Socioeconomics Update in Thyroid Practice

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1 Socioeconomics Update in Thyroid Practice Mark A. Lupo, MD, FACE, ECNU Thyroid & Endocrine Center of Florida Assistant Clinical Professor of Medicine Florida State University, College of Medicine Sarasota, Florida

2 This 9mm left inferior nodule should remind us all why we re here!

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4 Neck Ultrasound Just Do It (yourself)! Most patients undergoing thyroid ultrasound have static images by an ultrasound technician or sonographer that are limited to the thyroid gland only These images are later interpreted by a radiologist without thorough knowledge of the patient s history Sonologist Clinician Performing Ultrasound Access to the US Machine is key put it in your contract!

5 ECNU Increase patient and public confidence Certifies the Endocrinologist as an accomplished Sonologist Highlights Thyroidology as a significant part of your practice

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7 And many more! Nickie Mizell

8 In an increasingly competitive health care climate with limited resources, it is imperative that ultrasound practitioners demonstrate excellence in their practices. Patients demand and deserve high-quality care. The American Institute of Ultrasound in Medicine (AIUM) Ultrasound Practice Accreditation Council has developed standards for the accreditation of ultrasound practices. These standards serve as a benchmark for ultrasound professionals seeking to meet nationally accepted protocols. Your competitors are accredited; don't fall behind.

9 My Thyroidology Practice Single sub-specialty private practice Practice limited to thyroid, parathyroid and bone Practice started from scratch right out of fellowship Office Staff Four Full-Time Thyroidologists/Endocrinologists Office manager, 2 front office, 1 RN, 3 MAs, 1 New Patient Coordinator, 1 Billing, Part-time lab tech and CRA Services provided Ultrasound (not by a tech), US-FNA with cytology adequacy assessment, on-site laboratory, (previously.i-131 rx) Clinical Research

10 Adding Value at Many Levels Patient Convenience: one-stop shop Service to Consulting Physicians More Cost Effective Approach Research Opportunities Practice Satisfaction and Enjoyment

11 Patient Convenience At the Initial Consultation: Diagnostic Neck Ultrasound by Clinical Thyroidologist Explanation of the findings Correlation with clinical history FNA at time of initial consult IF indicated Rapid On Site Evaluation (ROSE) of FNA cytology Blood draw in office At the follow-up visit Follow-up by same sonologist with direct, real-time comparison to prior studies FNA during the visit if deemed necessary

12 Realities of Private Thyroid Practice Hassle factor has increased considerably with PQRS, MIPS and MACRA Reimbursement has decreased while overhead continues to increase Limited ancillary testing to subsidize salaries Increasing need to consider: Different marketing strategies Offering more out-of-pocket services NOT FOR PROFIT ENTITY

13 ICD-10 Be Specific C73 Malignant Neoplasm of Thyroid Much better to use Papillary Microcarcinoma of Thyroid or Medullary Thyroid Cancer *E03.9 Hypothyroidism, unspecified Give as much detail as possible: E89.0 Post ablation Hypothyroidism or Postsurgical **E03.2 Medication Induced Hypothyroidism E05 Hyperthyroidism many options to be more specific with this

14 No code for It s not your Thyroid Consider these instead: X52: Prolonged stay in weightless environment V91.07XA: Burn due to water skis on fire, initial encounter Y34: Unspecified event, undetermined intent Y92253: Hurt at the opera

15 CPT Codes Fine needle aspiration; without imaging guidance Fine needle aspiration; with imaging guidance (For radiological supervision and interpretation, see 76942, 77002, 77012, 77021) (For percutaneous needle biopsy other than fine needle aspiration,, see for thyroid ) Biopsy thyroid, percutaneous core needle Diagnostic ultrasound of neck soft tissues, including the use of Doppler Use of ultrasound for needle guidance placement 88172* Cytology adequacy assessment (first evaluation episode, each site) 88177* Repeat adequacy assessment (each separate additional evaluation episode, same site) *Requires MODERATELY COMPLEX CLIA LICENSE for more information on CLIA

16 Cytology: Fragments of skeletal muscle; insufficient thyroid cells for evaluation

17 Ultrasound & FNA Coding Information is based on national CMS guidelines Check with local carriers for specific guidelines Coding and reimbursement vary tremendously by geography, insurance carrier, hospitals/offices etc. All medical coding must be supported by documentation and medical necessity

18 National Medicare 2018 Allowable (diagnostic US) $ (global) (US guidance for bx) $61.20 (global) (Bx with US) $ (Bx w/o US) $ (percutaneous core needle thyroid BX) $ (adequacy) $59.04 (global) (adequacy) $ /5 (New Patient) $167.40/$ /4/5 (Return) $74.16/$109.44/$147.60

19 2018 National Medicare Allowable & WRVU Code Allowable WRVU $ $ $ *76942 $ *76536 $ $ $ $ / $74.16 / $ / 1.5 Professional component only 19

20 Modifiers May be Required Right or Left Modifiers- RT/LT indicate locations and are typically coded subsequent to any payment specific modifiers such as 59 or 76. Modifier 76 describes the same procedure or service repeated. It is used when the same physician repeats a procedure on the same day. Do Not Use modifier 76 on E/M codes or when procedures are performed on multiple sites Modifier 59 affects payment, can NOT be used on E/M codes and should only be used when no other modifier is appropriate. Documentation MUST support o Different site o Separate incision/excision o Separate lesions Please check with commercial carriers for their guidelines regarding modifiers.

21 Expected Combination and Ultrasound guidance Biopsy with US Must use in combination for ultrasound guided FNA procedures

22 -59 Modifier Indicates that a procedure is separate and significant from another procedure performed that day Used for procedures that are not usually reported together or represent expected combinations Used for multiple nodules as well as diagnostic US same day as USG-FNA Not used with E/M codes

23 Coding Examples FNA using US guidance on 2 right nodules RT RT Right nodule and 2 left nodules aspirated under US RT LT LT A diagnostic US is performed and indicated a suspicious right thyroid nodule. An US guided FNA is performed RT * *Can modify either or w/ -59 in this case

24 Modifier 25 Reports to insurance carriers that an E/M was performed on same day as minor procedure. If this modifier is used incorrectly, it can affect reimbursements. New patient presents with enlarged thyroid. After history and exam performed, the decision was made to perform an FNA (no imaging guidance). 9920x Rationale- The physician did an E/M and then determined that a FNA was to be performed. The E/M documentation could stand alone; with or without the FNA. 24

25 A consultation is performed on a non-medicare* patient and indicates the need for a diagnostic US of the thyroid. After review of the diagnostic US, the endocrinologists determines the need for an USFNA. 9524x *Medicare and carriers who follow Medicare guidelines do not reimburse for a diagnostic ultrasound and ultrasound guidance on the same date of service.

26 Resolving the CMS ruling on and Cannot code for both codes on same day in MCR patients or insurance carrier who follow these guidelines (will be increasingly common) We do a full neck exam at initial visit FNA not needed: complete US report and bill FNA needed limited US report and full FNA report, billing 76942, Others divide it into multiple visits

27 Patient is seen in on Monday and has a diagnostic US preformed indicating a right thyroid nodule. Endocrinologist schedules the patient to return on Friday for an USFNA of the right thyroid nodule. Endocrinologists also goes over the lab results from Monday (which could justify an E/M reported with the USFNA). MONDAY FRIDAY 9920X X RT 76942

28 ROSE - Coding Examples Right nodule aspirated under US and evaluated under microscope. Specimen found to be adequate RT Right nodule aspirated under US and evaluated under microscope. Specimen found to be inadequate. Additional pass made, reviewed under microscope and specimen found to be adequate RT (first review) (additional review of subsequent pass into same nodule) *Additional passes should not be reported to carriers unless there is CLEAR evidence in the documentation that it was medically necessary. Typically Medicare will not reimburse for 2 nd passes.

29 Coding, Billing and Practice Management Resources Coding Inquiries & insurance hassle factors Live coding courses uses endocrine examples Locations: Portland, OR; Mount Laurel, NJ (outside of Philadelphia), Lake Charles, LA Weekly Live Webinars on Practice Management Challenges offered in partnership with the Practice Management Institute (PMI) Complimentary Webinars offered in Partnership with LilesParker Medicare Coverage Determinations for Common Endocrine Procedures Endocrine Toolkit for Success Free materials for providers and their staff on CMS programs, policies and initiatives. 29

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31 Michelle Cobb King, MBA AACE Director of Socioeconomics & Member Advocacy (904) ext. 142 Nickie Mizell, CMA AACE Certification Manager (904) ext. 145 Vanessa Lankford, CPC, CMCO, CMOM, AACE CEC AACE Practice Management Coordinator (904) ext /16/

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33 The Search for Thyroid Measures No existing measures pertaining to any thyroid condition AACE is working diligently on creating measures to present to CMS ATA collaboration ATA MTC registry exists, but not for MIPS Thyroid Care Collaborative (TCC) working on being recognized by CMS as registry

34 Thyroid Care Collaborative INFORMATION FLOW (TCC) Endocrinologist Surgeon Nuclear Medicine Radiologist TCC Medical Oncologist Cytologist Patient PCP/OB GYN 1. Portability of clinical information 2. HIPAA compliant 3. De identified patients

35 Patient Education Modules to save time during consultations and follow up

36 System for standardized reporting & assessment of risk for thyroid nodules and lymph nodes Transforming this into this!

37 The TCC Advances Disease Research With over 1300 unique, thyroid specific data points collected, the TCC creates a platform for: Tracking the efficacy of treatments over time Curating customized prospective and retrospective studies Identifying unique prognostic variables to target treatments in specific patient populations Providing clinical trial placement for patients

38 Thyroid Practice Settings Increasingly difficult to start your own practice Consider joining an endocrine group looking for a thyroidologist-sonologist Team up with surgeon in hospital-based practice Multispeciality/Hospital practice general endocrine but with access to US/FNA Academic-based Thyroid Unit

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40 AACE Disclaimer: Proprietary information and intellectual property of the American Association of Clinical Endocrinologists (AACE) may not be shared with any third-party or utilized in any manner without the express written consent of AACE. Comments, information or advice (collectively referred to as information ) provided by AACE coding specialists and staff reflect our organization s current understanding of the proper use and application of CPT 1, ICD, HCPC codes, and claims modifiers. The information provided is solely intended as general information only. Ultimately, it is the provider s responsibility to understand and comply with National Coverage Determinations (NCD), Local Coverage Determinations (LCD) and any other complex coverage requirements established by relevant government and private payors, which are subject to frequent change. AACE does not make any representations regarding the appropriateness of use or the likelihood of reimbursement with respect to a specific code or claim. The information presented in this presentation is for informational purposes only, and is not meant as a substitute for professional medical and/or legal advice, both of which should be obtained independently from qualified professionals. CPT Disclaimer: 1 CPT Copyright 2018 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein