip
Q37.9, unspecified cleft palate with unilateral cleft lip

Our last congenital malformation for the day is syndactyly. In ICD-9-CM, the codes include webbing of digits and are divided into fingers and toes, and with or without fusion.

ICD-10-CM codes report the same information, but separate out webbing and fusion into different code series. The ICD-10-CM codes also include laterality.

For fused toes on the right foot, report Q70.21. For webbed toes on the right foot, you would use code Q70.31. And so on.

This article originally appeared on HCPro, Inc.’s ICD-10 Trainer blog.

Don’t let underpayments fly under the radar

Mon, 03 Jun 2013 05:00:00 GMT

Nearly 75% of participating hospitals nationwide with Recovery Auditor (RA) activity reported receiving at least one underpayment determination, according to the AHA RACTrac survey, fourth quarter 2012, released in March. Sixty-nine percent of hospitals with underpayment determinations cited incorrect MS-DRG as a reason for the underpayment.

Incorrect principal diagnosis code assignment—as well as the inadvertent omission of CCs and MCCs—can potentially yield lower-paying and inaccurate DRGs, says Donna Didier, MEd, RHIA, CCS, director of coding compliance for TrustHCS in Springfield, Mo. It’s important to monitor data and ensure accurate coding that reflects patient severity, she adds.

“In our experience, we have found that if a chart is coded incorrectly, more often than not, the chart is undercoded,” says Patricia L. Belluomini, RHIA, director of CBIZ KA Consulting Services, LLC, in East Windsor, N.J. Missing CCs or MCCs is usually the culprit, she adds.

Continue reading “Don't let underpayments fly under the radar” on the HCPro website. Subscribers to Briefings on Coding Compliance Strategies have free access to this article in the May issue.

Product of the week: Acute and Chronic Renal Failure Coding

Mon, 03 Jun 2013 05:00:00 GMT

Renal failure coding continues to be a problem area for even the most experienced professionals. Join us for this 90-minute webcast at 1 p.m. (Eastern) Wednesday, June 12. Our expert speakers, Garry L. Huff, MD, CCS and Brandy Kline, RHIA, CCS, CCS-P, CCDS, will address new Acute Kidney Injury Network (AKIN) criteria, acute vs. chronic kidney disease, and other clinical aspects of renal failure and related conditions. They also deal with the common documentation shortcomings related to this subject area and appropriate physician query techniques to resolve them. Two live question-and-answer sessions will follow the presentation.

In addition to the expertise and advice presented during this webcast, you'll also receive a slide presentation of the program materials plus the following bonus items:

Table of CKD
Table of AKI
ICD-10 crosswalk for AKI, CKD, and different types of dialysis

For more information or to order, call 800/650-6787 and mention Source Code EZINEAD or visit the HCPro Healthcare Marketplace.