2015 Reimbursement Strategies

Michael A. Granovsky MD CPC FACEP

President LogixHealth

2015 What’s The Forecast?

RVUs Payments Quality Programs

Risk Areas

Opportunities

▪ 85% of ED doc’s revenue derived from 99281-99285

▪ Critical Care up to 89% ▪ Widen the lens to 100%

– RVUs per patient – Includes procedures

Where Are The RVUs?

OIG Report: PROGRAM INTEGRITY PRACTICES TO ADDRESS VULNERABILITIES IN EHRS

BCBS Accusation of Cloning

Bullet Proof Hx and PE Documentation ▪ 4 HPI with case specific detail ▪ Recognize high complexity cases ▪ ROS with clinical detail

– 2-3 pertinent positives/negatives ▪ PE macros

– Case specific detail ▪ Harness nurses notes but review and

confirm for Past/Family/Social Hx ▪ Cleary state history caveat ▪ Clearly document acuity caveat

RAC Prevent Defense Basic Best Practice

▪ Document a differential diagnosis: – Chest pain: ACS, GERD, Pneumothorax, PE

▪ Clearly state co-morbidities – IDDM, Htn, Lymphoma

▪ Be aware of diagnoses qualifying as high risk – Abrupt change in mental status

(seizure, TIA, weakness, numbness)

Documentation Best Practice: Defending the Patient’s Acuity

Work RVUs Practice Expense RVUs +Liability Insurance RVUs Total RVUs for a given code

RVUTotal X Conv. Factor = Medicare Payment

2015 RBRVS EQUATION

Work RVUs typically only change as part of a large mandated review

Practice Expense and PLI (Liability) are updated each year with small variations

78% of ED Total RVUs derived from Work 2015 RVU update

2015 ED work RVUs stable 2015 Total RVUs up slightly

+PLI increase 2017 next possible E/M 5 year work review

Future RVU Evolution

2014 and 2015 RVUs

Code 2014Work

2015 Work

2014 PE

2015 PE

2014 PLI

2015 PLI

2014 Total RVUs

2015 Total RVUs

99281 0.45 0.45 0.11 0.11 0.03 0.03 0.59 0.59

99282 0.88 0.88 0.21 0.21 0.07 0.07 1.16 1.16

99283 1.34 1.34 0.29 0.29 0.10 0.12 1.73 1.75

99284 2.56 2.56 0.53 0.53 0.21 0.24 3.30 3.33

99285 3.80 3.80 0.76 0.75 0.29 0.38 4.85 4.93

99291 4.50 4.50 1.44 1.43 0.33 0.40 6.27 6.33

April 1 2014 President Signs H.R. 4302 Protecting Access to Medicare Act of 2014

Stabilized the CF at $35.8013 3.31.2015 17th SGR patch since 1997 Sequester continues (2024)

Technical Correction from 12.29.14 update Dropped the CF to $35.7547 for Q1 2015 Increase of PLI RVUs of .02 for ED codes of interest

The Conversion Factor: Where Are We?

2015 Reimbursement By Specialty

The Dreaded SGR Is Gone!

H.R. 2: Medicare Access and CHIP Reauthorization Act of 2015

Date: Apr 14, 2015 Senate Vote #144

114th Congress

▪ REPEALS SGR and avoids future cuts ▪ Conversion Factor Updates

– 2015-2019 0.5% • 7.1.2015- 12.31.2015

– 2020-2025 0.0% – 2026 2 CF pathways

• APM involvement 0.75% • Lacking APM involvement 0.25%

▪ GPCI work floor extended for 2 years

SGR FIX Passed April 14th 2015

▪ No further ICD-10 delay – Implementation left at 10/1/15

▪ The two midnight rule is continued in a “probe and educate” status through 9/30/15

▪ 10 day and 90 day global procedural packages continue

Some of the “pay fors”: ▪ Increases means testing for Medicare

beneficiaries. Make more…pay more ▪ Hospital “market basket” set at 1%

SGR Repeal Details

▪ PQRS and Value Based Modifier continue through 2018 and then consolidated

▪ 2019 PQRS, VBM, and EHR incentive programs rolled up

▪ Merit Based Incentive Payment System (MIPS) – 4% 2019 escalating to 9% in 2022

▪ MIPS Assessment categories: – Quality (PQRS), Resource use (VBM cost metrics),

Clinical practice improvement (MOC part IV) , EHR Meaningful use (likely not apply to hospital based)

SGR Repeal and PQRS

2019 – 2025 potential 5% lump sum bonus ▪ 2019-2020: 25% of Medicare revenues furnished as part of

an eligible APM ▪ 2021--2022: 50% of Medicare revenues from APMs Or 25% of Medicare revenues from APMs AND 50% of all payer revenues from APMs ▪ The professional “is willing to provide the data to CMS” ▪ 2023+- 75% of Medicare revenues from APMs or 25% of

Medicare revenues from APMs and 75% of all payer revenues from APMs

The Secretary shall…

SGR Repeal Alternative Payment Model Bonus

DOCUMENTATION & CODING 2015 Increases With Each E/M Level

0

1

2

3

4

5

6

7

9928199282

9928399284

9928599291

0.59 1.16 1.753.33

4.936.33

$226.33 $176.27 $119.06 $62.57

Q1 & Q2 2015

0%

10%

20%

30%

40%

50%

60%

99281 99282 99283 99284 99285 99291

0.2% 1.5%

13.5%

25.2%

52.2%

7.4% 0.2% 1.3%

12.1%

25.4%

52.7%

8.3%

National WA

Updated National Medicare BESS Data

ED E/M Acuity Distribution

Effective for dates of service January 1, 2015 •New code ▲Revised code Contains new or revised text ~FDA approval pending # Resequenced code

2015 CPT Update

CPT 2015 264 new codes 143 deleted codes 134 revised codes

▪ Military History added as an element

Social History

New code set now exists to describe arthrocentesis performed with Ultrasound guidance. The code set is further delineated by the size of the joint: 20604 Arthrocentesis, aspiration and/or injection; small

joint or bursa (eg, fingers, toes) with ultrasound with permanent recording and reporting

20606 Arthrocentesis intermediate joint or bursa (e.g., wrist or elbow) with ultrasound with permanent recording and reporting

20611 Arthrocentesis major joint or bursa (eg, shoulder, hip) with ultrasound

New for 2015: US Guided Arthrocentesis

▪ 76645 US breast(s) (unilateral/bilateral) deleted

▪ 76641- US breast, unilateral real time with image documentations; including when performed axilla complete

▪ 76642 US breast, unilateral real time including when performed axilla limited

▪ Code 21800(Closed treatment of rib fracture, uncomplicated, each) deleted

2015 CPT Update and Changes

▪ Requires interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site

▪ Apply the GT modifier to signify the patient was at a qualified “originating site” Federal telemedicine demonstration projects in Alaska and Hawaii use the GQ modifier- allows asynchronous

▪ Growing list of qualifying services: smoking cessation, alcohol misuse screening, many psychiatric services

▪ 16 states require private payers to reimburse, 9 states provide Medicaid reimbursement :>

Telemedicine Details

▪ Originating site- where the patient is located – Facility fee if qualified report w/ code Q3014 – Payment $24.83 Previously restricted to originating sites in low population density rural counties January 1, 2014, originating sites definition expanded to include: rural portions of urban and high population counties may also be eligible for reimbursement. http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx

Facility Telemedicine Payment

▪ Service by the Provider where the patient is not located – “the distant site”

CMS Professional Services

▪ SSB 5175 – requires private carriers and Medicaid to reimburse telemedicine & allows for non rural originating sites

▪ It is the intent of the legislature to recognize the application of telemedicine as a reimbursable service by which an individual receives medical services from a health care provider without in-person contact with the provider.

▪ April 13th sent to the governor for signature & would go into effect July

WA Telemedicine Update

▪ CMS will delete place of service code 22 outpatient hospital for the CMS 1500

▪ CMS will develop two new provider based physician place of service codes – Off campus place of service – On campus place of service

▪ Issued through sub-regulatory guidance – Not before July 1 2015

▪ ED POS #23 will be retained

2015 Update: Physician Billing Off Campus Provider Based POS

▪ SGR Repeal signed- No current ICD 10 delay – 10.1.2015

▪ No new codes of consequence ▪ Additional guideline clarifications ▪ Active treatment- Examples of active treatment are:

surgical treatment, emergency department encounter While the patient may be seen by a new or different provider, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.

2015 Diagnosis Guidelines Update

In both ICD-9-CM and ICD-10-CM, sign/symptom and unspecified codes have acceptable, even necessary, uses. In some instances signs/symptoms or unspecified codes are the best choice to accurately reflect the health care encounter. You should code each health care encounter to the level of certainty known for that encounter.

CMS ICD 10 Myths and Facts

▪ Final Rule released October 31, 2014 ▪ Published Federal Register 11/10/2014 CMS-1613-FC ▪ CMS will continue to pay 5 distinct ED facility levels ▪ No national ED facility guidelines ▪ Small ED Facility revenue increases ▪ Packaging of items with cost < $100 finalized

– Most plain films and most labs – Some US – Foley, TC of EKG – Not Hydration, Injection, Infusion

▪ Many smaller ED procedures – simple laceration

2015 OPPS Update

$0.00

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

99281 99282 99283 99284 99285 99291

$55.65

$100.91

$166.45

$293.71

$455.93

$634.94

$60.46

$112.74

$198.31

$333.67

$492.49

$656.69

2014 2015

2015 Facility Level Revenue

2015 PQRS: How Much Money At Stake

PQRS Financial Modelling ▪ 45,000 visits with 20% Medicare ▪ 9,000 Medicare patients @ $135/patient ▪ $1,215,000 annual Medicare revenue ▪ 1% of Medicare revenue = $12,150 ▪ Extrapolate to your group:

– For every 10,000 visits 1% of Medicare = $2700 ▪ 50k group receives a 6% penalty $81,000

▪ Final Rule published a requirement for: – 9 measures across 3 domains for 50% of patients

including 1 cross cutting measure ▪ 2015 Removal of ED Measures

– #28: Aspirin for AMI – #55: 12-Lead ECG for Syncope – #56: Pneumonia (CAP): Vital Signs – #59: Pneumonia (CAP): Empiric Antibiotic

▪ Most ED Groups will not have 9 measures ▪ Will fall under MAV (Measure Applicability

Validation)…Huh?

How To Satisfactorily Report PQRS In 2015

MAV is a validation process that will determine whether eligible professionals (EPs) should have reported additional measures OR domains. MAV is applied to individual EPs and group practices that report less than nine measures OR less than three domains for PQRS. If MAV analytically determines that the EP or group practice could have reported additional measures or domains within the clinical cluster, then the PQRS payment adjustment may apply. (FAQ10058)

What is Measure-Applicability Validation (MAV)?

MAV Complexity

Emergency Care Cluster & Cross Cutting

Minimum Threshold Test The common minimum threshold, based on statistical and clinical frequency considerations, will not be less than 15 patients

▪ Case specific documentation is protective – EHRs and Coding: RAC Attacks…Don’t be a

victim ▪ RVUs are stable for 2015 ▪ Conversion factor now safe ▪ Increased packaging will create heightened

resource use awareness ▪ Physician quality programs are expanding in

importance

Conclusions

Michael A. Granovsky MD CPC FACEP

President Logix Health

MGranovsky@logixhealth.com

781.280.1575

Contact Information

Educational Appendix

SGR Repeal Surgical Package Details

Sec. 523. Payment for global surgical packages. This provision reverses the CMS decision to

eliminate the bundled payment for surgical services that span a 10 and 90-day period. It

requires CMS to periodically collect information on the services that surgeons furnish during

these global periods beginning not later than 2017 and use that information to ensure that the

bundled payment amounts for surgical services are accurate. The Secretary has the authority to

delay a portion of payment for services with a 10 and 90-day global period to incentivize

reporting of information. The Secretary can cease the collection of information from surgeons

once the needed information can be obtained through other mechanisms, such as clinical data

requires and electronic medical records

Total Potential Impact of PQRS Participation 2015 3 PQRS Programs Based on 2015 Reporting

Traditional PQRS Bonus Gone PQRS MOC Incentive 0.5% paid in 2016

Deadline was Feb. 13, 2015 Subtotal Potential PQRS Incentives +0.5% in 2015

PQRS Penalties -2.0% deducted in 2017 Value-Based Modifier : (>10 providers) -4.0% deducted in 2017

Subtotal Potential PQRS Penalties -6.0% in 2017

TOTAL PQRS IMPACT 6.5% of ALL Medicare $$$

2015 PQRS Programs Overview

▪ Measure #317, Screening for HBP and F/U Documented-Claims and Registry-Cross-Cutting Measure

Domain: Community/Population Health – Description: % of pt’s 18 & older who were screened

for HBP AND a documented f/u plan. – Numerator: Pt’s who were screened for HBP AND

have a f/u plan documented, if the blood pressure is pre-hypertensive or hypertensive.

– Denominator: Pt’s ≥ 18 yrs AND pt encounter 99281-99285 (see appendix for complete CPT list).

2015 ED Measures

▪ Measure #317, Screening for HBP and F/U Documented-Claims and Registry – Complete Denominator Encounter Code List:

90791, 90792, 90834, 90837, 90839, 90845, 90880, 92002, 92004, 92012, 92014, 96118, 97532, 99201-99205, 99212-99215, 99218-99220, 99224-99226, 99234-99236, 99281-99285, 99304-99310, 99318, 99324-99328, 99334-99337, 99340-99345, 99347-99350, D7140, D7210, G0101, G0402, G0438, G0439

Measure # 317 Specifications

▪ CMS concerned : provider based cost >> physician office/clinic

▪ New hospital modifier for services furnished in off campus provider based clinics

▪ Modifier PO- Off campus provider based department – Off campus location is defined as > 250 yards from

main buildings of hospital ▪ Voluntary reporting in 2015 ▪ Mandated reporting January 1, 2016

2015 Provider Based Billing

Michael A. Granovsky MD CPC FACEP

President Logix Health

MGranovsky@logixhealth.com

781.280.1575

Contact Information