2009 Pain Coding Update and Pain Industry Business Trends

Transcription

1 2009 Pain Coding Update and Pain Industry Business Trends Linda Van Horn, MBA June 13, Pain Coding Update and Pain Industry Trends Agenda 2009 CPT Coding Updates Pay For Incentives ICD-10 American Recovery and Retirement Act of 2009 EMR HIPAA Privacy 2009 Pain Coding Update and Pain Industry Trends Agenda Part B Reimbursement Trends for Physicians ASC s and Device Packaging CCI s, LCD s, NCD s, MUE s OIG Report on Facet Injections Advanced Beneficiary Notice (ABN) st Century Edge 1

2 Authoritative Sources AMA CPT codes Medicare Rules and HCPCS Level II World Health Organization - ICD CPT Changes New Codes New Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes Example aspiration of fluid build up in disc to see if there is a bacterial infection Use for fluoroscopic guidance or for CT guidance was revised to remove aspiration 2009 CPT Changes New Codes New Injection(s) anesthetic agent and/or steroid, common digital nerve(s) (e.g. Morton s neuroma) Report once regardless of the number of nerves injected Procedure is unilateral, use modifier 50 for bilateral Use for fluoroscopic guidance st Century Edge 2

3 2009 CPT Changes New Codes Destruction by neurolytic agent; prudendal nerve New plantar common digital nerve Commonly provided for Morton s neuroma 2009 CPT Changes Removed Daily Management Injection, anesthetic agent; trigeminal nerve, any division or branch Changed brachial plexus, continuous infusion by catheter (including catheter placement) Changed sciatic nerve, continuous infusion by catheter (including catheter placement) Changed femoral nerve continuous infusion by catheter (including catheter placement) Changed lumbar plexus continuous infusion by catheter (including catheter placement) 2009 CPT Changes Deleted Codes & Modifiers Deleted 0027T Endoscopic Lysis of Epidural Adhesions (use 64999) Deleted Modifier 21 Prolonged Services (see ) st Century Edge 3

4 Pay for Incentives HCPCS Level II for Physician e-rx 2% Medicare incentive bonus for e-rx G8443 all prescriptions in connection to the visit were electronically prescribed G8445 no prescriptions were generated during the visit G8446 some or all prescriptions were written or phone in due to State or Federal pharmacy regulations / controlled substance law Pay for Incentives 2009 Category II Codes for PQRI 2% Medicare incentive bonus for reporting at least 3 measures 80% of the time Category II codes are optional Used for tracking / performance measurement Four digits ending with the letter F 10 Back Pain Category II codes added for pain assessment and management in 2009 for PQRI for physicians ICD-10 January 16, 2008, CMS announced that effective October 1, 2013 providers will be required to report ICD-10 (ICD-9 will become obsolete) st Century Edge 4

5 The American Recovery and Retirement Act 2009 aka Stimulus Package Encourage adoption of certified electronic medical records system (CCHIT?) Must use EMR in a meaningful way and report quality measures Up to $41,000 per physician incentive paid over 5 years $15,000 for the first year $12,000 for the second year $8,000 for the third year $4,000 for the fourth year $2,000 for the fifth year Reduced Medicare Payment if not adopted by 2015 The American Recovery and Retirement Act 2009 aka Stimulus Package No incentive payments for hospital-based professionals who furnish services in a hospital setting and use the facilities equipment including computers such as: Pathologist Anesthesiologist Emergency room physician The American Recovery and Retirement Act 2009 aka Stimulus Package Changes to HIPAA Privacy EMR will need to account for all disclosures of patient data, even in the cases of treatment, payment and health care operations (previously exempt under HIPAA) Requires notification of patients of breach Requires notification of media of breach involving more than 500 patients st Century Edge 5

6 Part B Medicare How Physicians Get Paid Each CPT is assigned a RBRVS (Resource Based Relative Value System) weight which consists of: - Relative Value Unit (RVU) Conversion Factor Geographical Adjustment Factor Physician RVU Changes Three year phase in to affect site of service differential % decrease per year 27% decrease over 3 years on in-office RVU s However, Medicare can (and does) change RVU s on a procedure per procedure basis 2009 Physician MFSDB July 15, 2008 Congress enacts 1.1% increase in the Conversion Factor October 30, 2008 Final Rule yanks increase away with a Budget Neutrality Adjustment result is -6.41% Net Result 2009 CF is $ (2008 was $ ) -5.3% st Century Edge 6

7 The Past and Future of the Physician Conversion Factor Start End Amount % Change 1/01/ /31/2007 $ n/a 1/01/ /31/2008 $ % 1/01/ current $ Net result 2005 to 2009 Decrease 4.83% In Office RVU and CF Net Affect As Compared with 2007 Year CF RVU Combined Jan Jun % -10.0% -9.6% Jan Dec % -10.0% % Jan Dec 2010 * -10.0% -34.3% * Assumes no change in conversion factor Part B Medicare ASC Reimbursement Surgical Services CPT Codes that can be safely performed in ASC Reimbursement based on 67% of OPPS, with some exceptions Office Based Procedures Device Dependent Procedures To be phased in over four years 2008 Transition 75% of 2007 rate / 25% new rate 2009 Transition 50% of 2007 rate / 50% new rate 2010 Transition 25% of 2007 rate / 75% new rate 2011 Paid at 100% of new rate ASC Conversion Factor for 2009 is $ st Century Edge 7

8 Part B Medicare ASC Reimbursement Beginning in 2010, APC s increase will be based on CPI (Consumer Price Index) to update for inflation in the general economy OPPS increase is based on Hospital Market Basket which is based on increases cost for goods and services in hospitals ASC Device Packaging Device intensive procedures (e.g. > 50% of APC) will be offset by device offset percentage SCS Electrodes 54.06% SCS Elect w/ Laminectomy 60.06% SCS Pulse Generator 77.65% Spinal Infusion Pump 80.27% Spinal Infusion Pump 80.27% Device intensive procedures (e.g. >50% of APC) will be paid the full device amount paid under OPPS Most device intensive procedure are not subject to multiple procedure reductions Changes Modifier FB to indicate the device was provided at NO COST Modifier FC to indicate the device was provided at REDUCED COST such as a device recall Discontinue Using Modifier 50 Medicare has stopped recognizing the 50 modifier, list as two line items or one line item with a 2 in the units column st Century Edge 8

9 SG Modifier No Longer Valid Medicare claims on CMS1500 use TOS of F and POS of 24 SG Ambulatory Surgical Center (ASC) Facility Service Deleted on 1/1/2008 New ASC Modifiers for Reduced Services paid at 50% and not subject to multiple procedure discount 73 Discontinued procedures before administration of anesthesia paid at 50% and not subject to multiple procedure discount 74 Discontinued procedures after administration of anesthesia paid at 100% Non-Medicare ASC Reimbursement Many insurers still are grouper based Carve out devices L codes, drugs J codes, and fluoroscopic guidance Add services that were non-covered on the 2007 Medicare ASC list st Century Edge 9

10 Accept the Fact: Reimbursement is Driven by Medicare Government is not the solution to our problem. Government is the problem. - Ronald Reagan Correct Coding Initiative Pairs of CPT and HCPCS Level II codes which are not reimbursable under certain circumstances CCI s go into effect quarterly Jan, Apr, Jul, Oct National Carrier Decision Local Carrier Decision NCD s Policy rules published by CMS LCD s - Policy rules published by each of the 12 Medicare Carriers, explains: Coverage Documentation requirements Clinical indications e.g. CPT / ICD-9 codes Utilization frequency - # of levels per case, # of injections per year, timing between injections Expected outcome e.g. 50% pain relief for at least 6 months st Century Edge 10

11 Many LCD s Have Common Themes Diagnostic vs. Therapeutic Multiple different type of procedures on the same date of service Number of levels 2009 Medicare National Coverage Decision Changes Effective September 29, 2008 Thermal Intradiscal Procedures are Non-covered (IDET and Annuloplasty) T 0062T Physician National Medicare Fee Schedule Database Changes Global period 10 days (was 90 days) for SCS lead / electrode SCS neurostimulator pulse generator SCS revision or removal of pulse generator st Century Edge 11

12 Medically Unlikely Edits (MUE s) New edits based on anatomical considerations that addresses approximately 2,800 codes Excess charges due to the units column greater that the MUE may NOT be billed to beneficiary and can not be waived via an ABN CMS originally said they would not, but now has agreed to publish MUE s OIG Report on Facet Injections From 2003 to 2006 payments for facet injections increased 76% from $141 to $307 63% of facet injections did not meet Medicare program requirements CMS instructed carriers to strengthen: Update frequency requirements in LCD s Clarify billing for bilateral 50 modifier instead of an additional level Require that facets must be done under fluoroscopic guidance Advance Beneficiary Notice ABN New form went into effect March 1, 2009 A written form signed by the patient prior to rendering services which informs Medicare patients that services are not covered by Medicare The patient agrees to pay for services st Century Edge 12

13 Advance Beneficiary Notice ABN Used for non-covered services Cannot be used to get Medicare patients to pay for component services when Medicare is paying for a comprehensive code About the Speaker: Linda M. Van Horn, MBA President/CEO 21 st Century Edge 222 West Gregory Blvd, Suite 210 Kansas City, Missouri (816) st Century Edge 13