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MANAGING MANAGING MEDICAREMEDICARE

California Society of Pathologists San Francisco,

California December 4, 2009

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WE WILL DISCUSSWE WILL DISCUSS• National and Local Lab Policies• Requesting Reconsiderations• Referral Rules• Enrollment: PECOS

– Revalidation– Reporting any Changes

• HIGLASS—December Payment Changes• On-Line Viewing of Claims—soon a reality• Signature Rules• Coverage for New Lab Tests

– National Versus Local Coverage– Meet with CMDs & Others– Thoughts on Pricing & Coding– Time Factors for Decisions

• Some 2010 Reimbursement Changes• Questions and answers

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NATIONAL COVERAGE DECISIONS

• National: NCDs come from CMSNational: NCDs come from CMS– Based on scientific studies & data collectedBased on scientific studies & data collected– Presented often at MCAC-open meetingsPresented often at MCAC-open meetings– Notice and comment welcomeNotice and comment welcome– Reconsiderations always possibleReconsiderations always possible

• NCDs cover entire countryNCDs cover entire country– May specify services May specify services alwaysalways covered covered – May specify services May specify services nevernever covered covered– Published in CMS Coverage ManualPublished in CMS Coverage Manual– May change as science changes, new studies May change as science changes, new studies

emerge, or as laws change.emerge, or as laws change.

– Reconsiderations always possible

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NATIONAL COVERAGE DECISIONS

• Examples of NCDs (over 300 currently)Examples of NCDs (over 300 currently)– Alpha-fetoproteinAlpha-fetoprotein– Collagen crosslinks, any methodCollagen crosslinks, any method– Cytogenic studiesCytogenic studies– Digoxin therapeutic drug assayDigoxin therapeutic drug assay– Fecal occult blood testingFecal occult blood testing– Genetic testing for warfarin Genetic testing for warfarin – HIV testingHIV testing– Prostate cancer screening testsProstate cancer screening tests– Sweat testSweat test

• National Laboratory Coverage Determinations (23 National Laboratory Coverage Determinations (23 currently)currently)

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LOCAL COVERAGE DECISIONS• Local: LCDs from 1 or more states/areasLocal: LCDs from 1 or more states/areas

– Written by local CMDs about situations that are data Written by local CMDs about situations that are data based & need control or instructionbased & need control or instruction

– Presented at state CACs open to medical and specialty Presented at state CACs open to medical and specialty societies representativessocieties representatives

– Notice and comment always welcome Notice and comment always welcome – Reconsiderations always possibleReconsiderations always possible

• LCDs cover a Medicare Jurisdiction (e.g., J-1)LCDs cover a Medicare Jurisdiction (e.g., J-1)– Discuss and describe medical necessityDiscuss and describe medical necessity– Usually give codes & conditions for paymentUsually give codes & conditions for payment– May state frequency of service and diagnoses and May state frequency of service and diagnoses and

always published locally and nationallyalways published locally and nationally

– Reconsiderations always possible

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LOCAL COVERAGE DECISIONS• Example of J-1 LCDs (Currently 80+ “B” LCDs)Example of J-1 LCDs (Currently 80+ “B” LCDs)

– Category III codes – temporary or trackingCategory III codes – temporary or tracking– Cytogenic studiesCytogenic studies– Free PSAFree PSA– MammaprintMammaprint– Oncologic in-vitro chemoresponse assaysOncologic in-vitro chemoresponse assays– Oncotype DX Oncotype DX – Flow cytometry and immunohistochemistry Flow cytometry and immunohistochemistry

(article) – soon to be policy(article) – soon to be policy• Some Part A LCDs may also applySome Part A LCDs may also apply• Local articles may also specify lab use or instruct Local articles may also specify lab use or instruct

in billing/codingin billing/coding

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FINDING LCDs & NCDsFINDING LCDs & NCDs

• www.cms.hhs.gov/MCD/overview.asp– Click “indexes” from left box– Click “national” or “local” coverage– For local coverage, click LCDs by contractor

(We are MACs—Part A or Part B---Palmetto)– For articles, we are MACs---Part A or Part B---

Palmetto

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REQUESTING LCD RECONSIDERATIONS

• Send in writing to local ContractorSend in writing to local Contractor– Specific address for reconsiderations on our web siteSpecific address for reconsiderations on our web site– Specific address of CMDsSpecific address of CMDs

• Add supporting scientific evidenceAdd supporting scientific evidence– Literature in peer reviewed journalsLiterature in peer reviewed journals– Expert opinion from credible sourcesExpert opinion from credible sources– Guidelines/statements from specialty societiesGuidelines/statements from specialty societies– Results of medium or long term studiesResults of medium or long term studies

• Be specific in requestsBe specific in requests– CPT, ICD-9, organ systems or special circumstancesCPT, ICD-9, organ systems or special circumstances

• Be conscious of vested interestsBe conscious of vested interests• Contractor must respond in 30 days to valid Contractor must respond in 30 days to valid

reconsideration requestsreconsideration requests

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ORDERING-REFERRING DOCS

• MD Clin. Nurse Specialist• DO Clin. Psychologist• Dental Surgery Nurse Midwife• Dental Medicine Clin. Social Worker• Podiartist Nurse Practitioner• Optometrist Chiropractor• Physician Assistant

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ORDERING PHYSICIANS• Claims ordered / referred must:

– NPI of ordering provider– Name in PECOS or MAC system – Specialty as listed

• Grace Period– Phase 1: 10/5/09 to 3/31/10 warning

message on remittance– Phase2: 4/01/10 and after: claim

rejected if referring individual not in Pecos or MAC list

4/01/10 and after:

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OTHER ENROLLMENTOTHER ENROLLMENT• Revalidation of older physicians

not in PECOS• Revalidation of some labs• Need to update any changes

within 30 days– Address, phone, suite– New members in group– Other changes

• If no claims to Medicare in one year—physician is disenrolled in Medicare

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HIGLASS-FINANCIAL CHANGEHIGLASS-FINANCIAL CHANGE

• Healthcare Integrated General Ledger Accounting System (HIGLASS)

• Change CMS accounting system– More accurate, timely, consistent payments– More CMS direct oversight

• Dec. 9th – Payment floor to 0– All claims approved are paid

• Dec. 14 – Payment floor returns– 14 days for electronic claims– 28 days for paper claims

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CHANGE IN CHANGE IN PAYMENT FLOORCHANGE IN PAYMENT FLOOR

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ON-LINE CLAIMS MANAGEMENTON-LINE CLAIMS MANAGEMENT

• On-line provider service– Claims status– Eligibility status– Remittance Status– Financial Status

• In real time, updated daily• Must have EDI enrollment agreement

signed with Palmetto

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ON-LINE CLAIMS MANAGEMENTON-LINE CLAIMS MANAGEMENT

• Register on OPS home page

• Get user ID and PasswordGet user ID and Password•Answer security questionAnswer security question

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ON-LINE CLAIMS MANAGEMENTON-LINE CLAIMS MANAGEMENT

• Log in:

•Claim status: claim status, claim lines

•Remits online: list of remits, e-remits

•Eligibility: Inquiry, deductibles, caps, MSP, more

•Financial Tools: payment floor, cash flow, more

•Administration: control who can use tool

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SIGNATURES • Handwritten signatures or initialsHandwritten signatures or initials

– Must be legibleMust be legible • Electronic signatures: Electronic signatures: 

– Digitized-Digitized- an electronic image of an individual’s an electronic image of an individual’s handwritten signature reproduced in its identical form handwritten signature reproduced in its identical form using a pen tablet using a pen tablet

– ElectronicElectronic signatures usually contain date & timestamps signatures usually contain date & timestamps and include printed statements, e.g., 'electronically signed and include printed statements, e.g., 'electronically signed by,' or 'verified/ reviewed by,' followed by physician’s by,' or 'verified/ reviewed by,' followed by physician’s name & preferably a professional designation.  Note: The name & preferably a professional designation.  Note: The responsibility and authorship related to the signature responsibility and authorship related to the signature should be clearly defined in the record should be clearly defined in the record

– Digital signatureDigital signature - an electronic method of a written - an electronic method of a written signature typically generated by encrypted software that signature typically generated by encrypted software that allows for sole usage allows for sole usage

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SIGNATURESChart 'Accepted By' with provider’s nameChart 'Accepted By' with provider’s name

'Electronically signed by' with provider’s name 'Electronically signed by' with provider’s name 'Verified by' with provider’s name 'Verified by' with provider’s name 'Reviewed by' with provider’s name 'Reviewed by' with provider’s name 'Released by' with provider’s name 'Released by' with provider’s name 'Signed by' with provider’s name 'Signed by' with provider’s name 'Signed before import by' with provider’s name 'Signed before import by' with provider’s name 'Signed: John Smith, M.D.' with provider’s name 'Signed: John Smith, M.D.' with provider’s name Digitalized signature: Handwritten & scanned into the Digitalized signature: Handwritten & scanned into the

compute. compute. 'This is an electronically verified report by John Smith, M.D.' 'This is an electronically verified report by John Smith, M.D.' 'Authenticated by John Smith, M.D.' 'Authenticated by John Smith, M.D.' 'Authorized by: John Smith, M.D.' 'Authorized by: John Smith, M.D.' 'Digital Signature: John Smith, M.D.' 'Digital Signature: John Smith, M.D.' 'Confirmed by' with provider’s name 'Confirmed by' with provider’s name 'Closed by' with provider’s name 'Closed by' with provider’s name 'Finalized by' with provider’s name 'Finalized by' with provider’s name

'Electronically approved by' with provider’s name'Electronically approved by' with provider’s name

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Unacceptable Signatures• See unacceptable signature examples: See unacceptable signature examples: • 'Signing physician' when 'Signing physician' when provider's name is typedprovider's name is typed

Example: Signing physician: ______________________Example: Signing physician: ______________________                                                     John Smith, M.D.                                                      John Smith, M.D.

• 'Confirmed by' when a 'Confirmed by' when a provider's name is typedprovider's name is typedExample: Confirmed by: ______________________Example: Confirmed by: ______________________                                                    John Smith, M.D.                                                     John Smith, M.D.

• 'Signed by' provider's name typed and the signing 'Signed by' provider's name typed and the signing line above, but line above, but done as part as the transcriptiondone as part as the transcription. .

• 'This document has been electronically signed in the 'This document has been electronically signed in the surgery department' surgery department' with no provider namewith no provider name. .

• 'Dictated by' when 'Dictated by' when provider's name is typedprovider's name is typedExample: Dictated by:  ______________________Example: Dictated by:  ______________________                                              John Smith, M.D.                                               John Smith, M.D.

• Signature stamp Signature stamp • 'Signature On File''Signature On File'

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SIGNATURES: WHAT WE FIND• Illegible, unrecognizable Illegible, unrecognizable

handwritten signatures or initials handwritten signatures or initials • Unsigned “typewritten” progress Unsigned “typewritten” progress

notes with a typed name only notes with a typed name only • Unverified or unauthorized Unverified or unauthorized

electronic signatureselectronic signatures• No indication of the rendering No indication of the rendering

physician/practitionerphysician/practitioner • Required for all labs, progress notes, Required for all labs, progress notes,

orders and the likeorders and the like

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IF SIGNATURE IS AN ILLEGIBLE IF SIGNATURE IS AN ILLEGIBLE SCRAWL…SCRAWL…

• Have an official signature Have an official signature page with name and page with name and signature signature OROR

• Send an attestation Send an attestation statement certifying that statement certifying that physician saw patient physician saw patient and wrote note on that and wrote note on that datedate

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MAC OVERVIEW-15 AREAS• 15 MACs, 4 DMACs, 4RHHIs• Companies may have > 1MAC• MAC may have >1 CMD• CMDs work together

– Within MACs– Within Companies– Across MACs– Within CMS Committees, Workgroups

• Many MAC Contracts in Dispute

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NATIONAL VS LOCAL LAB COVERAGE

• Advantages – Policies, coverage, coding and pricing

same everywhere – More publicity, fewer local hassles– More likely private insurance accepts

• Disadvantages of National– Requires more evidence, studies– Longer time frame for acceptance– Usually requires FDA clearance– Increased marketing costs required – Access across all states/territories when

lab not large enough for tests

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NATIONAL VS LOCAL COVERAGE

• Advantages of Local– Home brew possible, without FDA approval

needed– Quicker, less intensive reviews– Easier to convince CMDs– Can select areas for introduction– Can use 1-2 MACs to influence others

• Disadvantages of Local– Less uniform coding, coverage, pricing– Variation in payment, acceptance– Private insurance may not go along– Have to repeat work with each MAC

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MEETING WITH LOCAL CMDMEETING WITH LOCAL CMD• CMDs are very busy

– Policies, articles, coverage– Med Review and chart adjudication– Education, outreach to societies / groups– Contact with CMS & other organizations

• Most CMDs will find time for meeting– In Person: office, hotel, other location– Telephone, Web, etc. may be more efficient

• Time is always a consideration– Send info, data, literature in advance– Allows CMDs to be prepared, shortens meeting,

allows quicker resolution– Must fit between CMDs travel, outreach,

teleconferences with CMS and home office

–Send info, data, literature in advance

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MEETING WITH LOCAL CMDMEETING WITH LOCAL CMD• Show us the data

– Published peer reviewed data– Statistically significant differences– Demonstrate effect on patient diagnosis

or patient therapy

• Bottom Line– Does it work & affect patient care– Sensitivity, specificity & related– Outcomes for patients– Cost (and more important: pricing)

- Demonstrate effect on patient diagnosis or patient therapy

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HELP US WITH PRICINGHELP US WITH PRICING• Show us the pricingShow us the pricing

– Prefer single pricing vs code stackingPrefer single pricing vs code stacking– Reality versus imagination:Reality versus imagination:

• What is included in pricingWhat is included in pricing• What should not be includedWhat should not be included

• Can it be cross walked to existing Can it be cross walked to existing CPT codesCPT codes– Easier to determine prices Easier to determine prices – May use NOC codes at first to describe May use NOC codes at first to describe

its useits use– Remember least costly alternative Remember least costly alternative

situationssituations

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SELECTING CPT CODES• Stacking codes problematic

– Don’t define test to us– May give inaccurate prices--- too high

or too low

• Use NOC code (e.g. 84999)– Use with name of test (e.g.

“WonderTest”)– We can assign specific price– We can follow use of test for policy– Less confusing for ordering MD

• We can consider development costs or small quantity costs

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LONGER TERM CODING• Real CPT Code Helps Define Test

– Can take years– Usually associated with national

coverage and national pricing

• Consider HCPCS or Category III– HCPCS comes from CMS– Category III easy to obtain

• Allows national tracking of data• Can allow for payment also• Category III can progress to regular CPT

• Consider Coverage With Evidence Development– Obtained from CMS

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GENETIC TESTING• Consider the science

– Same proof & science as other tests

– Same clinical validity– Same peer reviewed data

• Consider the ethics– Who gets tested– Under what circumstances– When tests done

• Consider the costs– Once per lifetime?

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GENETIC TESTING

• Consider if the test is screening-& not covered– Each screening test requires new

law from Congress– When is screening not screening

but disease management – gray area

• Future CMS & legal issues dealing with genetic testing

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OTHER ASPECTS OF NEW TESTSOTHER ASPECTS OF NEW TESTS• Coverage for a new test (service) may

be positively influenced by– Requests from physicians in practice– Clinical society white papers or guidelines– Technical Advisory Committees– Other Medicare MACs or insurers

• Coverage for a new test (service) may be negatively influenced by– Over-marketing by manufacturer – Inadequate data with “spin” by consultants– Ridiculous pricing demands– Use of stacking codes when other coding

more appropriate

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TIME FACTORS FOR DECISIONS• Review (re-review) literature• Discuss with staff• Review other Contractors for like policies• Add as article: 3-6 weeks

– Includes code decision, price decision– Claims personnel education

• Formal Policy due to restrictions of use or diagnoses: 3-6 months– Write & review policy– Draft on web for public review– CAC and open meetings required– Open for comments from anyone– Notice of final policy before effect date

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Welcome to The ACP Advocate

Our second story, as promised, is an analysis of the Medicare Fee Schedule for next year. ACP’s Advocacy Web Site also has answers to your frequently asked questions about the new rule. While the new schedule is considered final, we still expect that Congress will step in to stop the 21 percent overall fee cut that is supposed to start Jan. 1.  On Thursday afternoon, the House passed H.R. 3961, a bill that would fix the problems in Medicare payments caused by the sustainable growth rate formula. If they manage to work with the Senate to pass similar legislation, this would provide a fix for not only the 21 percent cut; it would pave the way for the long-term fix we’ve been waiting for.

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MAJOR PRICING CHANGES 2010

• PPIS (AMA Physician Practice Information Survey) data

• Change in utilization rate• ???Medicare Consultations eliminated –

some other CPT changes• 5 year review of malpractice RVUs• Implementation of MIPPA provisions• Not many changes for routine lab

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PPIS SURVEY FOR PRACTICE PPIS SURVEY FOR PRACTICE EXPENSE INFORMATIONEXPENSE INFORMATION• PPIS is multispecialty survey of

physicians and NPPs – Used consistent survey instrument– 3,656 across 51 specialties and

professional groups

• New survey conducted by AMA– Expanded to include NPPs– CMS purchased updated specialty

specific PE / hr data for PE RVUs

• Most consistent source of practice expense survey information to date

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PPIS SURVEY FOR PEPPIS SURVEY FOR PE• PPIS data has effects of redistribution with

negative aspects to some groups– Cardiology– Radiology– Oncology– Urology

• Positive aspects for primary care• PPIS data transitioned over 4 years• Supplemental survey data also used

– Clinical labs– IDTFs– Oncology and Drug Administration

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Specialty Average change

Ophthalmology 5%

Family medicine 4%

General practice 3%

Geriatrics 3%

Internal medicine 2%

Interventional radiology -3%

Urology -4%

Radiology -5%

Cardiology -8%

Nuclear medicine -18%

Source: Centers for Medicare & Medicaid Services, "Payment Policies Under the Physician Fee Schedule and Other Revisions

to Part B for CY 2010," Federal Register, Oct. 30 (www.federalregister.gov/ofrupload/ofrdata/2009-26502_pi.pdf)

CHANGES

FOR

2010

WINNERS

AND

LOSERS

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CMS ACTION (not final) from AMA Meeting

• Eliminated use of all consultation codes Eliminated use of all consultation codes (except for telehealth consult G-codes)(except for telehealth consult G-codes). .

• Increased work RVUs for new & established Increased work RVUs for new & established office visits office visits

• Increased work RVUs for initial hospital and Increased work RVUs for initial hospital and initial nursing facility visitsinitial nursing facility visits

• Incorporated the increased use of these visits Incorporated the increased use of these visits into PE and malpractice RVU calculations. into PE and malpractice RVU calculations.

• Increased incremental work RVUs for E&M Increased incremental work RVUs for E&M codes built into the 10-day and 90-day global codes built into the 10-day and 90-day global surgical codes.surgical codes.

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CONSULTATION: Decision not FinalCONSULTATION: Decision not Final• Per AMA-CPT Meeting: Consultations no longer Per AMA-CPT Meeting: Consultations no longer

reimbursed for Medicarereimbursed for Medicare– Effective 1-1-10 unless rules changeEffective 1-1-10 unless rules change– Regular initial E&M codes for initial inpatient hospital Regular initial E&M codes for initial inpatient hospital

& nursing facilities& nursing facilities– Regular follow up codes for hosp / SNF-NFRegular follow up codes for hosp / SNF-NF– Regular office initial & follow up codesRegular office initial & follow up codes

• Principal physician of record uses a modifier: to Principal physician of record uses a modifier: to be listedbe listed

• CPT still lists consult codes for non-Medicare CPT still lists consult codes for non-Medicare patientspatients

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QUESTIONS