Tag: Doctors Pay

ICD-10: CMS won’t deny claims for first year

In a surprise concession, the Centers for Medicare & Medicaid Services announced Monday that it would work with the American Medical Association on four steps designed to ease the transition to ICD-10.

Despite longtime disagreements on the topic, CMS will now adopt suggestions made by none other than the AMA with regard to the code set conversion. Those changes concern:

1. Claims denials. “While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family,” CMS officials wrote in a guidance document.

2. Quality reporting and other penalties. “For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes,” CMS explained. “Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes.”

3. Payment disruptions. “If Medicare contractors are unable to process claims as a result of problems with ICD-10, CMS will authorize advance payments to physicians,” AMA president Steven Stack, MD, noted in a viewpoint piece on the group’s website.

4. Navigating transition problems. CMS intends to create a communication center of sorts, including an ICD-10 Ombudsman, “to help receive and triage physician and provider issues.” The center will also “identify and initiate” resolution of issues caused by the new code sets, officials added.

“These provisions are a culmination of vigorous efforts to convince the agency of the need for a transition period to avoid financial disruptions during this time of tremendous change,” wrote Stack.

While AMA played a pivotal role in bringing about these CMS concessions, it was not the only party calling for a smoother conversion to the new code set.

Some members of the U.S. Congress have publicly suggested a dual-coding conversion period wherein CMS would accept and process claims in both ICD-9 and ICD-10. Instead of dual coding, CMS indicated that “a valid ICD-10 code will be required on all claims starting Oct. 1, 2015.”

So as things stand today, providers have to use ICD-10 come October – but CMS will be more flexible about denials and payments than it has previously suggested it would be.

Medicare Explains New Home Health Coding, Payment Policy

Medicare reimbursement information systems recently began comparing two distinct codes on home health agency claims before the claims are paid.

The rule change comes after an extended period of upgrading information systems and testing with the industry. The IT systems are comparing the Health Insurance Prospective Payment System code (HIPPS) on a claim to the HIPPS coded generated by a corresponding Outcomes and Assessment Information Set, known as OASIS.

According to the Centers for Medicare and Medicaid Services, “OASIS is a group of data elements that represent core terms of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement.” The goal of developing OASIS was to measure patient outcomes and support outcome monitoring, clinical assessment, care planning and internal agency activities.

“If the HIPPS code from the OASIS assessment differs, Medicare will use the OASIS-calculated code for payment,” according to available guidance. “At this time, if no corresponding OASIS assessment is found, the claim will process normally.”

Many home health agencies create software to integrate necessary data entry and grouping functions in their information systems to support the new policy. Agencies without such software or unhappy with a current product can get free grouping software from Medicare.

Kidney-care providers to face 2% cut to Medicare payments and see new quality metrics

Kidney-care providers could see their Medicare payments reduced by up to 2% in the next few years if they do not score high enough on quality measures.

The CMS on Friday proposed updates to policies and payments for end-stage renal disease, which would affect payments to more than 6,000 U.S. kidney dialysis facilities.

In recent years, the agency has focused on efforts to drive high-quality care, such as disease prevention, chronic disease management, improving outcomes and promoting efficiency.

The ESRD proposal released last week is part of that broader push. It would change how dialysis facilities are reimbursed by linking a portion of their payments directly to quality scores. It would also eventually add new metrics to the ESRD Quality Improvement Program.

There are currently 11 measures to evaluate end-stage renal disease care through the quality program. They include eight clinical measures, such as: how many patients receive the best vein access method (arteriovenous fistula) versus the least recommended (catheter), how well toxins are being filtered from the blood during dialysis; infection rates; and how well hypercalcemia is controlled. They also include three reporting measures, including patient experience, anemia and bone mineral metabolism management.

The CMS assigns a score for each measure, and those scores are later combined to create a “total performance score”—which ranges from zero to 10- for each facility. Centers that do not meet the minimum score established by a benchmark determination would be financially penalized up to 2% of its Medicare reimbursement.

It is estimated that the treatment of end-stage renal disease costs Medicare $34 billion in 2011, about 6% of all Medicare spending. Hemodialysis for end-stage renal disease costs the program about $88,000 annually per patient.

The CMS plans to add quality-of-life measures, such as pain and depression management and readmission rates in 2018. By 2019, two new measures will be adopted: one looking at seasonal flu vaccination, and ultrafiltration rates, a process for removing excess water and sodium from the body of kidney-failure patients.

Although studies have suggested that higher ultrafiltration rates in hemodialysis patients are associated with a greater risk of all-cause and cardiovascular deaths, nephrologist Dr. Alan Kliger, chief quality officer for Yale New Haven Health System, cautions against the premature use of the ultrafiltration metric.

Higher amounts of life-threatening fluids accumulate between treatments for patients who eat or drink more than recommended, and they would need ultrafiltration. “That doesn’t necessarily mean that higher filtration causes more deaths,” Kliger said. “They may be dying not because we are ultrafiltering them more but because they have physiologies that make them more dangerous patients.”

That particular measure has not been endorsed by the National Quality Forum, a nonprofit that reviews and endorses quality improvement metrics. In a  draft report issued in June, the NQF’s Renal Standing Committee declined to recommend the metric the CMS plans to adopt and instead recommended a different one for ultrafiltration.

Dr. Frank Maddux, chief medical officer of Fresenius Medical Care, one of the two largest U.S. dialysis providers, expressed similar concerns about CMS’ use of measures that are either not endorsed or are being considered for removal by NQF.

He also raised questions about measures for standardized transfusion and hospitalizations, which he said appear to rely on baseline performance data submitted in 2013 for the 2018 payment year.

“It strikes me that those measures are not very mature,” he said. That’s a major concern since a 2% reduction is a “substantial issue all providers take seriously.”

However, even imperfect measures can work if they are valid, reliable and feasible in the evolution of the systems to capture data, Maddux said. “They become points of concentration for the organizations that are providing care.”

But, he added, “If that concentration is not aligned with the state of the science, then we aren’t spending our time on those things that are most important.”

House Bill Seeks ICD-10 Grace Period

With the October 1 ICD-10 deadline rapidly approaching, another member of Congress has introduced legislation that would establish a “grace period” following the compliance date during which providers could not be denied Medicare/Medicaid payments because of coding errors.

Rep. Gary Palmer (R-Ala.) has sponsored the “Protecting Patients and Physicians Against Coding Act” (H.R. 2652) which calls for a two-year grace period so that providers can “focus on patient care instead of coding and receiving compensation for their care while ICD-10 is being fully implemented.” With ICD-10’s five-fold increase in codes compared to ICD-9, Palmer warned that the code switchover creates significant administrative challenges for rural and small town providers in particular, who lack the resources to fully prepare for the ICD-10 implementation.

As a result, the congressman said he is concerned that some providers will not receive payments for “what they are owed” due to current law which could prevent them from being reimbursed by the Centers for Medicare and Medicaid Services “because of simple coding mistakes or systemic failures.” According to Palmer, a two-year grace period “will provide time for the system to be implemented and kinks worked out without threatening the quality or availability of healthcare for Americans who live in small towns or rural areas.”

Likewise, Rep. Diane Black (R-Tenn.) recently introduced her own ICD-10 legislation seeking to institute an 18-month transition period beginning October 1, during which no claim submitted for payment by a provider would be denied as a result of using an unspecified or inaccurate code.

While Black’s bill only has five cosponsors, Palmer’s bill has 32 original cosponsors—including House Budget Committee Chairman Tom Price, M.D. (R-Ga.) and Rules Committee Chairman Pete Sessions (R-Tex.)—and has been referred to the Committees on Energy & Commerce and Ways & Means.

However, the American Health Information Management Association opposes Palmer’s bill on the grounds that the ICD-10 grace period would lead to inaccurate coding, improper payments, and potential medical billing fraud, opening the door to both intentional and unintentional coding errors. According to AHIMA, coverage determinations and validation of medical necessity of healthcare services also depend on codes submitted on claims and would be negatively impacted.

AHIMA counters Palmer’s assertion that the increase in the number of codes in ICD-10 versus ICD-9 will cause hardship for physicians by arguing that doctors and medical billers won’t need to learn every ICD-10 code in order to properly bill.

“Just as no healthcare provider uses every code in ICD-9-CM today, physicians and other providers will not use all the codes in ICD-10-CM,” states an AHIMA Frequently Asked Questions about ICD-10 document. “They will use a subset of codes based on their practice and patient population. The ICD-10-CM code set is like a dictionary that has thousands of words, but individuals use some words very commonly while other words are never used.”

Senate passes bipartisan ‘doc fix’ Medicare bill

The Senate passed a bipartisan ‘doc fix’ bill Tuesday to prevent a 21% cut in payments to doctors who treat Medicare patients just hours before that cut was to take effect.

President Obama is expected to quickly sign the bill into law.

The 92-8 vote came just in time to stop doctors from receiving dramatically smaller checks. The current funding formula expired on April 1. However, the Centers for Medicare and Medicaid Services said that it takes a minimum of 14 days to pay claims from doctors, giving senators until midnight Tuesday to act before checks went out.

Sen. Rand Paul, R-Ky., one of three GOP senators who have announced that they are running for president, voted to approve the bill. The other two presidential hopefuls, Sens. Ted Cruz of Texas and Marco Rubio of Florida, voted against it.

Senate Majority Leader Mitch McConnell said the bill would “ensure seniors on Medicare don’t lose access to their doctors.” Many doctors would have been reluctant to accept Medicare patients if the federal payments to physicians had dropped 21%, the bill’s supporters said.

The bill would repeal the current Medicare payment formula for doctors and replace it with one that would increase payments to doctors by one-half of 1% every year through 2019. After that, doctors would receive bonuses or penalties depending on performance scores from the government. Their scores would be based on the value of the care they provide rather than on the volume of patients they see.

Medicare recipients with incomes of more than $85,000 a year would be required to pay higher Medicare Part B premiums starting in 2018.

The legislation would end the annual scramble by lawmakers to pass a temporary patch to keep the payments from plummeting. Congress has been struggling with what both sides call a “flawed formula” since lawmakers enacted it in 1997.

“It’s a solution to a broken Medicare payment system that had vexed congressional leaders of both parties for years,” McConnell said. “It would mean an end to the annual exercise of Congress passing a temporary ‘fix’ to the problem one year and then coming right up to the very same cliff the next year, without actually solving the underlying problem.”

Oregon Sen. Ron Wyden, the senior Democrat on the Finance Committee, said the bill gives Congress a chance to “stop patching this leaky boat.”

“We have a chance for seniors and their providers to cross the victory line and be better off and have a better system for all Americans,” Wyden said.

Medicare Advantage Pay Rates to Rise 1.25% in 2016

Medicare Advantage pay rates will increase by an average of 1.25% in 2016, the Centers for Medicare and Medicaid Services (CMS) has announced.

The increase, announced as part of CMS’ final notice and call letter for Medicare Advantage in 2016, is a change from the projected decrease of 0.95% announced in the advanced notice and draft call letter issued in February.

The change occurred “largely because the Medicare actuaries recently updated Medicare per capita spending estimates for 2014 and 2015,” CMS said Monday in a press release, adding that “Medicare per capita spending in 2014, 2015, and 2016 is still expected to be below historical standards.”

Sean Cavanaugh, director of the Center for Medicare at CMS, told reporters Monday on a conference call that 0.1 percentage points of the increase was related to the proposal now being considered in Congress to permanently repeal the sustainable growth rate (SGR) formula for physician reimbursement under Medicare.

“In the past 2 years, the [Secretary of Health and Human Services] instructed the actuaries to assume that the SGR cut in the fee schedule payment would not take effect because the most likely scenario was they would not — and, in fact, they did not,” he said. “This year the secretary expanded on those comments and instructed the actuaries to not only assume the cuts would not take effect but to assume the pending legislation to permanently fix the SGR would take effect.”

The agency also withdrew its plan to modify its “star ratings” system for Medicare Advantage, Cavanaugh said. “In the draft call letter, we proposed to downgrade a subset of measures in the star rating system. We proposed that policy in response to concerns that plans with high numbers of dually eligible beneficiaries … may be disadvantaged under the current star rating system.”

“Because the vast majority of commenters opposed this proposal, CMS is withdrawing its proposed policy and will make no adjustment in this area to the 2016 star ratings,” he continued. “Given the uncertainty about what is driving this association, any long-term adjustments will be based on further in-depth examination of this issue by CMS, its [Health and Human Services] partners in quality measurement, and external measure developers. The call letter reiterates our commitment to continue to research this issue.”

The draft call letter also proposed stronger enforcement of the requirement that Medicare Advantage plans keep provider directories up-to-date and accurate. “In the final version, CMS clarified some of these expectations for plans and their communication with providers,” Cavanaugh noted.

In response to a question about the provider directories, another agency spokesperson added, “We’re clarifying policies that currently exist, and detailing what we believe an effective process would look like for keeping them up-to-date, and we are also adding that they [should] include whether or not providers are open and accepting new patients.”

Karen Ignagni, president and CEO of America’s Health Insurance Plans, a trade group for health insurers, gave the CMS announcement mixed reviews. “The final rate notice took a notable step to provide stable funding for the Medicare Advantage program,” Ignagni said Monday in a press release. “However, the lack of action to address policy concerns around providing care for the chronically ill and vulnerable populations could undermine health plans’ efforts to address the needs of these beneficiaries.”

 


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