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HHS Releases a Proposed Rule for ICD-10 Go-Live October 2014

Garden with some tulips and narcissus

Today HHS announced a proposed rule (complete rule here – 175 page pdf) that would delay the go live for ICD-10 from October 1, 2013 to October 1, 2014. What follows are excerpts from the proposed rule.

Why Has HHS Proposed a Change to the Live Date for ICD-10-CM and ICD-10-PCS?

The final rule adopting ICD-10-CM and ICD-10-PCS (collectively, “ICD-10”) as HIPAA standard medical data code sets was published in the Federal Register on January 16, 2009. The ICD-10 final rule requires covered entities to use ICD-10 beginning October 1, 2013.

In late 2011 and early 2012, three issues emerged that led Secretary of HHS Kathleen Sebelius to reconsider the compliance date for ICD-10:

  1. The industry transition to Version 5010 did not proceed as effectively as expected;
  2. Providers expressed concern that other statutory initiatives are stretching their resources; and
  3. Surveys and polls indicated a lack of readiness for the ICD-10 transition.

The Transition to Version 5010

As the industry approached the January 1, 2012 Version 5010 compliance date, a number of implementation problems emerged, some of which were unexpected. These included–

  • Trading partners were not ready to test the Version 5010 standards due to vendor delays in delivering and installing Version 5010-compliant software to their provider clients;
  • Version 5010 errata were issued to correct typographical mistakes and other maintenance issues that were discovered as the industry began its internal testing of the standards, which delayed vendor delivery of compliant products and external testing;
  • Differences between address requirements in the “provider billing address” and “pay to” address fields adversely affected crossover claims processing;
  • Inconsistent payer interpretation of standard requirements at the front ends of systems resulted in rejection of claims, as well as other technical and standard misinterpretation issues;
  • Edits made in test mode that were later changed when claims went into production without adequate notice of the change to claim submitters; and
  • Insufficient end to end testing with the full scope of edits and business rules in place to ensure a smooth transition to full production.

Given concerns that industry would not be compliant with the Version 5010 standards by the January 1, 2012 compliance date, the HHS announced on November 17, 2011 that they would not initiate any enforcement action against any covered entity that was not in compliance with Version 5010 until March 31, 2012, to enable industry adequate time to complete its testing and software installation activities. On March 15, 2012, this date was extended an additional 3 months, until June 30, 2012.

The ICD-10 final rule set October 1, 2013 as the compliance date, citing industry testimony presented to NCVHS (National Committee on Vital and Health Statistics) and many of the over 3,000 industry comments received on the ICD-10 proposed rule.

The analysis in the ICD-10 final rule with regard to setting a compliance date emphasized the interdependency between implementation of ICD-10 and Version 5010, and the need to balance the benefits of ICD-10 with the need to ensure adequate time for preparation and testing before implementation.

As noted in the ICD-10 final rule, “[w]e cannot consider a compliance date for ICD-10 without considering the dependencies between implementing Version 5010 and ICD-10. We recognize that any delay in attaining compliance with Version 5010 would negatively impact ICD-10 implementation and compliance.” (74 FR 3334) Based on NCVHS recommendations and industry feedback received on the proposed rule, we determined that “24 months (2 years) is the minimum amount of time that the industry needs to achieve compliance with ICD-10 once Version 5010 has moved into external (Level 2) testing.” (74 FR 3334) In the ICD-10 final rule, we concluded that the October 2013 date provided the industry adequate time to change and test systems given the 5010 compliance date of January 1, 2012.

As implementation of ICD-10 is predicated on the successful transition of industry to Version 5010, we are concerned that the delays encountered in Version 5010 have affected ICD-10 planning and transition timelines.

Providers have Expressed Concern that Other Statutory Initiatives are Stretching Their Resources

Since publication of the ICD-10 and Modifications final rules, a number of other statutory initiatives were enacted, requiring health care provider compliance and reporting. Providers are concerned about their ability to expend limited resources to implement and participate in the following initiatives that all have similar compliance timeframes:

  1. The EHR Incentive Program was established under the Health Information Technology for Economic and Clinical Health (HITECH) Act, a part of the American Recovery and Reinvestment Act of 2009 (Pub. L. 111-5). Medicare and Medicaid incentive payments are available to eligible professionals and hospitals for adopting electronic health record (EHR) technology and demonstrating meaningful use of such technology. Eligible professionals and hospitals that fail to meaningfully use EHR technology could be subject to Medicare payment adjustments beginning in FY 2015.
  2. The Physician Quality Reporting System is a voluntary reporting program that provides incentives payments to eligible professionals and group practices that satisfactorily report data on quality measures for covered Physician Fee Schedule services furnished to Medicare Part B Fee-for-Service beneficiaries.
  3. The eRx Incentive Program is a reporting program that uses a combination of incentive payments and payment adjustments to encourage electronic prescribing by eligible professionals. Beginning in 2012 through 2014, eligible professionals who are not successful electronic prescribers are subject to a payment adjustment.
  4. Finally, section 1104 of the Affordable Care Act imposes additional HIPAA Administrative Simplification requirements on covered entities.

January 1, 2013
•    Operating rules for eligibility for a health plan and health care claim status transactions

December 31, 2013
•    Health plan compliance certification requirements for health care electronic funds transfers (EFT) and remittance advice, eligibility for a health plan, and health care claim status transactions

January 1, 2014
•    Standards and operating rules for health care electronic funds transfers (EFT) and remittance advice transactions

December 31, 2015
•    Health plan compliance certification requirements for health care claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, health care claims attachments, and referral certification and authorization transactions

January 1, 2016
•    Standard for health care claims attachments •    Operating rules for health care claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, referral certification and authorization transactions

Proposed October 1, 2014
•    Unique health plan identifier

Current State of Industry Readiness for ICD-10

It is crucial that all segments of the health care industry transition to ICD-10 at the same time because the failure of any one industry segment to successfully implement ICD-10 has the potential to affect all other industry segments. Ultimately, such failure could result in returned claims and provider payment delays that disrupt provider operations and negatively impact patient access to care.

In early 2012, it became evident that sectors of the health care industry would not be prepared for the October 1, 2013 ICD-10 compliance date. Providers in particular voiced concerns about their ability to meet the ICD-10 compliance date as a result of a number of factors, including obstacles they experienced in transitioning to Version 5010 HIPAA Requirements from the Affordable Care Act and the other initiatives that stretch their resources. A CMS survey conducted in November and December 2011 (hereinafter referred to as the CMS readiness survey) found that 26 percent of providers surveyed indicated that they are at risk for not meeting the October 1, 2013 compliance date.

Given the evidence that segments of the health care industry will likely not meet the October 1, 2013 compliance date, the reasons for that likelihood, and the likelihood that a compliance date delay would significantly improve the successful and concurrent implementation of ICD-10 across the health care industry, we are proposing to extend the compliance date for ICD-10.

One-Year Delay Justification

The HHS is proposing to extend the compliance date for ICD-10 for 1 year, from October 1, 2013 to October 1, 2014. This change would be reflected in the regulations at 45 CFR 162.1002. While a number of alternatives were considered for the delay, as discussed in the Impact Analysis of this proposed rule, it is believed a 1-year delay would provide sufficient time for small providers and small hospitals to become ICD-10 compliant and would be the least financially burdensome to those who had planned to be compliant on October 1, 2013.

To determine the new compliance date for ICD-10, the need for additional time for small providers and small hospitals to become compliant was balanced with the financial burden of a delay on entities that have developed budgets and planned process and system changes around the October 1, 2013 compliance date. Entities that have started planning and working toward an October 1, 2013 implementation would incur costs by having to reassess and adjust implementation plans and maintain contracts to manage the transition beyond October 1, 2013. We concluded that a 1-year delay would strike a reasonable balance by providing sufficient time for small providers and small hospitals to become compliant and would minimize the financial burden on those entities that have been actively planning and working toward being compliant on October 1, 2013.

Finally, in its March 2, 2012 letter to the Secretary on a possible delay of the ICD-10 compliance date, the NCVHS urged that any delay should be announced as soon as possible and should not be for more than 1 year. The NCVH made this recommendation in consideration of its belief that a delay would cause a significant financial burden “that accrues with each month of delay.”

The HHS believes that a 1-year delay would benefit all covered entities, even those who had are actively planning and striving for a 2013 implementation. A 1-year delay would enable the industry as a whole to test more robustly and implement simultaneously, which would foster a smoother and more coordinated transition to ensure the continued and uninterrupted flow of health care claims and payment.

Therefore, the HHS is proposing that covered entities must comply with ICD-10 on October 1, 2014.

 Bonus: Some Interesting Data I Found in the ICD-10 Proposed Rule:

  • The total number of health care claims in 2013 is projected to be 5.8 billion.
  • The cost to health plans for manually processing a pended claim is $2.30 per claim.
  • According to the Medical Group Management Association (MGMA), the staff time required to manually process a returned claim is 15 minutes, at a cost of approximately $4.14 for labor, a factor derived from the Bureau of Labor Statistics. This includes staff time spent to correct the error and resubmit claims that are returned.
  • Using the experience of one university’s bachelor’s-level health information management program, students take the ICD coding course in the spring of their junior year. Students enrolling in Spring 2012 courses will graduate in May 2013. Anticipating the October 1, 2013 compliance date, the university started offering ICD-10 courses this spring in place of ICD-9 with the understanding that it will be preparing students for employment after graduating in 2013. If ICD-10 is delayed a year, as proposed in this rule, the 30 students in the program will have to take ICD-9 courses in addition to their ICD-10 courses in order to obtain the ICD-9 competencies to get jobs. The extra course will cost each of the 30 students approximately $2,000 (in-state tuition) or a total of $61,000.
  • Total cost of a 1-year delay in the compliance date of ICD-10 = $3,808M (mean average)
  • According to the U.S. Census Bureau, Detailed Statistics, 2007 Economic Census, there are approximately 220,100 physician practices.. The U.S. Census Bureau data indicates that two percent of physician practices have revenues of $10 million or more, therefore approximately 4,400 physician practices are not small entities.
  • According to the Small Business Administration’s size standards, a small entity is defined as follows according to health care categories: Offices of Physicians are defined as small entities if they have revenues of $10 million or less; most other health care providers (dentists, chiropractors, optometrists, mental health specialists) are small entities if they have revenues of $7 million or less; hospitals are small entities if they have revenues of $34.5 million or less.
  • The 2007 Census Bureau reports that there are approximately 6,500 hospitals. The data indicates that 85 percent of hospitals have sales/receipts/revenues of $10 million or more.
  • Statistics cost of delaying ICD-10 to 2014 were based on:
    • Physician practices with less than 50 physicians = 233,239
    • Physician practices with 50 to 100 physicians = 590
    • Physician practices with more than 100 physicians = 393
    • Hospitals with less than 100 beds = 2757
    • Hospitals with 100 to 400 beds = 2486
    • Hospitals with more than 400 beds = 521

 

Haven’t Started Your ICD-10 Preparations Yet?

Start your plan by reviewing the resources below:

 

Manage My Practice offers ICD-10 transition help to physician practices, focusing on documentation improvement to support ICD-10 coding. For more information, please complete the contact form here.

 

 

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Mary Pat and Dr. Peter Polack Discuss (Approximately) 101 Ideas to Increase Revenue and Decrease Costs in a Two Part Podcast

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Mary Pat recently sat down with Peter Polack, MD of Medical Practice Trends for another podcast to talk about one of the most important parts of any practice: The Bottom Line. In this two-part podcast series, Dr. Polack and MP discuss ideas for cutting costs and raising revenue to strengthen any group’s financial position.

Click here to listen to part 1

Click here to listen to part 2




A Manage My Practice Classic: 101 Ideas for Increasing Revenue and Decreasing Expenses in Your Medical Practice

Mary Pat’s Note: This post has always been popular because it answers one of the most burning questions in Healthcare: “How can I improve my bottom line?” If you have used any of these ideas in your practice- or have some of your own to share- let us know in the comments below!

 

BUILD ON WHAT YOU’RE CURRENTLY DOING:

1. Add physician hours – add evening or weekend hours; start your office hours earlier and end hours later.

2. Reduce physician time off – decrease vacation or change weekly days off to 1/2 days off.

3. Set a minimum number of providers to be in the office seeing patients at all times the office is open.

4. Have each provider add one new patient visit to his/her schedule weekly.

5. Add ePrescribing to recoup additional Medicare revenue and streamline prescribing (there are free ePrescribing software packages available, but evaluate them carefully so they don’t add more complexity to the system instead of less.)

6. Report PQRI measures to recoup additional Medicare revenue.

7. Charge patients an out-of-pocket fee for completing patient forms – disability forms, etc. and reserve office visits for treating patients.

8. Choose an EMR that qualifies your practice for the ARRA money (although it has been widely promoted that in a larger practice, an EMR and its associated work will cost more than you will get from the government.)

9. If you are in an underserved or rural area, check to see if there might be grants or funds available locally, in the state or federally, for adding a service to your practice.

10. If your practice does Independent Medical Exams (IMEs), reviews records or depositions, make sure that your fee schedule for such services is current and that the fees are collected before the physician provides the service.


ADD TO YOUR CURRENT SERVICES:

11. Allergy testing & treatment

12. Dispensing pharmaceuticals

13. Dispensing nutriceuticals

14. Dispensing Durable Medical Equipment

15. Group patient visits

16. Coumadin Clinic

17. Heart Failure Clinic

18. Diabetes Education Classes

19. Add primary care to specialty care practices

20. Add specialty care to primary care practices

21. Research

22. Joint Ventures with other practices or hospital

23. Lease space to other entities

24. eVisits (virtual visits or email visits)

25. Elective procedures or services

26. Mid-level providers

27. Walk-in clinic

28. Occupational medicine: drug screens, employment physicals, etc.

29. Hospitalists

30. Medical Director of local nursing homes

31. Complementary & alternative medicine (CAM)

32. Aging in Place services

33. Social worker

34. Concierge practice

35. School team physician

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EVALUATE YOUR REVENUE CYCLE MANAGEMENT:

36. Are you renegotiating payer contracts regularly?

37. Do your scheduling staff know how to educate patients about what payers you have contracts with and are in network with and what the patient’s financial responsibility will be?

38. Do staff know what typical new patient charges are to tell the patient?

39. Do you check every patient’s eligibility for insurance benefits immediately prior to every service?

40. Do you have patients sign a financial policy to acknowledge what they are responsible for based on their payer type?

41. Do you copy the patient’s insurance cards at every visit, or at least compare their current card to the card you have on file? Are you able to scan patient insurance cards and driver’s licenses into your practice management (PM) system?

42. Is your PM system able to download the information from the scan into the patient registration screen? If not, do you have a way to confirm that demographic and insurance information has been entered correctly from the cards?

43. Are your charges being posted daily?

44. Does the person who provides the service, or a documentation coding specialist, choose the CPT and ICD9 code?

45. Is the documentation for the charges being completed within 24 hours of the service?

46. Is your encounter form up-to-date with current CPT and ICD9 codes; do you order smaller batches of them so you can change the codes as new services are added in the practice?

47. Do you check the CPT and ICDD9 matching to make sure the codes are valid for the year, the codes adhere to NCCI and LCD edits before you finalize the charges?

48. Do you regularly audit medical records for coding and documentation and give providers feedback on where coding could be improved?

49. Are you using ABNs for Medicare patients who want services that Medicare might not pay for?

50. Do you file claims daily?

51. Do you correct claims daily when they are rejected at the practice management, claims clearinghouse or payer level?

52. Do you correct claims daily when they are rejected at the claim level and are not paid for for reasons that can be corrected?

53. Do you have your contract allowables in your PM system so you know when you are not being paid correctly by contract?

54. Do you appeal unpaid or underpaid claims?

55. Do you check recoupments or requests for refunds from payers and make sure they truly should be refunded?

56. Do you send insurance and patient payments to a lockbox to be scanned and stored digitally for your staff to post from?

57. Do you make payment arrangements in the office for balances after insurance has paid, or payment plans by drafting credit or debit cards?

58. Do you have a policy of not sending statements?

59. Do you collect the patient’s portion of the service at the time of service?

60. Do you collect fees for elective services prior to providing these services?

61. Can your patients make payments online through your website?

62. Do you file a claim with a patient’s estate if they have died?

63. Do you accept cash only from patients who have passed bad checks?

64. Do you accept cash only from patients who have filed bankruptcy with your practice?

65. Do you inadvertently see patients who have been dismissed from your practice?

66. When adding a physician to the practice, do you timeline the credentialing appropriately so the physician can see patients with insurance as well as those without?

67. If your new physician is only partially credentialed with payers, do you have him/her see the patients with payers they are credentialed with and add payers to their schedule load as the credentialing comes through?

68. Do you meet with representatives from your largest payers monthly to establish relationships and bring problems to their attention? (the squeeky wheel theory of payer relations)

69. Are you pre-certing everything that needs pre-certification or pre-authorization or pre-notification to be sure the service will be paid?

70. Are you receiving payments via electronic funds transfer (EFT)?

71. Are you receiving explanation of benefits (EOBs) or remittance advice (RA) electronically?

72. Are you posting your RA electronically?

73. Are you protecting your practice from embezzlement? (see my post on this here.)

74. Is someone in the practice responsible for staying current on changing coding requirements for Medicare, Medicaid, Tricare and commercial payers?

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DECREASE EXPENSES:

75. Eliminate overtime. Evaluate the need for additional staff (part-time?) vs. overtime.

76. Send some staff home (sometimes called “low census”) when there are no patients to be seen.

77. Use volunteers. Tap into the local hospital volunteers, or recruit and train your own.

78. Hire an after-school student employee to do routine jobs.

79. Discontinue paying staff for inclement weather closings when the practice is not open.

80. Shop everything. Negotiate existing service contracts. Do not assume anything is non-negotiable. Negotiate the rent.

81. Get rid of yellow pages advertising. It rarely brings you new patients and is primarily a place to look up phone numbers. You will still get your white pages listing free with your phone service.

82. Utilize pre-employment testing to make sure job applicants have the skills you need.

83. Shop postage machines or look into stamps.com.

84. Join a group purchasing entity (hospital, professional association, etc.)

85. Improve your accounting cycle. Invoices and statements are matched up with packing slips and negotiated prices. Use purchase order numbers.

86. Get the payment discount by paying on time or early – ask vendors for an on-time or early payment discount.

87. Make sure office supplies are not going home with the employees. Make sure office supplies that are ordered are “really need” and not “sure would be nice.”

88. Remind patients of their appointments to decrease no-shows. Call patients who no-show and attempt to reschedule (unless they feel better!) Track no-shows and evaluate the reasons for them.

89. Consider charging for no-shows or dismissing patients for no-shows.

90. Have a good recall system in place. If patients leave without scheduling a needed follow-up, make sure that they are called if they have not scheduled within a certain amount of time. Keep track of annual wellness visits and remind patients to schedule them.

91. Take advantage of any discounts offered by your malpractice carrier by completing risk management surveys and having speakers give annual updates on decreasing malpractice claims. Some carriers give discounts for managers who are members of MGMA or Fellows in the ACMPE.

92. Evaluate any discounts on services or products offered by your physicians’ professional associations and societies.

93. Evaluate your leases – are those big old copiers and faxes worth paying for a service contract?

94. Consider speech recognition/voice recognition and eliminate transcription.

95. Review your computer maintenance contracts. Are you paying for maintenance on equipment or software that is no longer being used?

96. Take advantage of online CME for physicians, midlevel providers, clinical staff and managers.

97. Make plans to attend face-to-face seminars well in advance to take advantage of early enrollment discounts and good flight deals.

98. Evaluate outsourcing. Think about outsourcing transcription, coding, billing, pre-authorizations, credentialing, switchboard, payroll, accounting and medical records copying.

99. Replace your answering service with an answering machine educating patients on the limited reasons for calling after hours and giving the number of the physician on call.

100. Destroy archived financial and medical records that you are paying to store, once you have ascertained that they exceed the required time limit.

101. Hold a brainstorming session with the staff and ask for their ideas for increasing revenue and reducing expenses. The people on the front lines will have excellent ideas. In return, do not nickle and dime the staff to death by charging for coffee, reducing parking stipends or eliminating uniform allowances. Keep in mind that for your rank and file staff, having to pay for their own uniforms or paying more for parking might be a deal-breaker that causes them to search for work elsewhere. Try to focus on the bigger items for savings and make sure the staff know you are trying to keep their small benefits in place in appreciation for their work.




My Notes on the March 22, 2011 CMS Open Door Forum on Physician Quality Reporting System (PQRI) for the Beginner

Very scary

Today’s CMS Open Door Forum was a good one. The slides (pdf here), although reviewed quickly during the call, are a comprehensive resource for anyone needing in-depth information on qualifying for incentives through PQRI. The information is complex, but anyone can start the process tomorrow and successfully get their check (next year.)

PQRI has been renamed PQRS.

These are the key points of the information presented:

  1. You can tell if you are eligible for the incentive program by checking the main PQRS site here. Scroll down to Downloads and click on “List of Eligible Professionals.”
  2. There is no registration required to report quality data.
  3. PQRS should not be confused with incentives offered for ePrescribing or meaningful use of a certified Electronic Health Record – these are three distinct systems.
  4. There are new Physician Quality Reporting Measure Specifications every year – use the correct year.
  5. Reporting can be done as individual eligible providers or as groups, however groups needed to be self-nominated by January 31, 2011, so that door is closed for this year.
  6. Eligible providers can choose to report for 12 months: January 1”“December 31, 2011 or for 6 months: July 1-December 31, 2011 (claims and registry-based reporting only.)
  7. There are two reporting methods for submission of measures groups that involve a patient sample selection: 30-patient sample method and 50% patient sample method. An “intent G-code” must be submitted for either method to initiate intent to report measures groups via claims. If a patient selected for inclusion in the 30-patient sample did not receive all the quality actions and that patient returns at a subsequent encounter, QDC(s) may be added (where applicable) to the subsequent claim to indicate that the quality action was performed during the reporting period.
    Physician Quality Reporting analysis will consider all QDCs submitted across multiple claims for patients included in the 30-patient samples.
  8. Eligible professionals who have contracted with Medicare Advantage (MA) health plans should not include their MA patients in claims-based reporting of measures groups using the 30 unique patient sample method. Only Medicare Part B FFS patients (primary and secondary coverage including Railroad Medicare) should be included in claims-based reporting of measures groups.
  9. Choose which group measures OR individual measures (3 minimum) you want to report on based on your method of reporting. Review your choices here.
  10. If you plan to report using a registry or EHR, make sure the systems are qualified by checking here.
  11. Here is the schedule for PQRS incentives and “payment adjustments” (financial dings.)
  • Incentives (based on the eligible professional’s or group’s estimated total Medicare Part B PFS allowed charges)
    • 2007 ”“1.5% subject to a cap
    • 2008 ”“1.5%
    • 2009, 2010  ”“2.0%
    • 2011 ”“1%
    • 2012, 2013, 2014 ”“0.5%
  • Payment Adjustments (you lose money)
    • 2015 ”“98.5%
    • 2016 and subsequent years ”“98.0%

What follows are the Questions and Answers from the listeners.

Q: Do PQRS measures need to be reported once per encounter or once per episode?

A: It depends on the measure. Check the list to see what each measure requires.

Q: Is there a code to submit if we cannot qualify due to low numbers of Medicare patients?

A: No, CMS will calculate this and will know you cannot qualify and you will be exempt from the payment adjustment.

Q: Can both admitting physicians and consulting physicians submit the same quality codes?

A: Yes, all eligible providers working with a patient can report the same code if appropriate.

Q: How do we know if we qualified for the eRx incentive for 2010?

A: Payments will come early fall and feedback reports will be available that break down each provider’s incentive.

Q: For the eRx incentive, is it 10 eRxs before June 30, 2011 and 25 before January 31, 2011 for each PROVIDER or each PRACTICE?

A: Each provider.

Q: What is the difference between the numerator and the denominator in PQRS?

A: The numerator is the clinical quality action (for instance, putting a patient on a beta blocker) and the denominator is the group of patients for whom the quality action applies (which patients with appropriate diagnoses are eligible for beta blocker therapy.)

Q: Do all the preventive measures in this group have to be utilized?

A: Not all measures will apply to all patients, for instance mammograms for females only.

Q: Is there a code to be placed on the claim that says a measure is not applicable for this patient?

A: No.

Q: How do you know if a measure code on a claim has been accepted?

A: You will receive a rejection code on your EOB that indicates the code was submitted for information purposes only. Remittance Advice (RA) with denial code N365 is your indication that Physician Quality Reporting codes were passed into the National Claims History (NCH) file for use in calculating incentive eligibility.

Q: How can a new provider get started with quality reporting?

A: Any provider can start any time by reporting through claims, a registry or an EHR.

Q: Should providers bill for PQRI under their individual number or under their group number?

A: Under their individual number.

Q: Can a physician delegate the eRx process to a staff member, just as they might have a nurse write a prescription for them?

A: Yes.

Q: Can you clarify the three incentive programs and which a practice can participate in at the same time?

A: The Physician Quality Reporting System, eRx Incentive Program, and EHR Incentive Program are three distinctly separate CMS programs.

The Physician Quality Reporting System incentive can be received regardless of an eligible professional’s participation in the other programs.

There are three ways to participate in the EHR Incentive Program: through Medicare, Medicare Advantage, or Medicaid.

If participating in the EHR Incentive Program through the Medicaid option, eligible professionals are able to also receive the eRx incentive.

If participating in the Medicare or Medicare Advantage options for the EHR Incentive Program, eligible professionals can still report the eRx measure but are only eligible to receive one incentive payment. Eligible professionals successfully participating in both programs will receive the EHR incentive.

Eligible professionals should continue to report the eRx measure in 2011 even if their practice is also participating in the Medicare or Medicare Advantage EHR Incentive Program because claims data for the first six months of 2011 will be analyzed to determine if a 2012 eRx Payment Adjustment will apply to the eligible professional.

If an eligible professional successfully generates and reports electronically prescribing 25 times (at least 10 of which are in the first 6 months of 2011 and submitted via claims to CMS) for eRx measure denominator eligible services, (s)he would also be exempt from the 2013 eRx payment adjustment.

The transcript and a recording of today’s call will be posted on the CMS website within a few weeks.

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E-prescribing: Use it 10 times for Medicare Patients Between Now and June 30, 2011 or Lose Money in 2012

Should I consider ePrescribing in 2011 if I’m not ready to install an EMR? 

Physicians prescriptions carefully prepared. J...

  • In 2012 eligible professionals who are not successful eprescribers, based on claims submitted between January 1, 2011 ”“ June 30, 2011, may be subject to a “payment adjustment” (read payment cut) in their Medicare Part B Physician Fee Schedule (PFS) for covered professional services.
  • Those that don’t eprescribe as a part of 10 Medicare patient encounters by June 30, 2011 will only receive 99% of their Medicare payment for all encounters in 2012.
  • Those that don’t ePrescribe as a part of 25 encounters by December 31, 2011, will only receive 98.5% of their Medicare payments for all encounters in 2013 and only 98% of their Medicare payments for encounters during 2014 and going forward.
  • The payment adjustment does not apply if <10% of an eligible professional’s (or group practice’s) allowed charges for the January 1, 2011 through June 30, 2011 reporting period are comprised of codes in the denominator of the 2011 eRx measure.

The DENOMINATOR is the visit code that is eligible for an eprescribing code (see list below.)

Patient visit during the reporting period (CPT or HCPCS): 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109

The NUMERATOR is a prescription generated and transmitted via a qualified eRx system and reported using a quality data code.

G8553: At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system (reported via claims, a registry, or an EHR.)

Please note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.

How to Avoid the 2012 Payment Adjustment

An eligible professional can avoid losing 1% in 2012 if (s)he:

  • Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of June 30, 2011 based on primary taxonomy code in NPPES,
  • Does not have prescribing privileges. (S)he must report (G8644) at least one time on an eligible claim prior to June 30, 2011;
  • Does not have at least 100 cases containing an encounter code in the measure denominator;
  • Becomes a successful e-prescriber; and
  • Reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure.

Exemptions from the Medicare Payment Adjustment in 2012

  • An (EP) eligible professional or selected group practice may request an exemption from the eRx Incentive Program and from the payment adjustment based upon a significant hardship.
  • The qualifying circumstances are based upon two “hardship codes” that need reported on at least one claim prior to June 30, 2011 should one of the following situations apply:

G8642 – The eligible professional practices in a rural area without sufficient high speed internet access and requests a hardship exemption from the application of the payment adjustment under section 1848(a)(5)(A) of the Social Security Act.

G8643 – The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing and requests a hardship exemption from the application of the payment adjustment under
section 1848(a)(5)(A) of the Social Security Act

To Recap:

  1. Each Physician or practice that does not currently ePrescribe should consider whether or not ePrescribing is worthwhile. (Note:  For group practices participating in eRx GPRO I or GPRO II during 2011, the group practice MUST become a successful e-prescriber. Depending on the group’s size, the group practice must report the eRx measure for 75-2,500 unique eRx events for patients in the denominator of the measure. Check out the Group Practice Reporting Option here.)
  2. In estimating the value of ePrescribing, the practice manager must consider on one hand the expense (which there is, even for free standalone eRx systems) surrounding the implementation of ePrescribing, and the potential income from the ePrescribing Incentive.
  3. The practice must also determine if an EMR is in their future, and if so, if the installation will take place soon enough to report the 10 encounters with Medicare patients.
  4. Individual eligible professionals (EPs) may choose to participate in either the PQRI, eRx, or both. PQRI and eRx are separate incentive programs.
  5. If an eligible professional (EP) earns an incentive under the Medicare EHR Incentive Program, he or she cannot receive an incentive payment under the eRx Incentive Program in the same program year, and vice versa. However, if an EP earns an incentive under the Medicaid EHR Incentive Program, he or she can receive an incentive payment under the eRx Incentive Program in the same program year.
  6. Eligible professionals must have adopted a “qualified” eRx system. There are two types of systems: a system for eRx only (stand-alone) or an electronic health record (EHR system) with eRx functionality. Regardless of the type of system used, to be considered “qualified” it must be based on ALL of the following capabilities:
    • Generating a complete active medication list incorporating electronic data received from applicable pharmacies and benefit managers (PBMs) if available.
    • Providing information related to lower cost, therapeutically appropriate alternatives (if any). Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all alerts.
    • Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient’s drug plan, if available.

For a list of qualified registries and qualified EHR vendors and products, click here.

An excellent article, Choosing the Right E-prescribing Application: Should you buy a standalone app or an EHR-integrated module? was published in January 2011 by Physicians Practice here.

Image courtesy of Wikipedia

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CMS Introduces New and Revised MLN Publications for You, Your Staff, Your Physicians and Your Patients

Seniors Dancing, Mayfest

“Publications For Your Medicare Beneficiaries”
New! The Medicare Learning Network® (MLN) has released a new product titled “Publications For Your Medicare Beneficiaries.”  This factsheet lists a variety of beneficiary-related publications available to assist providers in responding to patients’ questions related to Medicare, all of which can be printed and provided to patients.  This product is available in downloadable format here. Check it out – links to more than 70 different publications!

“The 2007 Physician Quality Reporting Initiative”
New! A new Medicare Learning Network® publication titled “The 2007 Physician Quality Reporting Initiative (PQRI)” (November 2010) is now available in downloadable format here.  This booklet is a compilation of CMS’s various educational resources relevant to the 2007 Physician Quality Reporting Initiative.

“Guidelines for Teaching Physicians, Interns, and Residents”
The “Guidelines for Teaching Physicians, Interns, and Residents” (revised December 2010) is now available in downloadable format here. This factsheet provides information about payment for physician services in teaching settings, general documentation guidelines, and evaluation and management documentation guidelines.

“HIPAA EDI Standards” Web-Based Training
The Medicare Learning Network® is now offering the revised “HIPAA EDI Standards” web-based training (revised January 2011) for CE credit.  The goal of this activity is to provide information to physicians, suppliers, and healthcare professionals regarding electronic billing and other healthcare electronic transactions such as the Administrative Simplification provisions of HIPAA, electronic transaction standards and code sets required by HIPAA, and an overview of the steps involved in the Medicare electronic data interchange process.  To take this training, go here and click on “Web-Based Training Modules” under “Related Links Inside CMS.” There are 15 other web-based training classes available on the same site.

Money

“Understanding the Remittance Advice: A Guide for  Medicare Providers, Physicians, Suppliers and Billers”
The publication titled “Understanding the Remittance Advice: A Guide for Medicare Providers, Physicians, Suppliers and Billers” (revised October 2010) is designed to educate institutional and professional providers who bill Medicare with general remittance advice (RA) information.  It includes instructions to help you interpret the RA received from Medicare and reconcile it against submitted claims and provides guidance on how to read Electronic Remittance Advices (ERAs) and Standard Paper Remittance Advices (SPRs), as well as information on balancing an RA.  This publication may be downloaded here. If you are training an employee to be a biller or post payments, or if you want to understand more about your billing yourself, this is an excellent resource.

“Evaluation and Management Services Guide”
The publication titled “Evaluation and Management Services Guide” (revised December 2010) is now available in downloadable format from the Medicare Learning Network® here.  This guide is designed to provide education on medical record documentation and evaluation and management billing and coding considerations.  The “1995 Documentation Guidelines for Evaluation and Management Services” and the “1997 Documentation Guidelines for Evaluation and Management Services” are included in this publication.  This is another great resource that you can use to train staff, physicians, and other providers, or to get up to speed yourself if E & M codes are not part of your education or experience.

Image Credits:

Dancing Seniors: Image by StevenM_61 via Flickr

Money Rainbow: Image by TW Collins via Flickr




When, If Ever, Do You Get a New NPI Number and Other NPI Questions

Questions

Image by Oberazzi via Flickr

What is a NPI again?

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.

As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.

When should you get a new NPI?

The National Provider Identifier (NPI) is meant to be a lasting identifier, and is expected to remain unchanged even if a health care provider changes his or her name, address, provider taxonomy, or other information that was furnished as part of the original NPI application process. There are some situations, however, in which an NPI may change such as when health care provider organizations determine they may need a new NPI due to, for example, certain changes of ownership, the conditions of a purchase, or a new owner’s subpart strategies. There also may be situations where a new NPI is necessary because the current NPI was used for fraudulent purposes.

A health care provider (or the trustee/legal representative of a health care provider) should deactivate its NPI in certain situations, such as retirement or death of an individual, disbandment of an organization, or fraudulent use of the NPI. To deactivate an NPI, a health care provider (or the trustee/legal representative of a health care provider) must complete a CMS-10114 and mail it to the NPI Enumerator.

Does the NPI replace the tax ID number?

The billing provider’s tax ID number and NPI are always required on claims. Any other providers identified on the claim, such as rendering provider or service facility, must be identified with their NPI only. Their tax ID number should not be included.

For eligibility, claim status inquiry, referral and precertification, only the NPI (no tax ID number) is used.

How does a rendering physician report their National Provider Identifier (NPI) on a claim that includes Physician Quality Reporting Initiative (PQRI) or Electronic Prescribing Incentive Program (eRx) quality-data codes (QDCs)? What if he/she is part of a group and the group NPI is used on the claim?

Your individual National Provider Identifier (NPI) must be included on the claim line items for the quality-data codes (QDCs) you submit as well as the line items for the services to which the QDC is applicable. The PQRI/eRx QDC must be included on the same claim that is submitted for payment at the time the claim is initially submitted in order to be included in PQRI analysis.

If a group NPI is used at the claim level, the individual rendering physician’s NPI must be placed on each line item, including all allowed-charge and quality-data line items. See the PQRI Implementation Guide for a sample CMS-1500 claim. This is available as a download from the Measures/Codes section of the CMS PQRI website. For eRx, see the Claims-Based Reporting Principles for eRx, available on the CMS eRx website.

If a health care provider with a National Provider Identifier (NPI) moves to a new location, must the health care provider notify the National Plan and Provider Enumeration System (NPPES) of its new address?

Yes.  A covered health care provider must notify the NPPES of the address change within 30 days of the effective date of the change. We encourage health care providers who have been assigned NPIs, but who are not covered entities, to do the same. A health care provider may submit the change to NPPES via the web or by paper. If paper is preferred, the health care provider may download the NPI Application/Update Form (CMS-10114) from the Centers for Medicare & Medicaid Services’ forms page or may call the NPI Enumerator (1-800-465-3203) and request a form.

What happens when you join a group?

In Section 4B of the CMS-855I, the NPI of the Group should be entered if it has been issued to the Group. If you are joining a group, the group is responsible for providing you with their current Provider Identification Number (PIN) and the NPI, if they have been issued.

If you are a solo physician with an incorporated practice, how many NPIs should you have?

An individual is eligible for only one NPI. In the above example, there are two health care providers: the physician and the corporation. The physician would obtain an NPI (Entity Type Code 1, Individual). The corporation would obtain an NPI (Entity Type Code 2, Organization). Generally, the corporation’s NPI would represent the Billing and Pay-to Providers and the physician’s NPI would represent the Rendering, Referring/Ordering, Attending, Operating and/or Other Providers. These physicians should ensure that their enrollment records with the health plans to whom they will be sending claims are up to date, that those health plans are aware of the assigned NPIs, and that the NPIs are used in a way that is compatible with their enrollment.

I do not submit healthcare claims to Medicare; do I need a National Provider Identifier (NPI)?

Yes. NPIs are required by the NPI Final Rule to be used to identify health care providers in HIPAA standard transactions (including claims) that are conducted with any health plan, not just with Medicare. So even if you do not submit claims to Medicare, but submit HIPAA standard claims transactions to some other health plan, you are required to use an NPI in those transactions, and should be doing so as of May 23, 2007. Additionally, many health plans are requiring that providers use NPIs on paper claims. Providers should check with any health plan with whom they conduct business to determine their policy on the use of the NPI for paper claims.
*Questions and Answers excerpted from the CMS website.

Where can you look up NPIs?

https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
http://nynpi.com/
http://www.npinumberlookup.org/
http://www.npinumberlookup.org
http://www.npivalidator.com/
http://npidb.org/
http://www.hmedata.com/npi.asp
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FAQ on HITECH, Meaningful Use, Eligible Providers, and the Stimulus Money

NOTE: Read my latest post on how to register and attest for the EHR Incentive Programs here.

Where Did the Idea of Meaningful Use of Electronic Medical Records Come From?

The American Recovery and Reinvestment Act of 2009 was signed by President Obama on February 17, 2009.  The Law includes the Health Information Technology for Economic and Clinical Health Act or the HITECH Act.  The HITECH Act establishes programs under Medicare and Medicaid to provide incentive payments for the Meaningful Use of Certified Electronic Health Records technology.

The goal of the HITECH legislation is to improve healthcare outcomes, to facilitate access to care and to simplify care.  It is believed that the installation of electronic health records in medical practices is only the beginning.  The goals of HITECH will be met when the EHR is used in a meaningful way.

What is Meaningful Use (MU)?

There are three  identified components of Stage I Meaningful Use.  They are:

  1. Use of a certified EHR in a meaningful manner such as e-prescribing.
  2. Use of Certified EHR Technology for the exchange of health information (exchange data with other providers of care or business partners such labs or pharmacies)
  3. Use of Certified EHR Technology to submit clinical quality and other measures.

The first stage of Meaningful Use is capturing and sharing the data.  Meaningful Use Stage II is advanced clinical processes and Stage III is starting to look Meaningful Use of an EHR in the context of improved healthcare outcomes.

There are 25 specific criteria for MU Stage I listed in this article in Healthcare IT News:

[1] Objective: Use CPOE (Computerized Physician Order Entry)
Measure: CPOE is used for at least 80 percent of all orders

[2] Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The EP (Eligible Provider) has enabled this functionality

[3] Objective: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data.

[4] Objective: Generate and transmit permissible prescriptions electronically (eRx).
Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

[5] Objective: Maintain active medication list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data.

[6] Objective: Maintain active medication allergy list.
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data.

[7] Objective: Record demographics.
Measure: At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data

[8] Objective: Record and chart changes in vital signs.
Measure: For at least 80 percent of all unique patients age 2 and over seen by the EP, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20.

[9] Objective: Record smoking status for patients 13 years old or older
Measure: At least 80 percent of all unique patients 13 years old or older seen by the EP “smoking status” recorded

[10] Objective: Incorporate clinical lab-test results into EHR as structured data.
Measure: At least 50 percent of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

[11] Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach.
Measure: Generate at least one report listing patients of the EP with a specific condition.

[12] Objective: Report ambulatory quality measures to CMS or the States.
Measure: For 2011, an EP would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an EP would electronically submit the measures are discussed in section II.A.3. of this proposed rule.

[13] Objective: Send reminders to patients per patient preference for preventive/ follow-up care
Measure: Reminder sent to at least 50 percent of all unique patients seen by the EP that are 50 and over

[14] Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the EP is responsible for as described further in section II.A.3.

[15] Objective: Check insurance eligibility electronically from public and private payers
Measure: Insurance eligibility checked electronically for at least 80 percent of all unique patients seen by the EP

[16] Objective: Submit claims electronically to public and private payers.
Measure: At least 80 percent of all claims filed electronically by the EP.

[17] Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request
Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours.

[18] Objective: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies)
Measure: At least 10 percent of all unique patients seen by the EP are provided timely electronic access to their health information

[19] Objective: Provide clinical summaries to patients for each office visit.
Measure: Clinical summaries provided to patients for at least 80 percent of all office visits.

[20]  Objective: Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically.
Measure: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information.

[21] Objective: Perform medication reconciliation at relevant encounters and each transition of care.
Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care.

[22] Objective: Provide summary care record for each transition of care and referral.
Measure: Provide summary of care record for at least 80 percent of transitions of care and referrals.

[23] Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted.
Measure: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries.

[24] Objective: Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice.
Measure: Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an EP or eligible hospital submits such information have the capacity to receive the information electronically).

[25] Objective: Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities.
Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1) and implement security updates as necessary.

Have the Details of MU been finalized?

The comment period for the NPRM (Notice of Proposed Rule Making) for Meaningful Use is currently open but will close on March 15, 2010. You can read the NPRM here.  Many individuals and organizations have expressed concern that the timeline for implementing EHR and meeting MU criteria is too short for the majority of providers. The American Academy of Family Physicians (AAFP) recently sent a 7-page letter to acting CMS Administrator Charlene Frizzerathat included the following concerns:

  1. The administrative burden of reporting computerized physician order entry measures “is excessive to the point of being unachievable for most eligible providers.”
  2. The rule could require manually entering results from laboratories that don’t have an interoperable interface with the physician’s electronic health record.
  3. The term “health information” is used throughout the proposed rule, but is never defined.
  4. A requirement that a patient’s health information be shared with that patient within 48 hours doesn’t take in account that physicians or their staff may not be able to process the information if that 48-hour period includes weekend days.
  5. There is no incentive for physicians who meet less than 100% of the proposed requirements, so it is an all-or-nothing approach.

The Medical Group Management Association recently surveyed (see Modern Healthcare story here) 445 physician practice administrators in February 2010 with the following feedback:

  1. Nearly all are aware of the upcoming incentive programs for meaningful use of electronic health records, but fear the programs will reduce physician productivity.
  2. 68% of respondents expect physician productivity will decrease if all 25 proposed meaningful use criteria are implemented.
  3. Nearly one-third believe the decrease in productivity will be greater than 10 percent.
  4. Almost 25% of practices without an EHR doubt some of their providers will ever attempt to qualify for incentives.
  5. Among practices with an EHR, nearly 84 percent believe some of their physicians will attempt to qualify for Medicare or Medicaid incentives by the end of 2011.

How Do I Comment on the MU Standard?

You can submit your comments on the NPRM on MU here.

You can read comments already submitted here.

How Do I Know if My EHR is Certified?

No EHRs have been certified for the CMS Incentive Program and the certifying bodies have not yet been announced.  It seems reasonable that CCHIT will be one certifying body, but there are expected to be others.  If your vendor tells you that his EHR is certified before the rule has been finalized and the certifying bodies have been announced, ask him “For what?”

What Does it Mean to Be Eligible? (description courtesy of Everything HITECH)

This term encompasses three general types of payers to establish eligibility: 1) Medicare Fee For Services (FFS), 2) Medicare Advantage (MA) and 3) Medicaid.

For hospitals to be eligible, they can be acute care (excluding long term care facilities), critical access hospitals, children’s hospitals.

For providers, these include non-hospital-based physicians who receive reimbursement through Medicare FFS program or a contractual relationship with a qualifying MA organization. The Act defines the term “hospital based” eligible professional to mean an EP such as a pathologist, anesthesiologist,or emergency physician, who furnishes substantially all of his or her Medicare covered professional services during the relevant EHR reporting period in a hospital setting (whether inpatient or outpatient) through the use of the facilities and equipment of the hospital, including the hospital’s qualified EHR’s (Fed Reg p. 1905). The determining factor is the site of service as to whether the service is hospital based or not. If the EP provides at least 90 % of their services in a hospital inpatient, hospital outpatient or hospital emergency room setting (Point of Service codes 21, 22, 23), then they are considered a hospital based EP and not eligible for EHR incentive payments (i.e. providing substantially all of his or her Medicare covered professional services).

There is a difference between Medicare and Medicaid when it comes to defining an eligible professional for EHR incentive payment purposes. Medicare defines an eligible professional as (Fed Reg p. 1996):

 

  1. doctor of medicine or doctor of osteopathy
  2. doctor of dental surgery or dental medicine
  3. doctor of podiatric medicine
  4. doctor of optometry
  5. chiropractor

Medicaid, on on the other hand, defines an eligible professional as (Fed Reg p. 2001):

  1. physician
  2. dentist
  3. certified nurse-midwife
  4. nurse practitioner
  5. physician assistant practicing in a Federally Qualified Health Center (FQHC) or a Rural Health Clinic, led  by a physician assistant.

What are the Guidelines for Providing Patients With Their Medical Records Electronically?

Under HIPAA, patients currently have the ability to access their medical records.  Meaningful Use does not change HIPAA in that regard.  You may charge patients for the expense related to providing paper or electronic medical records.  Each state has its own schedule for charging for medical records (state-by-state schedule here.)

Do Eligible Providers Have to be Participating With Medicare to Receive the Incentive Money?

No, the eligibility requirements only relate to the benchmarks for the percentage of Medicaid patients you have, or amount of allowed Medicare charges you have.

Can Eligible Providers Work at Locations Other Than Hospitals and Private Practices and Receive the Incentive Money?

The location where the provider works is not the issue.  The issue is whether or not the provider meets the requirements, either for Medicare or Medicaid, to be considered eligible for the program.

It doesn’t matter where the provider accesses the certified EHR.  If they meet the eligibility criteria, and they are using a certified EHR, they can collect on the stimulus money.

What Are Health Provider Shortage Areas?

Physicians practicing in determined “health provider shortage” (detailed info here) areas will be eligible for a 10% bonus payment.

How Does This Incentive Relate to ePrescribing or PQRI?

If the PQRI Program is extended in its current form, practices can participate in both PQRI and an EHR Incentive Plan.

If the EP chooses to participate in the Medicare EHR Incentive Program, they cannot participate in the Medicare eRx Incentive Program simultaneously.  If the EP chooses to participate in the Medicaid EHR Incentive Program, they can participate in the Medicare eRx Incentive Program simultaneously.

Also, e-prescribing penalties sunset after 2014, so that no physician will be subject to penalties for failing to both e-prescribe and use an EHR!

How Do EPs Get Paid For Meaningful Use of a Certified EHR?

For the first payment year only, all an EP or hospital has to do is to be a “meaningful user” for a continuous 90-day period during the payment year. Hospitals’ payment year is October 1 to September 30 and EPs’ payment year is the calendar year.  You must start and complete the 90-day period within the payment year with no overlapping.

 

Also, if  you can qualify as a Medicaid Eligible Provider (or Hospital), are in the process of adopting, implementing or upgrading your EHR  and your Medicaid patient volume is at least 30% (Pediatricians only need 20% minimum and Hospitals need 10% minimum), you can collect your incentive money without meeting Meaningful Use criteria.

Attestation forms and forms of other types are most likely the way that EPs will provide information to apply for the incentive funds, although the details have not yet been released.

What Does it Mean to Transition From One Program (Medicaid or Medicare) to Another?

EPs who meet the eligibility requirements for both the Medicare and Medicaid incentive programs will be able to participate in only one program, and will have to designate which one they would like to participate in.  After their initial designation, EPs are allowed to change their program selection only once during payment years 2012 through 2014.


To Recap:

How Do I Get My EHR Stimulus Money?

  1. Decide whether you are an eligible provider for any of the programs.
  2. If you are, buy a certified EMR (once certification has been defined.)
  3. Use your EMR in a way that demonstrates your meaningful use of the product.
  4. Pass “GO” and collect your money.

ARRA (Stimulus Bill) Acronyms

”¢ A/I/U ”“Adopt, implement or upgrade
”¢ CAH ”“Critical Access Hospital
”¢ CCN ”“CMS Certification Number
”¢ CDS ”“Clinical Decision Support
”¢ CMS ”“Centers for Medicare & Medicaid Services
”¢ CY ”“Calendar Year
”¢ EHR ”“Electronic Health Record
”¢ EP ”“Eligible Professional
”¢ eRx ”“E-Prescribing
”¢ FFS ”“Fee-for-service
”¢ FY ”“Federal Fiscal Year
”¢ HHS ”“U.S. Department of Health and Human Services
”¢ HIT ”“Health Information Technology
”¢ HITECH Act ”“Health Information Technology for Electronic and Clinical Health Act
”¢ HITPC ”“Health Information Technology Policy Committee
”¢ HIPAA ”“Health Insurance Portability and Accountability Act of 1996
”¢ HPSA ”“Health Professional Shortage Area
”¢ IFR ”“Interim Final Rule
”¢ MA ”“Medicare Advantage
”¢ MCMP ”“Medicare Care Management Performance Demonstration
Ӣ MITA-Medicaid Information Technology Architecture
”¢ MU ”“Meaningful Use
”¢ NPI ”“National Provider Identifier
”¢ NPRM ”“Notice of Proposed Rulemaking
”¢ OMB ”“Office of Management and Budget
”¢ ONC ”“Office of the National Coordinator of Health Information Technology
”¢ PQRI ”“Medicare Physician Quality Reporting Initiative
”¢ Recovery Act ”“American Reinvestment & Recovery Act of 2009
”¢ TIN ”“Taxpayer Identification Number

For more information who is eligible and for how much, read my post ARRA Eligible Providers: Who Is Eligible to Receive Stimulus Money and How Much is Available Per Provider?”




Is Your Practice Focusing on These Top Ten Preventive Services? (Your Reimbursement May Depend on It)

If you don’t have the following ten items on a manual checklist or in your EMR, you might want to add them.  Any time I hear someone list things that improve quality of life and downstream health, I think to myself “This is future reimbursement criteria.”  Actually, several of these are already included as measures in the 2010 PQRI (Physician Quality Reporting Initiative) list.

I came across this list on the physician blog “The Examining Room by Dr. Charles”.  Dr. Charles writes:

“These items were chosen by the National Commission on Prevention Priorities, and highlight those preventive services including immunizations, screenings, preventive medications, and counseling that give “the most bang for the buck.”

  1. Discuss Daily Aspirin Use
  2. Childhood Immunization
  3. Smoking Cessation Advice and Help to Quit
  4. Screening for Alcohol Misuse and Brief Counseling
  5. Colorectal Cancer Screening
  6. Hypertension Screening
  7. Influenza Immunization
  8. Vision Screening
  9. Cervical Cancer Screening
  10. Cholesterol Screening

Get ahead of the curve, and discuss with your providers how you can give your patients more bang for their preventive care buck by making these ten items standard questions in your practice.

Read more on Dr. Charles blog here.




101 Ideas for Increasing Revenue and Decreasing Expenses in Your Medical Practice

BUILD ON WHAT YOU’RE CURRENTLY DOING:

1.  Add physician hours – add evening or weekend hours; start your office hours earlier and end hours later.

2.  Reduce physician time off – decrease vacation or change weekly days off to 1/2 days off.

3.  Set a minimum number of providers to be in the office seeing patients at all times the office is open.

4.  Have each provider add one new patient visit to his/her schedule weekly.

5.  Add ePrescribing to recoup additional Medicare revenue and streamline prescribing (there are free ePrescribing software packages available, but evaluate them carefully so they don’t add more complexity to the system instead of less.)

6.  Report PQRI measures to recoup additional Medicare revenue.

7.  Charge patients an out-of-pocket fee for completing patient forms – disability forms, etc. and reserve office visits for treating patients.

8.  Choose an EMR that qualifies your practice for the ARRA money (although it has been widely promoted that in a larger practice, an EMR and its associated work will cost more than you will get from the government.)

9.  If you are in an underserved or rural area, check to see if there might be grants or funds available locally, in the state or federally, for adding a service to your practice.

10.  If your practice does Independent Medical Exams (IMEs), reviews records or depositions, make sure that your fee schedule for such services is current and that the fees are collected before the physician provides the service.


ADD TO YOUR CURRENT SERVICES:

11.  Allergy testing & treatment

12.  Dispensing pharmaceuticals

13.  Dispensing nutriceuticals

14.  Dispensing Durable Medical Equipment

15.  Group patient visits

16.  Coumadin Clinic

17.  Heart Failure Clinic

18.  Diabetes Education Classes

19.  Add primary care to specialty care practices

20.  Add specialty care to primary care practices

21.  Research

22.  Joint Ventures with other practices or hospital

23.  Lease space to other entities

24.  eVisits (virtual visits or email visits)

25.  Elective procedures or services

26.  Mid-level providers

27.  Walk-in clinic

28.  Occupational medicine: drug screens, employment physicals, etc.

29.  Hospitalists

30.  Medical Director of local nursing homes

31.  Complementary & alternative medicine (CAM)

32.  Aging in Place services

33.  Social worker

34.  Concierge practice

35.  School team physician

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EVALUATE YOUR REVENUE CYCLE MANAGEMENT:

36.  Are you renegotiating payer contracts regularly?

37.  Do your scheduling staff know how to educate patients about what payers you have contracts with and are in network with and what the patient’s financial responsibility will be?

38.  Do staff know what typical new patient charges are to tell the patient?

39.  Do you check every patient’s eligibility for insurance benefits immediately prior to every service?

40.  Do you have patients sign a financial policy to acknowledge what they are responsible for based on their payer type?

41.  Do you copy the patient’s insurance cards at every visit, or at least compare their current card to the card you have on file?  Are you able to scan patient insurance cards and driver’s licenses into your practice management (PM) system?

42.  Is your PM system able to download the information from the scan into the patient registration screen?  If not, do you have a way to confirm that demographic and insurance information has been entered correctly from the cards?

43.  Are your charges being posted daily?

44.  Does the person who provides the service, or a documentation coding specialist, choose the CPT and ICD9 code?

45.  Is the documentation for the charges being completed within 24 hours of the service?

46.  Is your encounter form up-to-date with current CPT and ICD9 codes; do you order smaller batches of them so you can change the codes as new services are added in the practice?

47.  Do you check the CPT and ICDD9 matching to make sure the codes are valid for the year, the codes adhere to NCCI and LCD edits before you finalize the charges?

48.  Do you regularly audit medical records for coding and documentation and give providers feedback on where coding could be improved?

49.  Are you using ABNs for Medicare patients who want services that Medicare might not pay for?

50.  Do you file claims daily?

51.  Do you correct claims daily when they are rejected at the practice management, claims clearinghouse or payer level?

52.  Do you correct claims daily when they are rejected at the claim level and are not paid for for reasons that can be corrected?

53.  Do you have your contract allowables in your PM system so you know when you are not being paid correctly by contract?

54.  Do you appeal unpaid or underpaid claims?

55.  Do you check recoupments or requests for refunds from payers and make sure they truly should be refunded?

56.  Do you send insurance and patient payments to a lockbox to be scanned and stored digitally for your staff to post from?

57.  Do you make payment arrangements in the office for balances after insurance has paid, or payment plans by drafting credit or debit cards?

58.  Do you have a policy of not sending statements?

59.  Do you collect the patient’s portion of the service at the time of service?

60.  Do you collect fees for elective services prior to providing these services?

61.  Can your patients make payments online through your website?

62.  Do you file a claim with a patient’s estate if they have died?

63.  Do you accept cash only from patients who have passed bad checks?

64. Do you accept cash only from patients who have filed bankruptcy with your practice?

65.  Do you inadvertently see patients who have been dismissed from your practice?

66.  When adding a physician to the practice, do you timeline the credentialing appropriately so the physician can see patients with insurance as well as those without?

67.  If your new physician is only partially credentialed with payers, do you have him/her see the patients with payers they are credentialed with and add payers to their schedule load as the credentialing comes through?

68.  Do you meet with representatives from your largest payers monthly to establish relationships and bring problems to their attention? (the squeeky wheel theory of payer relations)

69.  Are you pre-certing everything that needs pre-certification or pre-authorization or pre-notification to be sure the service will be paid?

70.  Are you receiving payments via electronic funds transfer (EFT)?

71.  Are you receiving explanation of benefits (EOBs) or remittance advice (RA) electronically?

72.  Are you posting your RA electronically?

73.  Are you protecting your practice from embezzlement? (see my post on this here.)

74.  Is someone in the practice responsible for staying current on changing coding requirements for Medicare, Medicaid, Tricare and commercial payers?

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DECREASE EXPENSES:

75.  Eliminate overtime. Evaluate the need for additional staff (part-time?) vs. overtime.

76.  Send some staff home (sometimes called “low census”) when there are no patients to be seen.

77.  Use volunteers. Tap into the local hospital volunteers, or recruit and train your own.

78.  Hire an after-school student employee to do routine jobs.

79. Discontinue paying staff for inclement weather closings when the practice is not open.

80.  Shop everything. Negotiate existing service contracts.  Do not assume anything is non-negotiable.  Negotiate the rent.

81.  Get rid of yellow pages advertising. It rarely brings you new patients and is primarily a place to look up phone numbers.  You will still get your white pages listing free with your phone service.

82.  Utilize pre-employment testing to make sure job applicants have the skills you need.

83.  Shop postage machines or look into stamps.com.

84.  Join a group purchasing entity (hospital, professional association, etc.)

85.  Improve your accounting cycle. Invoices and statements are matched up with packing slips and negotiated prices.  Use purchase order numbers.

86.  Get the payment discount by paying on time or early – ask vendors for an on-time or early payment discount.

87.  Make sure office supplies are not going home with the employees.  Make sure office supplies that are ordered are “really need” and not “sure would be nice.”

88.  Remind patients of their appointments to decrease no-shows.  Call patients who no-show and attempt to reschedule (unless they feel better!)  Track no-shows and evaluate the reasons for them.

89.  Consider charging for no-shows or dismissing patients for no-shows.

90.  Have a good recall system in place.  If patients leave without scheduling a needed follow-up, make sure that they are called if they have not scheduled within a certain amount of time.  Keep track of annual wellness visits and remind patients to schedule them.

91.  Take advantage of any discounts offered by your malpractice carrier by completing risk management surveys and having speakers give annual updates on decreasing malpractice claims.  Some carriers give discounts for managers who are members of MGMA or Fellows in the ACMPE.

92.  Evaluate any discounts on services or products offered by your physicians’ professional associations and societies.

93.  Evaluate your leases – are those big old copiers and faxes worth paying for a service contract?

94.  Consider speech recognition/voice recognition and eliminate transcription.

95.  Review your computer maintenance contracts. Are you paying for maintenance on equipment or software that is no longer being used?

96.  Take advantage of online CME for physicians, midlevel providers, clinical staff and managers.

97.  Make plans to attend face-to-face seminars well in advance to take advantage of early enrollment discounts and good flight deals.

98.  Evaluate outsourcing. Think about outsourcing transcription, coding, billing, pre-authorizations, credentialing, switchboard, payroll, accounting and medical records copying.

99.  Replace your answering service with an answering machine educating patients on the limited reasons for calling after hours and giving the number of the physician on call.

100. Destroy archived financial and medical records that you are paying to store, once you have ascertained that they exceed the required time limit.

101.  Hold a brainstorming session with the staff and ask for their ideas for increasing revenue and reducing expenses.  The people on the front lines will have excellent ideas.  In return, do not nickle and dime the staff to death by charging for coffee, reducing parking stipends or eliminating uniform allowances.  Keep in mind that for your rank and file staff, having to pay for their own uniforms or paying more for parking might be a deal-breaker that causes them to search for work elsewhere.  Try to focus on the bigger items for savings and make sure the staff know you are trying to keep their small benefits in place in appreciation for their work.