Health Care Economics Committee

Transcription

1 Health Care Economics Committee November 2012 Atlanta, GA SESSION ONE: Current Events 1

2 Financial No relevant financial relationships exists Non-Financial Health Care Economics Committee (American Speech-Language-Hearing Association) Receive no compensation as members 2

3 Assist Governmental Relations and Public Policy Board (GRPP) and ASHA staff in determining current economic issues and develop goals for ensuring equitable coverage and reimbursement Develop recommendations for coding (procedural and diagnostic) and relative values of procedural codes Anticipate further socioeconomic needs of the professions and the consumers 3

4 Audiology Members Stuart Trembath, Chair, alternate CPT Advisor Bob Fifer, RUC Advisor Faith Akin Bob Burkard Leisha Eiten George Lyons, Ex Officio, Director, ASHA Government Relations & Public Policy SLP Members Dee Adams Nikjeh, Co- Chair, alternate RUC Advisor Wayne Holland, CPT Advisor Gretchen Bebb Bernard Henri Bob Hillman Theresa Rodgers, VP for Government Relations and Public Policy 4

5 The Basics of Coding Current Procedural Terminology (CPT) Codes Healthcare Common Procedure Coding System (HCPCS) International Classification of Diseases (ICD) Codes Correct Coding Guidelines Physician Quality Reporting System Documentation Requirements Questions & Answers 5

6 Not a separate benefit but part of the Diagnostic Benefit. 1861(s)(3) of the Social Security Act Medical and Other Health Services (s) The term medical and other health services means any of the following items or services 6

7 Procedural Codes Describe what we DO with the client/patient Current Procedural Terminology CPT codes Healthcare Common Procedural Coding System HCPCS Diagnostic Codes Describe the REASON we are evaluating or treating the client/patient International Classification of Diseases or Disorders, 9th Revision, Clinical Modification ICD-9-CM codes 7

8 CPT and HCPCS 8

9 CPT Procedure Codes 9

10 Total RVU (work) + Total Practice Expense + Total Malpractice RVU x Conversion Factor = Payment See us in Session 2 for more 10

11 Each code is designated by 5 digits and represents a distinct procedure CPT codes are used for billing, data analysis of individual procedures, and insurance coverage decisions Each code must represent a procedure that is not experimental or investigational Vestibular and Audiology Function Tests are found in Special Otorhinolaryngologic Services, codes Interoperative Monitoring and Nerve Conduction Studies are found in 9590 to

12 Choose the descriptor that matches the procedure you just did Rule of thumb: one procedure one procedure code however Some audiology codes have been bundled: 92540: Basic vestibular evaluation 92557: Comprehensive audiometry threshold evaluation and speech recognition 12

13 Two new codes replace Continuous intraoperative neurophysiology monitoring: In the operating room:95940 Per 15 minutes Outside the operating room: Per hour Can be used for monitoring multiple patients Not a benefit of Medicare. For offsite monitoring of one Medicare beneficiary, use G0453 Per 15 minutes 13

14 Code Motor and Sensory nerve conduction study for: nerves nerves nerves nerves nerves nerves or more nerves New codes replace the traditional H- reflex codes (95934 and 95936). Includes motor, sensory, and mixed nerve conduction studies. Includes reports by the examiner and interpretation by the physician or other qualified health care professional. Each type of nerve conduction study is counted only once on the same nerve, even if multiple electrode sites are used. 14

15 CPT Code Description 2012 Rate 2013 Rate (with 26.5% cut, no Congressional intervention) 2013 Rate (estimated, with Congressional intervention) Comprehensive audiometry $39.14 $27.50 $ Acoustic Immittance Tinnitus Assessment $32.00 $23.50 $32.00 $66.71 $50.50 $ AR Evaluation $87.82 $66.75 $

16 Modifiers are two-digit numbers preceded by a hyphen that are added to CPT codes to describe unusual circumstances Use of a modifier means that the protocol for the procedure did not change, but there was something unusual about the circumstances under which the procedure was performed 16

17 -52 Abbreviated or shortened procedure -59 Two procedures are distinct and separate -22 Much longer than usual procedure -76 Repeat procedure by the same provider on the same date of service Documentation should reflect the unusual and extenuating circumstance as well as the rationale for use of a modifier 17

18 HCPCS Procedure and Device Codes 18

19 Application to CMS CMS Workgroup Evaluation Public Meeting Final Determination Anyone can submit Code must: not represent capital equipment not be exclusively for use in an inpatient setting not be appropriate for a different code set (i.e., procedure (CPT) or diagnostic (ICD)) 19

20 Each code is designated by a letter and 4 digits CPT codes are used for products, supplies, and services not included in the CPT codes durable medical equipment, prosthetics, orthotics, and supplies Cochlear Implants and Bone Anchored Hearing Aids are classified as Prosthetics: L8614-L8629 Hearing aids and FM Systems are classified in Hearing Services: V5008-V

21 Choose the descriptor that matches the device or procedure you performed Rule of thumb: if there is a CPT code, use it and not the HCPCS code Example: Patient seen for hearing aid assessment & selection 92591: Hearing aid examination and selection, binaural (CPT) V5010: Assessment for hearing aid (HCPCS) Many devices are not a benefit of Medicare Private insurers and Medicaid programs may have specific instructions for use of HCPCS codes 21

22 Examples: Codes still in use New FM System Codes Code V5011 Service/Device Fitting/Orientation /checking of hearing aid Code V5281 V5282 Assistive listening device, personal FM/DM: Monaural Binaural V5020 V5261 V5264 V5275 Conformity evaluation Hearing aid, digital, binaural BTE Ear mold/insert, non-disposable, any type Ear impression, each V5283 V5284 V5285 V5286 V5287 V5288 V5289 V5290 Loop receiver Ear level receiver Direct Audio Input receiver Blue tooth receiver Receiver, not specified Transmitter Boot coupling device Microphone 22

23 V5267: Hearing aid supplies/accessories IS NOW V5267: Hearing aid or assistive listening device/supplies/accessories, not otherwise specified 23

24 Modifiers may be used by Medicaid and private insurers LT or RT Identify left or right side NU New equipment RB Replacement of a part of a DME, orthotic, or prosthetic item Sometimes used by plans for cochlear implant parts RR Rental Used in select Medicaid programs 24

25 Search Terms and Links: Model Superbill Coding for Reimbursement Medicare CPT Coding Rules for Audiology Services coding_rules Bundling Versus Unbundling Questions: 25

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27 The International Classification of Diseases (ICD) Format for reporting causes of death on the death certificate. Assigns codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the U.S. Updated annually ICD-9-CM codes are 3-, 4-, and 5-digit codes Number of digits indicates level of code specificity Codes are arranged by categories There are levels within each category 27

28 Revision 1 st 2 nd 3 rd 4 th 5 th 6 th 7 th 8 th 9 th 10 th Years Covered * present 28

29 Began in 1994 CMS provides specific guidelines: Identify each service, procedure, or supply with an ICD-9 code Code the primary diagnosis first, followed by the secondary, tertiary, and so on. Do not code a diagnosis that is no longer applicable. Code to the highest degree of specificity. 29

30 Code a chronic diagnosis when it is applicable to the patient's treatment. When surgical procedures are performed, code the diagnosis applicable to the procedure. After the procedure code the most specific diagnosis determined to be the reason for the surgery. Avoid Not Otherwise Specified codes If results of diagnostic testing are NORMAL, code signs or symptoms to report the reason for test/procedure and explain normal result in report ICD-9 & CPT Code Should Agree! 30

31 DO NOT code conditions previously treated that no longer exist. code probable, suspected, questionable, or rule out diagnoses. misrepresent the service that was provided in order to receive reimbursement or for your patient s convenience = FRAUD! 31

32 389 Hearing Loss Conductive hearing loss Conductive hearing loss, unspecified Conductive hearing loss, external ear Conductive hearing loss, tympanic membrane Conductive hearing loss, middle ear Conductive hearing loss, inner ear Conductive hearing loss, unilateral Conductive hearing loss, bilateral Conductive hearing loss of combined types 32

33 Primary Diagnosis Condition chiefly responsible for visit Disease, condition, problem, symptom, injury, or reason for encounter If multiple problems exist, select most resource intensive diagnosis and list others as secondary Secondary diagnoses Co-existing conditions, symptoms, or reasons OR Symptoms found after study 33

34 Your patient presents to you, the audiologist, with congenital hearing loss and delayed speech and language development You evaluate the hearing loss so your primary ICD-9-CM code is Sensorineural hearing loss, bilateral The delayed speech development is due to the hearing loss. The secondary code is to denote Speech and language developmental delay due to hearing loss 34

35 Changes are Coming ICD- 10-CM 35

36 U.S. Dept of Health & Human Services has set October 1, 2014 as the new compliance date for implementation of ICD 10-CM ICD-10 includes ICD-10-CM diagnosis codes for all settings ICD-10-PCS procedure codes for hospital inpatients ICD-10 diagnostic code set contains more than 68,000 codes Combined with other ICD-10 code sets about 150,000 36

37 3-7 alphanumeric characters instead of ICD-9 with 3-5 digits to allow for more specificity Combination codes represent multiple conditions so that the need to determine primary and secondary codes is eliminated Clearer instructions than ICD-9 ICD-10 code descriptions contain detail, less room for error 37

38 Prevent and detect health care fraud and abuse Measure quality and effectiveness of health care Monitor resource use Improve systems for payment and claims processing Accommodate current, complex, and future health care needs 38

39 Benign paroxysmal positional vertigo H81.1 Benign paroxysmal vertigo H91.10 unspecified ear H91.11 right ear H91.12 left ear H91.13 bilateral ICD-9-CM ICD-10-CM 39

40 ICD-9-CM Diagnosis Codes for Audiology Audiology.htm ICD-10-CM Diagnosis Codes Guidelines for Coding & Reporting ICD-9-CM CDC ICD-9 Homepage Questions: 40

41 Non-payable G-codes for Physician Quality Reporting System 41

42 The Audiology Quality Consortium is made up of the following 10 Organizations: Academy of Doctors of Audiology Academy of Rehabilitative Audiology American Academy of Audiology American Academy of Private Practice in Speech Pathology and Audiology American Speech-Language-Hearing Association Association of VA Audiologists Directors of Speech and Hearing Programs in State Health and Welfare Agencies Educational Audiology Association Military Audiology Association National Hearing Conservation Association 42

43 Voluntary program designed to improve the quality of care to Medicare beneficiaries Participants receive bonus for participation through % bonus on claims for reporting on 50% of eligible patients In 2015, providers not participating receive penalty for not reporting 1.5% deduction of claims for all Medicare Part B services Based on reporting in 2013! 43

44 Quality measures represent a referral to a physician for specific conditions Measures are given G codes to add to the claim form Audiologists report:?ear deformity??sudden hearing loss??ear drainage??dizziness??medication??depression? 44

45 The Medicare final rule listed some measures as active, but discussed those same measures as being retired. The final rule also referred to measures with the incorrect numbers. Communications from CMS has been inconsistent and unclear ASHA is meeting with CMS officials following Convention to finalize measures for 2013 reporting Please sign up for ASHA Headlines! 45

46 Audiologist who is: Medicare provider Rendering services under NPI Billing for Part B Beneficiaries Non-facility based Private Practice Group 46

47 Medicare Part B Beneficiary Patient eligibility is based on procedure and diagnostic codes Patient eligibility is NOT based on the referral or the measure description It is likely you will need to report something on every Medicare patient you see 47

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51 Audiology Quality Consortium: PQRS Measures Reporting Audiology Quality Measures: A Step-by-Step Guide Audiology-Quality-Measures--A-Step-by-Step- Guide/ 51

52 Basic Guidelines 52

53 Report the code that corresponds with the procedure Stay within the appropriate family of codes If there is no code that is suitable, use Each test must be medically necessary 53

54 Accuracy problems occur when: Code descriptor is translated at the local level An in-house coding system is used rather than CPT, ICD-9, HCPCS Descriptor is abbreviated in such a way that the meaning changes Solution: obtain current copy of CPT, ICD-9, and Level II HCPCS manuals ( 54

55 Do not be locked into the referral diagnosis as your primary diagnosis Your primary diagnosis must match Who you are What you did What you found or Why you performed the test (presenting symptoms) Secondary diagnoses amplify and support the primary diagnosis 55

56 Establish guidelines on the basis of equipment capabilities rather than actual intent of code descriptor Ex: otoacoustic emissions 4 frequencies = screening? 6 frequencies = diagnostic? Clinical question asking if something could be wrong vs. mapping the cochlea 56

57 Putting it Down on Paper 57

58 Question: Why did you do that? Answer: Because that is how I was taught to do it in graduate school. I don t feel comfortable doing it differently. Reality: Establish a clinical question and choose your procedures to answer that question Document the medical justification for the procedures you performed 58

59 A primary principle of documentation: If it wasn t documented, It wasn t done! Documentation directly impacts reimbursement No documentation = No reimbursement No documentation = Repayment of fines if audited The audiogram of X s and O s cannot stand alone as the sole source of documentation 59

60 Name and professional identity of the person who ordered the evaluation Person who actually performed the service The reason for the test Procedures that were completed and their outcomes Clinical assessment of the findings Recommendations Signature Date of service 60

61 An acronym to keep in mind is the SOAP note Subjective findings, Objective findings, Assessment, Plan Speak in plain English minimize jargon Physicians, especially non-ent physicians, many times have no clue what we mean 61

62 DO NOT Destroy Rewrite Replace Single word or short phrase: Single line strikeout, initial, and date Error in interpretation or diagnostic status Write addendum note 62

63 Tympanometry was consistent with normal ear canal volume, normal compliance, and an appropriate gradient. Versus Tympanometry was normal bilaterally. 63

64 Right ear results showed a mild to profound hearing loss. Versus Right ear thresholds showed normal hearing sensitivity from 500 Hz to 1000 Hz, a mild sensorineural hearing loss at 2000 Hz, and a precipitous drop to a profound hearing loss at 3000 Hz and above. 64

65 The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately. The patient was to have a bowel resection. However, he took a job as stockbroker instead. The patient is tearful and crying constantly. She also appears to be depressed. The patient refused an autopsy. The respiration tube was disconnected and the patient quickly expired. 65

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67 Fraud: Charges for services not delivered Recovery of Funds Does not need to involve fraud Overbilling Audits Review of documentation Typically on site hour notification of selected records by patient name and date of birth 67

68 If discrepancies are found, amount to be refunded is extrapolated Example: 10/25 charts reviewed are found deficient = 40% Paid total of $270,000 over previous three years for all patients Return requested: ($270, * 0.40) = $108,000 Common citations: Insufficient history justifying medical necessity Unclear findings Mismatch between report date of service and claim form Absence of report only audiogram 68

69 Forbidden solicitation scenarios Health fair screenings Quid pro quo Exchange of money Screening a nursing home or rehab center 69

70 Know the regulations for covered vs. non-covered Ensure complete documentation with all elements fulfilled Ensure report DOS matches claim form DOS Know the payers and their rules they will be inconsistent! 70

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72 4 year old child presents parental concern for hearing History of 6 ear infections in the last two years with last treated infection 6 weeks ago. No family history of hearing loss, mother s pregnancy and the birth of the child were uneventful. The child passed newborn hearing screening at birth. 72

73 Test results revealed: Normal hearing sensitivity for both ears with no air/bone gaps. SRTs at 10 db, bilaterally. Speech recognition ability was excellent for both ears. Normally shaped and compliant tympanograms with peak pressure at 0 mm H2O. 73

74 What CPT codes do you bill? Basic comprehensive audiometry threshold evaluation and speech recognition Tympanometry (impedance testing) What ICD-9 diagnosis code should you use? Conductive hearing loss of combined types OR Sensorineural hearing loss, bilateral OR Dysfunction of Eustachian tube 74

75 18 year old presents c/o constant tinnitus in the right ear for the last 12 months. History of noise exposure from firecracker explosion by right ear, IPOD and hunting. Also complaining of hearing loss in both ears, right ear>left ear. Struggling in school to hear in class No other remarkable history. 75

76 Right ear test results: Normal hearing sensitivity through 1 KHz, falling to a moderate, sensorineural hearing loss at 2KHz and falling precipitously to a profound sensorineural hearing loss at 3KHz and above. SRT of 20 db with 76% recognition Left ear results: Normal hearing sensitivity through 2KHz with a mild, sensorineural hearing loss at 3,4 and 6KHz rising to normal hearing sensitivity at 8 KHz. SRT of 15 db with excellent recognition 76

77 Acoustic immittance testing revealed normal tympanograms, bilaterally. Contralateral and ipsilateral acoustic reflexes were obtained for both ears at expected levels for the left ear and at significantly reduced sensation levels for the right ear. No significant acoustic reflex decay was seen for either ear. 77

78 What CPT Codes do you bill? Basic comprehensive audiometry threshold evaluation and speech recognition Acoustic immittance testing, includes tympanometry(impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing. What ICD-9 diagnosis code should you use? Primary Sensorineural hearing loss, asymmetrical Secondary Tinnitus unspecified 78

79 2 year old with family history of significant sensorineural hearing loss Mother, grand father had a moderate, sensorineural hearing loss since birth Child passed newborn hearing screening. No other significant history was obtained. 79

80 The child refused to wear earphones. Sound field testing revealed good localization responses using VRA at 25 db. Normal tympanograms bilaterally. Distortion product OAE testing revealed robust responses for 6 frequency pairs between 1000 Hz and 6000 Hz for each ear. 80

81 What CPT codes will you bill? Visual reinforcement audiometry Tympanometry (impedance testing) Otoacoustic emissions, limited What ICD-9 diagnosis code should you use? Sensorineural hearing loss, bilateral 81

82 32 year old who will be treated with ototoxic medications for which their hearing will be monitored throughout treatment. No other significant history was obtained. 82

83 Test results revealed normal hearing sensitivity through 3000 Hz dropping to a mild, sensorineural hearing loss at 4000 Hz and above, bilaterally. SRT of 10 db for each ear and excellent speech recognition Distortion product OAE testing revealed robust responses for 16 frequency pairs between 4000 Hz and 12,000 Hz. All frequency pair measurements were evaluated to determine a cochlear map of this region of the cochlea. 83

84 What CPT codes should you bill? Basic comprehensive audiometry threshold evaluation and speech recognition Otoacoustic emissions, comprehensive What ICD-9 diagnosis code should you use? Sensorineural hearing loss, bilateral 84

85 Questions? 85

86 CPT Overview Procedure Evaluation Process Medicare Update Health Care Reform 86