medicare update march 11, 2008 debra l. patterson, m.d. j4 mac medical director trailblazer health...
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![Page 1: Medicare Update March 11, 2008 Debra L. Patterson, M.D. J4 MAC Medical Director TrailBlazer Health Enterprises, LLC](https://reader034.vdocument.in/reader034/viewer/2022052603/56649f175503460f94c2dedb/html5/thumbnails/1.jpg)
Medicare Update Medicare Update March 11, 2008March 11, 2008
Debra L. Patterson, M.D.J4 MAC Medical Director
TrailBlazer Health Enterprises, LLC
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TrailBlazer Part B Paid Claims Error Rates
0%
2%
4%
6%
8%
10%
12%
14%
16%
November 2004Report
(Claims 1/1/03-12/31/03)
January Update November 2004
Report(Claims 1/1/03-
12/31/03)
April Update November 2004
Report(Claims 1/1/03-
12/31/03)
July Update November 2004
Report (Claims 1/1/03-
12/31/03)
November 2005Report
(Claims 1/1/204-12/31/2004)
May 2006 Report (Claims
10/1/2004-9/30/2005)
November 2006Report
(Claims 4/1/2005- 3/31/2006)
May 2007 Report (Claims
10/1/2005 -9/30/2006)
November 2007Report
(Claims 4/1/2006- 3/31/2007)
Gro
ss E
rro
r R
ate
TX
MD/DC/DE/VA
National
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52.1%
22.9%
20.8%2.1%
2.1%Incorrect Coding
Insufficient Documentation
No Documentation
Medically Unnecessary Services
Other
November 2007 CERT Report - Part B Carrier Combined Error Rate by Type of Error
Claims Submitted 4/1/2006 - 3/31/2007
Paid Claims Error Rate4.8%
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November 2007 CERT Report - Part B TrailBlazer TX Top 10 BETOS on Projected Improper Payments
Claims Submitted 4/1/2006 - 3/31/2007
$0
$5,000,000
$10,000,000
$15,000,000
$20,000,000
$25,000,000
$30,000,000
$35,000,000
$40,000,000
Proj
ecte
d Im
prop
er P
aym
ents
Consultations Office visits - established Hospital visit -subsequent
Office visits - new Emergency room visit Nursing home visit
16.7%
6.0%
8.2%
8.2%
13.1%
10.8%10.0%
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Evaluation and Management ServicesEvaluation and Management Services
Correct coding based on two distinct but related sets of criteria
• Medical reasonable and necessity criteria set the following
– Appropriate frequency– Upper and lower limits of appropriate intensity of service
• Key component “work” defined by the correct medically reasonable and necessary must be demonstrated
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Medical Necessity DefinedMedical Necessity Defined
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Medical NecessityMedical Necessity
• Statute
• National Coverage Decisions
• Local Coverage Determinations
• Clinical judgment considering the “rules”– Safe and effective– Meet but not exceed patient’s need– Accepted standard of medical practice
• Medical literature• Practice guidelines • Respected textbooks• Authoritative opinion
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Medical Necessity – Beyond E/MMedical Necessity – Beyond E/M
• Medical literature
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Medical Necessity – Beyond E/MMedical Necessity – Beyond E/M
• Medical literature
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Medical Necessity – Beyond E/MMedical Necessity – Beyond E/M
• Medical literature
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Medical Necessity – Beyond E/MMedical Necessity – Beyond E/M
• Medical literature
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Medical Necessity – Beyond E/MMedical Necessity – Beyond E/M
• Medical literature
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Medical Necessity – E/MMedical Necessity – E/M
The nature of presenting problem(s)• Severity• Acuity• Number • Diagnostic complexity • Therapeutic complexity• Counseling and coordination
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Medical Necessity – E/MMedical Necessity – E/M
Medical Decision Making• # of diagnoses and/or management options
• Amount and complexity of medical records, diagnostic tests, and/or other information
• Risk of significant complications, morbidity, and or mortality due to – Nature of Presenting problems– Diagnostic tests performed or ordered – Therapeutic options chosen•Severity•Acuity
•Number
•Therapeutic complexity
•Diagnostic complexity
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Medical NecessityMedical NecessityFrequency
• Acute problems – generally frequency not an issue
• Sub-acute problems (with or without physician intervention)
– Incomplete resolution–Potential for worsening, recurrence or
negative consequences–Acute problem resolved but outcome was still
questionable when last seen
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Medical NecessityMedical NecessityFrequency
• Chronic conditions –For stable, well controlled, or inactive
conditions• Consider likelihood for problem to deteriorate or
become uncontrolled based on the nature of the problem and documented patient behavior/past history
• Use published guidelines regarding accepted standards of care for specific problems (when available)
–Treat poorly controlled, decompensated, or exacerbated problems as acute
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Medical NecessityMedical Necessity
Intensity of service• Nature of the presenting problem• Severity
– CPT Medical Necessity Guidance
– Contributory factor statements known as “Nature of Presenting Problems” (NPP) contained in most CPT E/M codes.
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Medical Necessity in Evaluation and Management Services
Medical Necessity in Evaluation and Management Services
• 99201
“Usually the presenting problems are self-limited or minor.”
• 99202
“Usually the presenting problems are of low to moderate severity.”
• 99203 “Usually the presenting problems are of moderate severity.”
• 99204
“Usually the presenting problems are of moderate to high severity.”
• 99205“Usually the presenting problems are of moderate to high severity.”
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Medical Necessity in Evaluation and Management Services
Medical Necessity in Evaluation and Management Services
• 99231“Usually the patient is stable, recovering, or
improving.”
• 99232
“Usually the patient is responding inadequately to therapy or has developed a minor complication.”
• 99233“Usually, the patient is unstable or has developed
a significant complication or a significant new problem.”
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Medical Necessity in Evaluation and Management Services
Medical Necessity in Evaluation and Management Services
“self-limited or minor”
.
A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status or has a good prognosis with management/compliance
“low severity”
A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected
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Medical Necessity in Evaluation and Management Services
Medical Necessity in Evaluation and Management Services
“moderate severity”
.
A problem where the risk of morbidity without treatment is moderate; risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment
“high severity”
A problem where the risk of morbidity without treatment is extreme; there is moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment
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Medical Necessity in Evaluation and Management Services
Medical Necessity in Evaluation and Management Services
CPT Appendix C – Clinical Examples
• 99231
Subsequent hospital visit for 50-year old male with an uncomplicated myocardial infarction who is clinically stable and without chest pain.
• 99232
Subsequent hospital visit for an 54-year old female admitted for myocardial infarction , but who is now having frequent premature ventricular contractions.
• 99233Subsequent hospital visit for a 65-year old male, following an
acute myocardial infarction, who complains of shortness of breath and new chest pain.
.
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Medical NecessityMedical Necessity
Other characteristics of the encounter
• Number of problems • Diagnostic complexity • Therapeutic complexity• Counseling and coordination
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Medical NecessityMedical Necessity
Other characteristics of the encounter
•Appropriate for the problem/complaint
•Supports conclusions
•Supports evaluations and treatments chosen
•Well documented
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Medical NecessityMedical Necessity
Medically reasonable Medical Decision Making
regarding one or more problems out of proportion
to severity of illness
• Large number of lower severity problems or clearly defined co-morbidities evaluated/managed during one encounter
• Extensive medically necessary data review
• Extensive medically necessary diagnostic and/or therapeutic interventions
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Medical NecessityMedical Necessity
Medically reasonable Medical Decision Making
regarding one or more problems out of proportion
to severity of illness
• Extensive medically necessary data review
• Extensive medically necessary diagnostic and/or therapeutic interventions
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Medical Decision MakingMedical Decision Making
MDM in CPT and CMS E/M Documentation Guidelines
• Number of diagnoses or management options
• Amount and/or complexity of data to be reviewed
• Risk of significant complications, morbidity, and/or mortality
– Presenting problem
– Diagnostic procedures ordered
– Management options selected
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Common E/M Coding ErrorsCommon E/M Coding Errors
Typical MDM Errors•No documentation of medical decision making at all
•MDM limited to a list of old and current diagnoses
•No indication that diagnoses/problems listed led to increased physician work
•No key component information to support diagnostic conclusions and/or diagnostic/therapeutic plans
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Medical Decision MakingMedical Decision Making
“Broad Brush” MDM
• Typical E/M CPT code includes descriptions of multiple levels of key component work
• For History and Physical, CMS Guidelines further describe and quantify CPT key component levels and descriptors
• CMS Guidelines do not quantify MDM descriptors except in the area of “Risk”
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Common E/M Coding ErrorsCommon E/M Coding Errors
CPT and EM Guideline MDM Definitions
• High complexity MDM
–Extensive diagnoses evaluated or problems managed
–Extensive amount and complexity diagnostic evaluation ordered or reviewed
–High risk problem(s), diagnostic intervention(s), or treatment option(s)
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Medical Decision MakingMedical Decision Making
MDM in CPT and CMS E/M Documentation Guidelines
99222
HX = Comprehensive
EX = Comprehensive
MDM = Moderate
•Extensive HPI
•Complete ROS
•Complete PFSH
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Medical Decision MakingMedical Decision Making
MDM in CPT and CMS E/M Documentation Guidelines
CPT
99222
MDM = Moderate
E/M Guidelines
Moderate MDM
• Extensive numbers of diagnoses and/or management options (extensive not defined)
•Extensive data reviewed (extensive not defined)
•High risk of complications (table of risk provided)
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Medical Decision Making Medical Decision MakingNo National Standard Method
• Many physicians and other providers use no logical mechanism for coding MDM
• Some use commercially and otherwise available score-sheets
–Use without reasonability testing–Undefined terms included– Inherent shortcomings
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MDM Rationale – Marshfield ClinicMDM Rationale – Marshfield Clinic
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Medical Decision Making Medical Decision Making
1. Uncomplicated rib fracture with chest x-ray and no treatment
2. Uncomplicated rib fracture with no imaging but treated with analgesic
3. Chronically uncontrolled diabetic with co-morbid conditions started on insulin therapy
4 points
3 points
1 point
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MDM Auditing - TrailBlazerMDM Auditing - TrailBlazer
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MDM Auditing - TrailBlazerMDM Auditing - TrailBlazer
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MDM Auditing - TrailBlazerMDM Auditing - TrailBlazer
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MDM Rationale – TrailBlazerMDM Rationale – TrailBlazer
http://www.trailblazerhealth.com/partb/tx/evalmgmt.asp?
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Medical Decision Making Medical Decision Making
What’s a doc to do?
Keep in mind what E/M coding is all about
• Medical Necessity
• Physician Work
–Number and nature of problems–Diagnostic complexity–Therapeutic complexity
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Medical Decision Making Medical Decision Making
Diagnostic complexity
• Differential diagnoses• Constellations of symptoms and signs• Appropriate H and P to support diagnostic
conclusions• Appropriately complex diagnostic
evaluation ordered, scheduled, or performed
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Medical Decision Making Medical Decision Making
Therapeutic complexity
–Therapeutic modalities Medications Surgical procedures Radiological interventions Many, many others
–Patient instruction–Referrals to other practitioners for treatment–Hospital admission
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Medical Decision Making Medical Decision Making
• Pick a method for coding MDM and apply it– Be consistent– Define quantitatively as many terms as
possible
• Validate that it does not lead to irrational coding considering physician work and medical necessity
• If a method results in codes that it look too good to be true….they probably are
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ConsultationsConsultations
• All consultations require the following
–Request for opinion or advice from another physician (for that physician to use in his or her care of the patient)
– A written report of the consultant’s findings, opinions, and recommendations to the requesting physician
• Documentation must demonstrate both the request and the report
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ConsultationsConsultations
• Opinion requested is specific to the patient’s condition
• Referring physician will use the consultant’s report to manage the patient (ie, has not transferred sole care for the problem to the consultant)
• Service performed by an appropriate practitioner adequately trained to provide the opinion requested
• Adds to the quality or scope of medical care reasonably available from the requesting physician
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Consultations Consultations • Pre-operative clearance must be medically reasonable
and necessary considering the patient’s health history and the nature of the proposed operation
• Pre-operative visits whose sole purpose is performing or recording the mandatory admission H/P for a surgical admission are not separately payable and are not consultations
• Continuation of care by the consultant for an established clinical problem of an established patient in a different clinical setting but with no significant change in health status (ie, post-operative concurrent care) is not a consultation
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ConsultationsConsultations
• May not be reported as a split/shared service with a non-physician practitioner in the same group
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Consultations Consultations • Orthopedist seeing patient with elbow pain at
request of family practitioner
• Internist seeing patient for hypertension at request of orthopedist
• Cardiologist seeing patient for chest pain at request of neurosurgeon
• Dermatologist seeing patient with melanoma at request of internist
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Medicare Contracting ReformMedicare Contracting Reform
Section 911 of the Medicare prescriptionDrug, Improvement, and Modernization Act of2003 (MMA)
• Replaces current contracting authority withthe new Medicare Administrative Contracting(MAC) authority.
• Requires CMS to compete and transition allwork to MACs by October 2011
Why?
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Medicare Contracting ReformMedicare Contracting Reform• Carriers
• Fiscal Intermediaries
• Durable Medical Equipment Contractors
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Medicare Contracting ReformMedicare Contracting Reform
• Process Claims MAC
• Fraud and Abuse PSC
• Fair Hearings QIC
• Post payment review RAC
• Beneficiary Call Center 1-800- Medicare
“Functional” Contractors
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Medicare Contracting ReformMedicare Contracting Reform
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2
1
2
1
4
3
5
7
9
10
15
8
6
11
14
13
12
Medicare Contracting ReformMedicare Contracting Reform
3
N
N
= Start-up
= Cycle One
= Cycle Two
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Medicare Contracting ReformMedicare Contracting Reform
Local Policy• A Contractor Medical Director required for each MAC
(not each state)
• LCD Consolidation during Implementation
• Following full MAC implementation, Local Policy development returns to “normal” (Program Integrity Manual instructions)
– Contractor Advisory Process (i.e. CAC)– Comment and Notice– LCD Reconsideration processes
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Medicare Contracting ReformMedicare Contracting Reform
“Least Restrictive” LCD• Other than “least restrictive” permitted when significant
program vulnerability exists (CMS approval required)
• “No policy” not necessarily “least restrictive” (CMS approval required)
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Medicare Contracting ReformMedicare Contracting ReformJ4 MAC Policy Consolidation
• 800+ legacy contractor policies
• 138 “consolidated policies”
– 50% are Trailblazer LCDs with or without limited changes
– Remaining 50% are Noridian and Pinnacle policies (mostly Noridian) with or without limited changes
– Some LCDs underwent major revision and now consist of provisions from 2 or more legacy policies
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Medicare Contracting ReformMedicare Contracting Reform
J4 LCD Consolidation Lessons-Learned• “Less restrictive” is often very subjective
• Huge volume of work with very short turn-around time (ie, potential to not fully appreciate all “less restrictive” provisions)
• Implementation approach not evident in the text of the policy
• Not everything that affects claim payment is R&N– Variations in interpretation of national policy– Coding requirements
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Medicare Contracting ReformMedicare Contracting Reform
LCD “Gotchas”
• Drugs and Biologicals• Non-covered Services • Routine Foot Care• Ambulance (ground) Services• Wound Care• Bariatric Surgery
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TrailBlazer WebsiteTrailBlazer Website
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TrailBlazer WebsiteTrailBlazer Website
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Questions?Questions?