CHANGE is Coming: Compliance & Coding

Transcription

1 CHANGE is Coming: Compliance & Coding John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute Excellence in Optometric Education

2 John A. McGreal Jr., O.D. McGreal Educational Institute Missouri Eye Associates Old Ballas Rd. St. Louis, MO FAX

3 2014 Compliance Issues HIPAA Privacy & Security regulations change Medicare Updates for 2014 RAC Audits CERT Audits OIG Workplan ICD-10 conversion Healthcare Reform Basics Affordable Care Act Implementation

4 Medicare Part B Deductible Deductible (Medicare Part B) Will increase to $ in 2014 thereafter increase by annual percentage increase in Part B expenditure

5 2012 New ICD-9 Glaucoma Coding Given great variability of cost of care & resource utilization among glaucoma patients, glaucoma care has been targeted for use of potential value-based modifiers in the future ICD-9 and ICD-10 codes reflect this and will allow stratification of a patient population Developed by the American Glaucoma Society (AGS) workgroup, including Drs. Fellman & Mattox Then enlisted comprehensive ophthalmologists, optometrists, and a few glaucoma specialists to evaluate and test for accuracy using real cases from Dr. J. Stein at University of Michigan

6 2012 New ICD-9 Codes Glaucoma Stages When coding glaucoma subcategories assign an additional code to identify specific stage of glaucoma (365.7) Glaucoma stage, unspecified Mild stage glaucoma Moderate stage glaucoma Severe stage glaucoma Indeterminate stage glaucoma Includes sequencing instructions to code first the glaucoma, by type Report new V19.11 history codes where appropriate

7 Step One: Code by Type Only the codes listed here require add-on staging codes Open angle glaucoma, unspecified Primary open angle glaucoma Low tension glaucoma Pigmentary glaucoma primary angle closure glaucoma, unspecified Chronic or primary angle closure glaucoma, unsp Steroid induced glaucoma Pseudoexfoliation glaucoma Glaucoma associated with ocular inflammations Glaucoma associated with vascular disorders Glaucoma associated with ocular trauma

8 Step Two: Add Stage Determine severity of glaucoma in worse eye Mild (disc abnormalities consistent w glaucoma but no VFD on SAP or Short wave-length doubling perimetry) Moderate stage (Disc abnormalities consistent w glaucoma and VFD in 1 hemifield, not w/in 5 degrees of fix) Severe stage (Disc abnormalities consistent w glaucoma VFDs in both hemifields, and/or loss w/in 5 degrees of fix in at least 1 hemifield) Indeterminate (VFs not performed yet, or patient incapable of VF testing or unreliable or uninterpretable VFs) Unspecified, stage not recorded in chart Compliance requires documentation of stage in medical record

9 Additional Glaucoma Code Changes Open angle suspect, Low Risk (1-2 risk factors) Open angle suspect, High Risk (3+ risk factors) Risk factors family history, race, elevated IOP, disc appearance and thin central corneal thickness Primary angle closure suspect (anatomical suspect, narrow angle) Primary angle closure without glaucoma damage (defined as angle damage such as synechia or high IOP, but w/o optic nerve damage) Chronic angle closure glaucoma (angle damage plus optic nerve damage)

10 Physician Value-Based Payment Modifier CMS will adjust payment to some physicians based on quality & resource use beginning in 2015 and all physicians by 2017 Now applies only to groups of 100 or more (originally 25) Smaller groups (2-99) remain unaffected until % payment penalty to hospitals began in 2012 for re-admission rates higher than national average Heart failure Pneumonia Myocardial infarction

11 Reduction in Diagnostic Testing CMS will decrease payment by 20% of technical component of second and subsequent diagnostic tests furnished by same physician (or physicians in same group) to same patient on same day Originally set at 25% A diagnostic service refers to any diagnostic test that has a technical & professional component CMS indicated they will closely monitor practice changes to bypass multiple payment reductions

12 Reduction in Diagnostic Testing

13 HHS Announces HIPAA Audits The Office of Civil Rights will begin assessments of compliance with HIPAA Privacy & Security rules Focus on providers and business associates Updated HIPAA Rules took effect September 23, 2013 for privacy & security Ensure patients receive electronic copy of PHI, on request Limit use or disclosure of PHI for marketing or fundraising, and advanced authorization required Prohibit sale of PHI for marketing w/o permission

14 HHS Announces HIPAA Audits Give patients who pay out of pocket for services the right to instruct doctors not to share information about treatment with insurance company Practitioners must have updated new business associates agreements documenting associates with access to PHI Billing firms, clearinghouses, IT, data storage companies Security changes focus on increased lockdowns of electronic PHI, securing servers Implementation of new Notice of Privacy Practices

15 New Notice of Privacy Practices (NPP) Add statement about opt out option for fundraising Add statement about HCP right to restrict PHI in cash pay patients Add individual right to be notified of breach within 60 days, notification of HHS, individual and media Delete statement about reminders, health benefits etc Post new NPP prominently in office Paper copies of new NPP available for established patients to review New NPP given to each new patient

16 New Business Associates Agreements New Business associates (BA) definitions and new business associates agreements (BAA) established Liabilities and responsibilities substantially increased HCP not required to have BAA with subcontractors of BA Adds the word maintains PHI definition of BA Substantial focus on data storage companies Requires ALL existing agreements be revised

17 Civil Monetary Penalties (CMPs) Unknowing violation $100-$50K $1.5M Reasonable cause $1000-$50K $1.5M Willful neglect, corrected $10K-$50K $1.5M Willful neglect, uncorrected $50K $1.5M Adoption of higher civil monetary penalties for violations of privacy or security

18 New CPT Codes for interprofessional telephone/internet assessment and management service including a verbal & written report, 5-10 minutes of review consultation as above, minutes consultation as above, minutes consultation as above, 31 minutes or more Insertion of anterior segment aqueous drainage device, w/o extraocular reservoir, external approach

19 CPT Category III Changes for T digital interferometry of the lipid layer of tear film for dry eye diagnosis, unilateral or bilateral with interpretation & report Do not report using external ocular photography 0333T VEP, screening of visual acuity Do not report VEP testing of CNS 0329T monitoring of IOP for 24 hours, unilateral or bilateral with interpretation & report Do not report serial tonometry 0341T quantitative pupillometry, unilateral or bilateral with interpretation & report

20 New 1500 Claim Form for 2014 CMS revised the 1500 form to more adequately support use of ICD-10CM code set Revised form version 02/12 will replace current form which is version 08/05 CMS accepts revised version of form January 6, 2014 CMS will ONLY accept new version after April 1, 2014 Allows ability to indicate use of version 9 or 10 Expands diagnosis code list from 4 to 12!

21 PQRS Incentive Programs CMS continues incentive payments in Successful PQRS reporters earn 0.5% in 2014 Must report on at least 9 measures Report for full year (Jan1-Dec31, 2014) Not participating in PQRS 2014 will reduce Medicare payments by 2% in 2016 Not participating in EHR/MU in 2014 will reduce Medicare payments by 2% in 2016

22 PQRS Measures for 2014 Required to report on 9 measures (up from 3 in 2013) Required to report on 50% of applicable patients Diabetes, AMD, and glaucoma are main measures Select 2 other measures applicable to your practice base Measure #236 HTN: controlling BP Measure #128 Preventive care & screening: BMI Measure #111 Preventitive care & screening: Pneumococcal vaccination in >65yo Measure #173 Preventitive care & screening: Unhealthy alcohol use

23 PQRS Measures for 2014 Measure #110 Preventative care & screening: Influenza immunization Measure #226 Patient screened for tobacco use and received cessation counseling if identified as user Measure #130 Current medications with name, dose, frequency, and route documented

24 PQRS 2014 In 2015 a 1.5% PQRS payment penalty will be applied, in 2016 this increases to 2.0% 2013 PQRS participation used to determine cuts in 2015 Participation means attempting to report at least one PQRS measure between Jan 1 Dec Glaucoma staging codes removed Measure 124: Health Information Technology eliminated CMS dramatically increases threshold to meet requirements report 9 measures for incentive 14

25 Measure 12: POAG Optic N. Evaluation CPT category II Code: 2027F Diagnosis codes Open angle glaucoma Open angle glaucoma Low tension glaucoma Residual stage of open angle glaucoma Glaucoma stages codes Documentation tips ON can be documented with a drawing, description, photograph or scan Modifiers -1P, -8P

26 Measure 141: POAG Reduction of IOP by 15% or Documentation of Plan of Care IOP reduced by 15% from pre-intervention CPT category II Code: 3284F IOP reduced less than 15% from pre-intervention CPT category II Code: 3285F plus CPT category II Code: 0517F to document plan of care Recheck IOP, Rx change, additional testing, referral, plan to recheck Once per reporting period CPT Codes: 92002, 92004, 92014, 92012, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337

27 Measure 141: POAG Reduction of IOP by 15% or Documentation of Plan of Care Diagnosis codes Open angle glaucoma Open angle glaucoma Low tension glaucoma Residual stage of open angle glaucoma Glaucoma Stage codes Modifiers -8P

28 Measure 14: AMD Dilated Exam CPT category II Code: 2019F Pts 50yrs+ with diagnosis AMD having DFE with documentation of presence or absence of macular thickening or hemorrhage AND level of severity (mild, moderate, severe) of AMD during one or more office visits w/in 12 mos, minimum of once per reporting period Diagnosis codes Macular degeneration, unspecified Non exudative senile macular degeneration (dry) Exudative senile macular degeneration (wet) Modifiers -1P, -2P, -8P

29 Measure 140: AMD Counseling on Antioxidant Supplement Patients aged 50 and older with a diagnosis of AMD and/or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the AREDS formulation for preventing progression of AMD CPT category II Code: 4177F Diagnosis codes Macular degeneration, unspecified Non exudative senile macular degeneration (dry) Exudative senile macular degeneration (wet) Modifiers -8P Note: If already receiving AREDS supplements, assumption is counseling has already been performed

30 Measure 140: AMD Counseling on Antioxidant Supplement CPT Codes: 92002, 92004, 92014, 92012, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337

31 Measure 117: Diabetes Mellitus Dilated Exam CPT category II Code: 2022F: dilated retinal exam by OD/OMD with interpretation documented and reviewed 2024F: 7 standard field stereophotos with interpretation documented and reviewed 2026F: eye imaging validated to match diagnosis from 7 standard field stereophotos with results documented and reviewed 3072F: low risk for retinopathy (no evidence of retinopathy in prior year) Modifiers -8P

32 Measure 117: Diabetes Mellitus Dilated Exam Diagnosis Codes DM w/o ophthal manif, type II, not uncontrolled DM w/o complication, type I, not uncontrolled DM w ophthal complications, type II, uncontrolled DM w/o complication, type I, uncontrolled DM w ketoacidosis, type II not uncontrolled DM w ketoacidosis, type I, not uncontrolled DM w ketoacidosis, type II, uncontrolled DM w ketoacidosis, type I, uncontrolled

33 Measure 117: Diabetes Mellitus Dilated Exam Diagnosis Codes DM w hyperosmolarity, type II, not uncontrolled DM w hyperosmolarity, type I, not uncontrolled DM w hyperosmolarity, type II, uncontrolled DM w hyperosmolarity, type I, uncontrolled DM w coma, type II, not uncontrolled DM w coma, type I, not uncontrolled DM w coma, type II, uncontrolled DM w coma, type I, uncontrolled

34 Measure 117: Diabetes Mellitus Dilated Exam Diagnosis Codes DM w renal complic, type II, not uncontrolled DM w renal complic, type I, not uncontrolled DM w renal complic, type II, uncontrolled DM w renal complic, type I, uncontrolled DM w ophthal manif, type II, not uncontrolled DM w ophthal manif, type I, not uncontrolled DM w ophthal manif, type II, uncontrolled DM w ophthal manif, type I, uncontrolled

35 Measure 117: Diabetes Mellitus Dilated Exam Diagnosis Codes DM w neurol manif, type II, not uncontrolled DM w neurol manif, type I, not uncontrolled DM w neurol manif, type II, uncontrolled DM w neurol manif, type I, uncontrolled DM w periph circ disord, type II, not incontrolled DM w periph circ disord, type I, not uncontrolled DM w periph circ disord, type II, uncontrolled DM w periph circ disord, type I, uncontrolled

36 Measure 117: Diabetes Mellitus Dilated Exam Diagnosis Codes DM w other manif, type II, not uncontrolled DM w other manif, type I, not uncontrolled DM w other manif, type II, uncontrolled DM w other manif, type I, uncontrolled DM w unspec complic, type II, not uncontrolled DM w unspec complic, type I, not uncontrolled DM w unspec complic, type II, uncontrolled DM w unspec complic, type I, uncontrolled

37 Measure 117: Diabetes Mellitus Dilated Exam Diagnosis Codes polyneuropathy in DM background diabetic retinopathy proliferative diabetic retinopathy nonproliferative dibetic retinopathy mild nonproliferative retinopathy moderate nonproliferative retinopathy sever nonproliferative diabetic retinoipathy diabetic macular edema diabetic cataract

38 Measure 117: Diabetes Mellitus Dilated Exam Diagnosis Codes DM unspecified as to episode or care or not applicable DM delivered, w or w/o mention of antipartum condition DM antepartum condition or complication DM postpartum condition or complication

39 Measure 18: DM Documentation of Presence of ME & Level of Severity of Retinopathy CPT category II Code: 2021F Pts 18yrs+ with diagnosis of Diabetic Retinopathy with DFE Documentation must include Level of severity of retinopathy (background, non-proliferative (mild, moderate, severe etc), proliferative) If macular edema is present or absent Diagnosis codes Background diabetic retinopathy Proliferative diabetic retinopathy Nonproliferative retinopathy, NOS Mild nonproliferative diabetic retinopathy Moderate nonproliferative diabetic retinopathy Severe nonproliferative diabetic retinopathy Modifiers -1P, -2P, -8P

40 Measure 19: Diabetic Retinopathy Communication with Physician Managing Diabetes Care CPT category II Code: 5010F (Findings of exam communicated) & G8397 (DFE performed documenting presence or absence of macular edema & level of severity of retinopathy) both required G8398 dilated macular exam not performed Patients 18 years+ diagnosed w DR and DFE, at least once per reporting period, documented verbally or by letter Diagnosis codes Background diabetic retinopathy Proliferative diabetic retinopathy Nonproliferative retinopathy, NOS Mild nonproliferative diabetic retinopathy Moderate nonproliferative diabetic retinopathy Severe nonproliferative diabetic retinopathy Modifiers - -1P added for 2011, all others fine

41 Medicare PQRS Maintenance of Certification Must participate in PQRS program over a 12 month period as well as participate in a qualified maintenance of certification program such as American Board of Optometry (ABO) Must exceed minimum participation levels for certification program Incentive bonus is 0.5%

42 OIG Audits / Work Plan Ophthalmological services 92xxx codes Reviewing claims during billion in claims by eye MDs & ODs Focus on 92004/92014, other 92- included E/M Services: Use of modifiers Modifiers -25 July policy statement warning not to use -25 for same day surgery Bilateral intravitreal injections Sequestration 2% payment reductions across the board in Medicare claims beginning April 1, 2013 Includes a 2% reduction in EHR incentive bonus

43 OIG Work Plan Ophthalmological services New Reviewing claims during 2011 $6.8 Billion paid to ophthalmologists & optometrists in % of all claims paid to all physicians in all specialties was 12 th highest paid code used in all specialties was 5 th highest paid code 99xxx E&M codes not included, not specialty specific E/M Services: Use of modifiers Modifiers -25 Bilateral intravitreal injections

44 OIG Work Plan Rank CPT Services Cat-IOL Comp eye exam, est pt Interm eye exam, est pt Scanning laser Comp eye exam, new pt Cat-IOL, complicated Anesthesia for proc, eye, lens Visual field, full Fundus photography Treatment of exten or prog retinopathy Blepharoplasty Ophthalmic biometry w IOL power calc

45 Recovery Audit Contractors RAC Evaluating RAC performance 2010 & 2011 Completed 3 year demonstration project in 2012 Congress will mandate a nationwide implementation of a permanent RAC program for Medicare part A & B Mandates by Tax Relief & Health Care Act 2006 and Affordable Care Act Tool used include comparative billing reports Shows specific provider billing patterns compared to peers

46 Health Insurance Portability and Accountability Act of 1996 President Clinton & USAG J. Reno #2 priority: prosecution of health care fraud $104 Million: Appropriations to HHS $70 Million: OIG $47 Million: FBI fraud investigation unit Criminal offenses expanded $10,000 fine / line item violation suspension of payment and participation from program Yielded $23 return on every $1 spent in 1997

47 Qui Tam Relaters Amendment to False Claims Act of 1986 Encourages private individuals to sue in the government s behalf Whistleblowers - 30% of recoveries $1 Billion paid since 1987 in Qui Tam actions Compliance Plan Eliminates aggressive or conservative billing philosophies Removes incentives for whistleblowers Improves collections while reducing audit risks

48 Top 10 Procedure Codes Optometry Missouri / Jan-June 2007 / 495 Providers $1,369, $ 634, $ 562, $ 551, $ 541, $ 395, $ 339, $ 277, $ 199, $ 195,427

49 2012 Comprehensive Error Rate Testing (CERT) There has been a HUGE increase in CERT audits of E/M services since October 2011 From April 2009-May 2010, E/M services accounted for 28 billion in Medicare Part B payments Estimated 8.4% billed incorrectly Providers encouraged to review 1997 E/M Guidelines for compliance

50 2011 CMS Optometry Probe Results Prepayment review of 100 services from 100 claims Probe: CPT (random) Results 66% allowed as billed 34% denied 23% No documents submitted 5% Services not documented in medical record 3% Non-covered services 3% Not medically necessary

51 Code Set Adoption in HIPAA CPT-4: Current Procedure Terminology CDT: Code on Dental Procedures and Nomenclature ICD-9-CM (Volume 1,2): International Classification of Diseases (Implementation of ICD-10 is October 1, 2014!!) ICD-9-CM (Volume 3): inpatient disease codes NDC: National Drug Code HCPCS: Healthcare Common Procedure Coding System

52 Medicare Just Give Me The Numbers Longevity Revolution First year of Baby Boomers hitting 65 years of age 10,000/day turn 65 years of age An individual turns 60 years of age every 8 seconds If you live until age 65, average life expectancy is age 84 47, 672,971 Medicare beneficiaries in US 15% of total population Cataract surgery is the most common surgical procedure in US in Medicare beneficiaries Also boasts best outcomes Lowest complication rate

53 Medicare Distribution by Age (2004) % % % % %

54 AOA Optometric Practice Profiles 2005 VSP 21% Other vision plans 8% Medicare 19.1% (fastest growing share of revenues) Medicare HMOs 3% Medicaid 7% HMOs (private sector) 8% Out of pocket 35% Respondents - 90% self-employed, 47% solo, 24% group, 86% male, mean years in practice 24.2 years

55 INTRODUCTION CMS CPT ICD Medicare Major Medical E/M Coding (99XXX) Eye Coding (92XXX) Special Ophthalmic Codes

56 E/M GUIDELINES New/Established Patient Chief Complaint History of Present Illness Family History Past History Social History New additions level of education, sexual history, marital status/living arrangements Review of Systems Time

57 E/M DESCRIPTORS History * Examination* Medical Decision Making* Counseling Coordination of Care Nature of the Presenting Problem Time

58 CATEGORIES OF SERVICE Office Visits (E/M Codes) New Estab Office Visits (Eye Codes) New Estab Consultations (E/M Codes) ELIMINATED for Medicare, Medicaid, Tricare and Medicare Advantage HMOs and when any of these are secondary payors Can still be used for other commercial plans

59 SELECTING AN E/M LEVEL Identify Category of Service Identify Extent of History Taking Identify Extent of Examination Identify Complexity of Medical Decision Making Review E/M Descriptors

60 E/M CODING - OFFICE VISITS New Patient (3 of 3) PFH / PFE / SDM / EFH / DFE / SDM / DH / DE / LDM / CH / CE / MDM / CD /CE / HDM / 60

61 E/M Coding - Office Visits Established Patient (2 of 3) Minimal / PFH / PFE / SDM / EFH / EFE / LDM / DH / DE / MDM / CH / CE / HDM / 40

62 DOCUMENTATION OF HISTORY Problem Focused History (PFH) CC / 1-3 HPI Expanded Problem Focused History (EPF) CC / 1-3 HPI / Ocular ROS Detailed History (DH) CC / 4 HPI / Ocular ROS / ROS-2 / 1 OF 3 PFSH Comprehensive History (CH) CC / 4 HPI / Ocular ROS / ROS-10 / 3 OF 3 PFSH (NEW) OR 2 OF 3 PFSH (ESTAB)

63 Eye Examination Documentation VA / CVF / Pupils & Iris / Adnexa Bulbar & Palp Conjunctiva EOM SLE: Cornea / Lens /AC IOP / Optic Nerve / Posterior Segment Neurologic: Orientation (Time / Place / Person) Psychiatric: Mood & Affect (Depression /Anxiety /Agitation)

64 DOCUMENTATION OF EXAMINATION Problem Focused Exam (PFE) Limited Exam / l - 5 Elements Expanded Problem Focused Exam (EPF) Limited Exam / 6 Elements Detailed Exam (DE) Extended Exam / 9 Elements Comprehensive Exam (CE) Complete Single System Exam All Elements

65 Medical Decision Making Straightforward (SF) # Dx / Rx Options - Min / Data - Min / Risk - Min Low Complexity (LC) # Dx / Rx Options - Lim / Data - Lim / Risk - Low Moderate Complexity (MC) # Dx / Rx Options - Mult / Data - Mod / Risk -Mod High Complexity (HC) # Dx / Rx Options - Ext / Data - Ext / Risk - High

66 Comprehensive Ophthalmological Service / Complete system evaluation, Need not be performed at one session Integrated services where med decision making cannot be separated from examination methods Itemization of service components, such as slit lamp examination, keratometry, routine ophthalmoscopy retinoscopy, tonometry, or motor evaluation is not applicable

67 Comprehensive Ophthalmological Service / Includes history, medical observation, external & ophthalmoscopic examinations, gross visual fields, sensorimotor examination Often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry Always includes initiation of diagnostic and treatment programs

68 Comprehensive Ophthalmological Service 92004/92014 Always includes initiation of diagnosis and treatment programs includes the prescription of medication, and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory procedures and radiological services

69 Intermediate Ophthalmological Service / Evaluation of new or existing condition, complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis Integrated services where med decision making cannot be separated from examination methods Includes history, medical observation, external & adnexal, & other diagnostic procedures as indicated; may include use of mydriasis for ophthalmoscopy

70 2004 New HCPCS Codes S codes are useful for some private insurers Medicare and other federal payers do not recognize them They are useful when CPT does not have a code to accurately describe the service (i.e. LASIK, PTK, PRK, corneal topography) or for invoicing self-pay patients. They specifically describe routine exams including refractions and permit a different charge

71 HCPCS S Codes S0620 Routine ophthalmologic exam including refraction; new patient S0621 S0625 Routine ophthalmologic exam including refraction; established patient Digital screening retina

72 2014 Medicare Physician Fee Schedule Physicians faced a 24% cut in payment effective January 1, 2014 based on Sustainable Growth Formula This is the 13 th time the SGF resulted in a payment cut, although all have been averted by Congress except 2002 December 12, 2013 House passed legislation with amendment that postpones pay cuts on January month reprieve provides lawmakers time to complete full medicare pay reform process During reprieve a fee cut is replaced by a 0.5% update

73 2014 Medicare Physician Fee Schedule House committee legislation includes 3 years of 0.5% updates until 2017, then replaced by new value based system. Original bill froze payments for 10 years Senate committee passed its version of pay reform which freezes payments for 10 years Growing differences between House & Senate versions make final resolution of the SGF repeal more challenging

74 Pathway for SGR Reform Act of 2013 Obama signed into law on December 26, 2013 Prevents scheduled fee cuts in Medicare Provides for 0.5% update Extends several provisions of the Middle Class Tax Relief Act of 2012 (Job Creation Act of 2012)

75 2014 Medicare Fee Schedule $ $ $ $ $ $ $ $ $ $ $ $ $ $123.76

76 Meaningful Use Stage 1 Changes 2014 HHS requires all EHR systems to meet both stage 1 and stage 2 MU in order to be certified for use in government incentive programs, even if attempting to meet stage 1 System updates will be required! Stage 1 MU objectives now require participants to provide patients with timely access to their health information online Stage 1 now requires blood pressure & height / weight Stage 2 MU provides functionality to make PHI available securely online, engages patients, increases exchange of PHI between providers

77 Meaningful Use Stage 2 Must use computerized Physician order entry (CPOE) Must use online clinical decision support Must use adverse drug interaction warnings on specified number of patients Must use e-prescribing Must provide patient access to PHI via secure websites and Must conduct follow up electronically and answer patient questions electronically EHRs must have secure interconnectivity meeting Nationwide Health Information Network standard Direct Access Technology

78 Meaningful Use Stage 3 CMS delays 3 rd stage of MU requirements for implementation of EHR system Under new guidelines, Stage 2 MU extended through 2016 Stage 3 requirements begin in 2017 for providers that complete Stage 2 requirements in 2015 and 2016 Until now providers who began MU program by 2012 had until 2014 to meet MU stage 2 Practitioners entering the program in 2014 can still earn a total of $6,000

79 Non-covered service Refraction Can be billed to beneficiary failure to do so results in lost revenues Reminders Charge only for Rx-able refractions Do not forget to charge for the final refraction when changing spectacles in a post-operative cataract patient

80 Bilateral Requires documentation Gonioscopy describe visible angle structures No limitations to diagnostic groups in most states Fee $ 27.12

81 Visual Field 9208x Bilateral Requires Interpretation separate report form narrative in body of medical record, on date of service Fee (-81) / $ Fee (-82) / $ Fee (-83) / $ 65.03

82 Extended Ophthalmoscopy / Unilateral Initial (-225) vs. Subsequent (-226) Implies detailed, extra ophthalmoscopy document fundus lenses used Modifiers RT /LT Requires retinal drawings & interpretation sizes, colors and dimensions carrier specific Fee ($ 27.13) ($ 24.38)

83 Bilateral Not Bundled Requires Interpretation Fee $ Fundus Photography 92250

84 External Ocular Photography Report for documentation of medical progress Ex.: close-up photography, slit lamp photography, goniophotography, stereo-photography Bilateral Not Bundled Requires Interpretation and report Fee $ 20.79

85 Special Anterior Segment Photography With specular endothelial microscopy and cell count Ex: Konan specular microscope Bilateral Not Bundled Requires Interpretation and report Fee $ 37.95

86 Special Anterior Segment Photography iridocyclitis chronic iridocyclitis Fuch s heterochromic iridocyclitis glaucomatocyclitic crisis lens induced iridocyclitis VKH syndrome essential iris atrophy iridoschisis pigmentary iris degeneration pupillary margin degeneration

87 Special Anterior Segment Photography Miotic Cysts of pupil margin degenerative changes of anterior structures Traumatic cataract cataract in inflammatory disorder cataract in ocular neovascularization corneal edemas folds or rupture in descemet s membrane , -.57,-.58, corneal dystrophy

88 Special Anterior Segment Photography corneal edema due to contact lens aphakia subluxation of lens anterior displacement of lens buphthalmos late effect of burn of eye/face alkaline burn of cornea/conj acid burn of cornea/conj other burn of cornea/conj V42.5 cornea replaced by transplant

89 Special Anterior Segment Photography mechanical complication of prosthetic corneal graft infection/inflammation due to unspecified implant and graft complication of other implant or graft complication of other transplanted organ other postoperative infection cataract fragments in eye following cataract surg V53.1 fitting & adjusting specs or CL after intraocular surgery

90 Tear Osmolarity Testing Unilateral Paired or cross walked to code Applies to TearLab s Osmolarity Device Novel Lab-on-a-chip Point of care, 50nl sample of tear fluid Sample-to-answer in less than 30sec CLIA waiver granted Requires Interpretation & report Fee $23.25

91 Computerized Corneal Topography Bilateral or unilateral Requires interpretation & report No limitations to diagnostic groups in most states Fee $ 37.56

92 92025 Corneal Topography ICD-9 Codes that Support Medical Necessity * Irregular astigmatism Corneal Opacity Unspecified Bullous Keratopathy Hereditary Corneal Dystrophy Unspecified Other Anterior Corneal Dystrophy Endothelial Corneal Dystrophy Keratoconus Unspecified Keratoconus Stable Condition

93 92025 Corneal Topography ICD-9 Codes that Support Medical Necessity Keratoconus Acute Hydrops Pterygium Unspecified Mechanical Complication Prosthetic Corneal Graft V42.5 Cornea Replaced by Transplant V45.61* Cataract Extraction Status V45.69* Other States Following Surgery of Eye /Adnexa * must be accompanied by V45.61 or V45.69 *V45.61 must be accompanied by *V45.69 must be accompanied by

94 Scanning Computerized Ophthalmic Unilateral or bilateral Diagnostic Imaging Applies to anterior segment evaluations Carl Zeiss / Optical Coherence Tomography (Cirrus) Optovue / (RTVue, ivue) Requires Interpretation & report Fee $ 35.66

95 Scanning Computerized Ophthalmic Diagnostic Imaging , Malig neoplasm of eyeball, ecept conj, cornea, retina or choroid malignant neoplasm of conjunctiva Malignant neoplasm of cornea 190.6, Malignant neoplasm of choroid, other sites Benign neoplasm of eyeball except conjunctiva, cornea, retina, or choroid Benign neoplasm conjunctiva Benign neoplasm of cornea 224.6, Benign neoplasm of choroid, other sites Foreign body in anterior chamber (magnetic) Foreign body in anterior chamber

96 Scanning Computerized Ophthalmic Diagnostic Imaging Essential iris atrophy Pigmentary iris degeneration Degeneration of pupillary margin Posterior synechia Anterior synechia Pupillary abnormalities Iridodialysis Recession of chamber angle Plateau iris syndrome Anatomical narrow angle Primary angle closure and other glaucomas

97 Scanning Computerized Ophthalmic Diagnostic Imaging Nuclear sclerosis Corneal ulcers Corneal opacities Corneal edema (includes due to CL) Endothelial dystrophy Pterygium Aphakia Subluxed lens Mechanical complication of corneal graft Mechanical complication of ocular lens prosthesis Infection & Inflammation due to other int prosthetic device implant or graft

98 Fitting CL for Ocular Surface Disease Unilateral; Use RT/-LT or -50 Do not report in conjunction with Report supply of lens separately with or appropriate supply code Fee $33.65

99 Fitting CL for Management Keratoconus Initial fitting For subsequent fittings, report E/M services or general ophthalmological services Do not report in conjunction with Report supply of lens separately with or appropriate supply code Unilateral payment; Use RT/-LT or -50 Fee $126.11

100 Serial Tonometry Bilateral Requires Interpretation & Report Example: Angle closure glaucoma multiple measurements over time Fee $ 79.89

101 Bilateral Pachymetry Measurement of central corneal thickness (CCT) proven by Ocular Hypertension Treatment Study (OHTS) to be standard of care in diagnosis and management of glaucoma, glaucoma suspect and ocular hypertension Also billable for keratoconus, corneal transplants, cataracts with corneal dystrophies, guttata, edema Requires Interpretation & Report Fee $ 14.39

102 Scanning Computerized Ophthalmic Diagnostic Imaging Unilateral or bilateral Applies to glaucoma or optic nerve evaluations Heidelberg / Heidelberg Retinal Topography (HRT, Spectralis) Carl Zeiss / Optical Coherence Tomography (GDX, Stratus, Cirrus) Optovue / (RTVue, ivue) Marco / Retinal Thickness Analyzer (RTA) Requires Interpretation & report Fee $ 44.37

103 Scanning Computerized Ophthalmic Diagnostic Imaging Hypotony and flat chamber Glaucomatocyclitic crises Glaucoma suspect, OCHTN Open angle glaucoma Primary angle closure glaucoma Steroid induced glaucoma Glauc w chamber anomalies Phakolytic glaucoma Pseudoexfoliation glaucoma Glaucoma assoc w lens disorders

104 Scanning Computerized Ophthalmic Diagnostic Imaging Glaucoma assoc w ocular trauma Visual field defects Acute inflammations of the orbit Papilledemas Foster-Kennedy Optic atrophy Glaucomatous atrophy Drusen Crater like holes of optic disc Coloboma of optic disc

105 Scanning Computerized Ophthalmic Diagnostic Imaging Pseudopapilledema Ischemic optic neuropathies Disorders of optic chiasm assoc w pit neoplasms or inflammatory disorders Disorders of other visual pathways assoc w neoplasms or inflammations Buphthalmos Cong anomalies of optic disc & vasc anomalies

106 Scanning Computerized Ophthalmic Diagnostic Imaging Unilateral or bilateral Applies to retinal evaluations Heidelberg / Heidelberg Retinal Topography (HRT, Spectralis) Carl Zeiss / Optical Coherence Tomography (GDX, Stratus, Cirrus) Optovue / (RTVue, ivue) Marco / Retinal Thickness Analyzer (RTA) Requires Interpretation & report Fee $ 45.35

107 Scanning Computerized Ophthalmic Diagnostic Imaging , Malignant neoplasm choroid 224.6, Benign neoplasm choroid or other sites Sympathetic uveitis Progressive high (degenerative) myopia Hypotony, flat chamber Retinal detachments Retinoschisis Serous retinal detachment Traction detachment Diabetic retinopathy, background to severe NPD

108 Scanning Computerized Ophthalmic Diagnostic Imaging Diabetic macular edema BDR, retinal vasculitis Central or branch retinal artery occlusion Central or branch retinal vein ooclusion Retinal layer separation, hemor detach RPE Macular degeneration, retinal dystrophies involving Bruch's membrane Retinal hemorrhage Retinal exudates and deposits Retinal edema

109 Scanning Computerized Ophthalmic Diagnostic Imaging Focal chorioretinitis Disseminated chorioretinitis chorioretinitis unspecified Angioid streaks Choroidal hemorrhage Choroidal rupture Choroidal detachmts Acute inflammations of orbit Scleral ectasia and other scleral disorders Vitreous degenerations & other disor of vitreous Contusion of eyeball

110 Epilation By forceps ICD-9 Correction Trichiasis 67820* Trichiasis without entropion Senile entropion Global days Fee $ 51.75

111 Removal of Foreign Body 65205* External Eye, Conjunctiva superficial scleral, non-perforating ICD FB in cul-de-sac Global days Fee $ 56.97

112 Removal of Foreign Body 65210* External Eye, Conjunctiva embedded (includes concretions) subconjunctival scleral, non-perforating ICD FB in other sites or combined sites Global days Fee $ 70.31

113 Removal of Foreign Body 65222* External Eye, Corneal with Slit Lamp ICD FB in cornea Global days Fee $ 69.04

114 Sensorimotor Examination Quantitative measurement of ocular deviation document all major fields of gaze Bilateral Requires interpretation and report Fee $ Orthoptic and / or pleoptic training, with continuing medical direction and evaluation Fee $ 53.98

115 Dilation of Lacrimal Puncta 68801* With or Without Irrigation ICD Epiphora, insufficiency of drainage Chronic Dacryocystitis Stenosis, Lacrimal Punctum Nasolacrimal Duct Obstruction Fee $

116 Punctal Occlusion By Plug Temporary (collagen) or Permanent (Silicone) Payment is per puncta (modifiers required) E1=left upper E3=right upper E2=left lower E4=right lower Global period - 10 days Supply code-included in procedure code, not separately billable Fee $151.71

117 ICD-9 Punctal Occlusion By Plug Punctate Keratitis Filamentary Keratitis Exposure Keratitis Other forms of Keratitis Unspecified Keratitis Recurrent Corneal Erosion Eyelid Retraction Unspecified Tear Film Insufficiency Sicca Syndrome; use additional systemic manif. code

118 Modifiers 79 Inside post-operative global period 50 Bilateral Procedure 24 Unrelated Service / Same Doctor 79 Inside Global Period 25 Separate Service / Same Doctor / Same Day 52 Reduced Service / Informational / Not Reduced Fee 54 Surgical Care Only 55 Post-Op Care Only 51 Multiple Procedures RT / LT Right / Left E 1- E4 Identifies Puncta 52 Reduced service

119 Comanagement of Surgery Procedures / / $ Global Periods - 90 days Value - up to 20% MD name and NPI Modifiers (-54 on MD claim, -55 on OD claim and RT/LT) Range Dates from transfer date to end of 90 day global Rules - Medicare Transfer Agreement in MD record Correspondence Legal/Political/Inter-professional Issues

120 Complicated Cataract Surgery New CPT code for 2001 / $ Extracapsular cataract extraction with insertion of IOL, complex, requiring devices or techniques not generally used in routine cataract surgery 2-3% of all cataract surgeries involve extraordinary work iris expansion devices, suture support for IOL, posterior capsulorrhexis, small pupil, subluxed lens, Pseudoexfoliation, trauma, Marfan s, glaucoma, uveitis pediatric population Advanced, white, hard cataract

121 Introducing ICD-10-CM John A. McGreal Jr., O.D. Missouri Eye Associates McGreal Educational Institute Excellence in Optometric Education

122 Understanding the Basics & Getting Ready Differences between ICD-9 & ICD-10 How the ICD-10CM is laid out How to Use the Alphabetic Index How to Use the Tabular List How to Use the Index of injuries How to Use the Table of Drugs & Chemicals How to Understand new Abbreviations How to Use Placeholders How to Use Code Extensions Understand laterality

123 The Lilliputians Take Control of the ICD-9 has 13,000 codes ICD-10 has 140,000 Healthcare Giant Effective date October 1, 2014 Transition will be difficult as there is little in common with our current coding paradigms Requires doctors, not staff to do the specific coding Every artery and nerve has been issued a number Number of physicians = 800,000/ 35% own their own practice (Source Accenture with data from Medical Group management Assoc and AMA)

124 Why Convert to ICD-10-CM? Clinical modification of WHO s ICD-10 Clinical emphasizes the intent to serve as a tool in classification of morbidity data for indexing, medical records care review, medical & ambulatory care programs, health statistics Better understand complications Better design robust algorithms Track outcomes To describe the clinical picture the codes must be more precise Far exceeds ICD-9 in number of concepts and codes Disease classification expanded to include health related conditions and provides greater specificity

125 Improvements Over ICD-9 Index MUCH longer Ex 28 pterygium, 69 conjunctivitis, 12 astigmatism codes Adds information relevant to ambulatory & MC encounters Expanded injury codes Combination diagnosis/symptom codes Addition of 6 th & 7 th characters Incorporates common 4 th & 5 th digit subclassification Laterality Allows further expansion

126 Organization of ICD-10-CM Alphabetical Index Alphabetical list of terms and corresponding codes Index of Diseases & Injury Table of Neoplasm Table of Drugs & Chemicals Index of External causes of injury Tabular List Chronological list of codes Divided into chapters Based on body systems

127 Organization of ICD-10-CM Alphabetical Index Define terms Provide directions Provides coding instructions Tabular List Categories 3 characters from Chapter 7 Disorders of Eye H00-H59 Subcategories 4 th character further defines site, etiology, manifestation or state of disease or condition 5 th & 6 th character increases specificity

128 Tabular List Detail Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapter 11 Infectious and parasitic diseases (A00-B99) Neoplasms (C00-D49) Diseases of Blood and blood forms (D50-D89) Endocrine, nutritional, metabolic (E00-E90) Mental & behavioral (F01-F99) Nervous system (G00-G99) Eye & adnexa (H00-H59) Ear and mastoid (H60-H95) Circulatory system (I00-I99) Respiratory system (J00-J99) Digestive system (K00-K94)

129 Tabular List Detail Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter 18 Chapter 19 Chapter 20 Chapter 21 Skin & subcutaneous (L00-L99) Musculoskeletal (M00-M99) Genitourinary (N00-N99) Pregnancy & childbirth (O00-O99) Conditions of perinatal period (P00-P96) Congenital / Malformations (Q00-Q99) Signs/Symptoms/abnormal clinical laboratory findings (R00-R99) Injury, Poisoning, consequences of external causes (S00-T88) External causes of morbidity (V01-Y99)z Factors influencing health status & contact with health services (Z00-Z99)

130 Chapter 7: Diseases of Eye/Adnexa Detail H00-H05 Eyelid, lacrimal, orbit H10-11 Conjunctiva H15-H22 Sclera, cornea, iris, ciliary body H25-H28 Lens H30-H36 Choroid/retina H40-H42 Glaucoma H43-H44 Vitreous & globe H46-H47 Optic nerve & pathways H49-H52 Ocular muscles, accomodation, refraction H53-H54 Visual disturbances and blindness H55-H57 Other disorders eye & adnexa H59 Intra-operative & post-procedural complications

131 Format & Structure Tabular list contains categories, subcategories & codes Characters may be letter or numbers Categories are 3 characters Character 1 is alpha All letter used except U Character 2 is numeric Character 3-7 are alpha or numeric Use decimal after 3 characters Subcategories are 4 or 5 characters Codes may be 3, 4, 5, 6 or 7 characters Laterality specific

132 Placeholder Characters Character X used as a placeholder Allows for future expansion Where it exists it must be used to be valid Ex S05.8x1A

133 Placeholder Characters Code extensions (seventh character) have been added for injuries and consequences of external causes (S00-T88), to identify the encounter A Initial encounter receiving active treatment D Subsequent encounter-use after Pt received active treamt S Sequelae-used for complications/conditions arise as result of injury S only added to injury code, not sequela code Sequela code first, followed by injury code Ex: S30 superficial injury of abdomen S30.810, code requires extension to indicate episode of care S30.810A

134 7 th Character Certain ICD-10-CM categories have 7 th digit characters Applicable 7 th character is required within the category If code requires 7 th character and there is not 6 characters, a placeholder X must be used to fill empty character Ex: S05 Injury of eye and orbit, subsequent visit S05.00 Looking it up you find x7th meaning no 6 th character exists but there is a 7 th character mandatory S05.00xD

135 7 th Character Extension Glaucoma staging by 7 th character for severity 1 = mild stage 2 = moderate stage 3 = severe stage 4 = indeterminate 0 = unspecified Ex: low tension glaucoma Glaucoma/low tension glaucoma/moderate R, severe left H40.-/ H40.12 / H , H

136 7 th Character Extension Corneal Abrasion Category - Chapter 19: Injury, Poisoning and other causes of external S05.- Injury of eye and orbit Subcategory Check 5 th SO5.0 Injury of conjunctiva and corneal abrasion w/o FB Specificity Check 7 th SO5.01 Injury of conjunctiva and corneal abrasion w/o FB, right eye Code SO5.01xA Injury on conjunctiva and corneal abrasion w/o FB, right eye, initial encounter

137 Laterality For bilateral sites, final character of code indicates laterality (-1 = R, -2 = L, -3 bilat, -0 or -9 nonspec) Unspecified side codes if side not identified in medical record If no bilateral code provided and condition is bilateral Assign separate codes for both left and right Ex: H Vitreous degeneration, right side H Vitreous degeneration, left side H Vitreous degeneration, bilateral H Vitreous degeneration, unspecified

138 Laterality Exceptions are when eyelid coding Ex: H Cicatricial entropion, right upper lid H Cicatricial entropion, right lower lid H Cicatricial entropion, right unspecified lid H Cicatricial entropion, left upper H Cicatricial entropion, left lower H Cicatricial entropion, left unspecified lid H Cicatricial entropion, unspecified eye, unspecified lid

139 Combination Coding Single code used to describe 2 diagnoses Diagnosis with a manifestation Ex: E Type 2 DM with mild non-proliferative retinopathy with macular edema Diagnosis with associated complication Ex: H CME following cataract surgery, left eye

140 Abbreviations NEC not elsewhere classifiable NOS not otherwise specified and represents and / or code also instructs two codes may be required [ ] Brackets identify manifestation codes ( ) parenthesis terms are non essential modifiers : Colon incomplete term needing more modifiers

141 Excludes Codes Excludes 1 pure excludes notes Means NOT CODED HERE Indicated code exclude should never be used same time as code above it Ex congenital vs acquired condition Exclude 2 Not included here Condition excluded is not part of the condition represented by the code

142 Etiology / Manifestation Convention Some conditions have underlying etiology and multiple body system manifestations due to the etiology Coding convention requires underlying condition be sequenced first, followed by manifestation use additional code note exists at etiology codes code first note at the manifestation code Ex; Dementia in Parkinson s disease Code G20 represents etiology [F02.80 or F02.81] represents manifestation of dementia With behavioral or without behavioral disturbances

143 General Coding Guidelines Locating a code in ICD-10-CM Locate term in Alphabetic Index Then verify code in the Tabular List Read and be guided by instructional notations appearing in both Essential to use BOTH Alphabetic index doesn t always provide FULL code Need Tabular List to assign laterality and 7 th character

144 Sign & Symptoms Codes that describe symptoms and signs, as opposed to diagnosis Are accepted when a definitive diagnosis has not been established Chapter 18 Expected to document behavioral and psychiatric issues R46.0 Low level of personal hygiene R19.6 Halitosis R14.3 Flatulence R45.84 Worries

145 Acute & Chronic Conditions Acute & Chronic Code acute or chronic If condition is both, code both with acute first Late Effects (Sequela) Residual effect after acute phase of illness or injury has terminated No time limit Coding requires 2 codes sequenced in order Condition first Late effect code second

146 External Cause Codes Chapter 20 Use full range of external cause codes to completely describe: the cause, the intent, the place of occurrence, and if applicable the activity of the patient at the time of the event and the patient s status for all injuries and other health conditions due to an external cause

147 Chapter 4 Endocrine, etc Diabetes mellitus Combination codes that include Type of Diabetes / Body system affected Complications affecting body system Sequencing depends on reason for the encounter 5 Categories E08. Diabetes mellitus due to underlying condition E09. Drug or chemical induced diabetes mellitus E10. Type 1 diabetes mellitus E11. Type 2 diabetes mellitus E13. Other specified diabetes mellitus

148 E11.9 Chapter 4 Endocrine, etc Type 2 DM without complications E Type 1 DM with moderate NPDR without macular edema E Type 2 DM with mild NPDR with macular edema, AND JUST MAYBE Z79.4 Long term (current) Use of Insulin (if documented) All Categories except E10 (Type 1 DM) require use of additional code to identify use of insulin

149 General Equivalence Mapping No direct cross walk exist from version 9 to 10 Mapping will greatly assist translation from version 9 Eye code translation is fairly easy EMR / PMS are creating bridges currently ICD -9 to ICD-10 ICD-10 to ICD-9 No decimal points in GEM files Three columns in GEM file layouts

150 General Equivalence Mapping Example ICD9 ICD10 Flags H H in first flag = approx H H H H H H H

151 Z Codes Z codes are analogous to the ICD-9CM V codes Most rules of V codes transfer over to the use of Z codes Used to describe routine examinations of many varieties Each with different codes Ex Z00 Encounter for general examination without complaint, suspected or reported diagnosis Ex Z01 Encounter for other special examination without complaint, suspected or reported diagnosis

152 Steroid Responder Visit Scenario Old Way 57 YOM with BRVO, s/p focal laser, IVDex, elevated IOP, OS CPT ICD:

153 Steroid Responder Visit Scenario New Way 57 YOM with BRVO, s/p focal laser, IVDex, elevated IOP, OS CPT ICD: T38.0x5 T38.0x1 = accident T38.0x2 = self harm T38.0x3 = assault T38.0x4 = undetermined T38.0x5 = adverse effect T38.0x6 = under-dosing ICD: H40.62 Glaucoma secondary to drugs, left eye Note states code first T36-T50 to identify drug

154 Ocular Trauma Visit Scenario Old Way 52 YOM hit with golf ball, OS while driving golf cart on 8 th hole, with mild hyphema CPT ICD:

155 Ocular Trauma Visit Scenario New Way 52 YOM with hyphema from golf ball, OS CPT ICD: S05.12xA Contusion of eyeball & orbital tissue, left eye, initial en V86.59xA Driver of golf cart injured in non-traffic accident W21.04xA Stuck by golfball Y92.39 Golf course as place of occurrence Y93.53 Activity, golf Hints Chapter 19 = injury, poisonings etc (S00-T88) Chapter 20 = external causes of morbidity (V01-Y99)

156 Ocular Trauma Visit Scenario Old Way 32 YOF struck by exotic bird (cockatoo) on vacation, OD, with corneal abrasion CPT ICD: 918.0

157 Ocular Trauma Visit Scenario New Way 32 YOF with corneal abrasion, OD CPT ICD: S00.1 Contusion of eye and periocular area S05.91 Unspecified injury of right eye and orbit S00.21 Abrasion of eyelid and periocular area S00.211A Abrasion of eyelid and periocular area, initial encounter W61.02xA Struck by parrot W61.12xA Struck by macaw W61.22xA Struck by other psittacines W61.62xA Struck by duck

158 Principles of Healthcare Reform Engage Pt involved in clinical decision making at every level (HCR is about INTERACTION) Use of Registry for outcomes analysis Clinical Decision Support plug in data / receive support U of H and U of Az - $15M SHARP Program Patient education examination summary Standardized communications coordinated care Attrition mandates offices know rate and why

159 Principles of Healthcare Reform HCR is about COST SAVINGS Two ways to save Capitate cuts fees without outcomes measured Coordinated care systems with outcomes measured Outcomes studies HCR challenges fees and benefits without outcomes studies Priority challenge is diagnostic testing for early detection Best practices, gaming system, fee for service model allows technology to take the lead

160 Principles of Healthcare Reform HCR is about Communication MU is NOT HCR Two ways to Communicate Connect Direct Most ODs are NOT involved in electronic communication Vast majority of EHRs cannot do this yet! Ex CCD problem list from PCP, truly co-managing DM, retina etc Ex Sharing data like OCTs Care coordination assures duplicate testing is not done (political)

161 Principles of Healthcare Reform Connect is a set of communications standards based on query method of sharing PHI. It is used by large health systems and hospitals to share PHI with other large systems. It involves a portal where outside providers view data, find what is needed through query and pull required information from data Direct messaging is a set of communication protocols provides secure exchange of PHI between providers over the internet by Health Information Service Providers (HISPs). Data is pushed to other providers and is best for independent providers

162 Principles of Healthcare Reform Health Information Exchange each state is responsible for establishing a secure communications exchange that links all health care providers together for purpose of sharing PHI. There are 2 technologies supported by the stimulus bill: Connect & Direct. This is NOT a health insurance exchange Health Insurance Exchange state or federally administered exchange designed to allow patient access to affordable insurance in a less complicated way promoting all patients to acquire health care coverage

163 Principles of Healthcare Reform Medical Home health care setting where patients receive comprehensive primary care services, have have ongoing relationship with PCP who directs and coordinates all care. This is the primary coordinated care model under HCR. Primary care is a core of patient centered delivery system, which involves the patient at high levels in MDM Pay for Performance payment system in which providers receive incentives for meeting or exceeding quality, cost benchmarks. Some systems penalize for not meeting benchmarks. Goal is improved quality over time

164 Principles of Healthcare Reform Shared Savings many P4P systems include incentive payments to providers to reduce cost of providing care through shared savings, with % of actual savings shared back to providers ro ACOs Registry data repositories that can mine data for outcomes analysis Risk Adjustment process of increasing or decreasing fees to health plans to reflect higher or lower than expected spending. Designed to compensate plans that enroll older and sicker populations

165 Principles of Healthcare Reform STARS Rating System - 5 star quality rating system for Medicare Advantage Plans is run by CMS to educate consumers on quality and make data more transparent Over 50 measures from 5 different ratings systems Applied to every encounter for every patient covered by any Medicare Advantage plan CMS will use this data to determine which plans get contract renual after January of the measure are directly or indirectly affected during an eye examination

166 CMS Quality & Performance Measure C01 Breast Cancer Screening 68% 3 C02 Colorectal Cancer Screening 58% 4 C03 Cardiovasc Care Choles screening 88% 4 C04 Diabetes Care Choles screening 88% 4 C05 Glauc testing 66% 3 C06 Annual flu vaccine 68% 3 C07 Improving maint physic health 65% 4 C08 Improve maint mental health 77% 2 C09 Monitoring physical activities 48% 2

167 CMS Quality & Performance Measure C10 Adult BMI Assmt 66% 4 C11 Care Old Adults Med review 68% 3 C12 Care Old Adults Func Status review 56% 3 C13 Care Older Adults Pain screening 54% 3 C14 Osteo mangmt in Women w hx frx 21% 1 C15 DM care eye exam 65% 3 C16 DM kidney dz monitoring 89% 2 C17 DM blood sugar controlled 72% 3 C18 DM cholest controlled 52% 3

168 CMS Quality & Performance Measure C19 Control BP 65% 3 C20 RA managmt 74% 3 C21 Improving Bladder control 35% 2 C22 Reducing Risk Falling 59% 3 C23 Plan all cause readmission 12% 3 C24 Getting needed care 85% 4 C25 Getting apt & care quickly 76% 3 C26 Customer service 88% 3 C27 Overall rating of healthcare quality 86% 4

169 CMS Quality & Performance Measure C28 Overall rating of plan 86% 3 C29 Care coordination 85% 3 C30 Complaints about healthcare 0.26% 3 C31 Beneficiary access & perform probs 65 4 C32 Members choosing to leave plan 11% 4 C33 Healthplan Quality Improvmt C34 Plan makes timely decis about appeals 87% 4 C35 Reviewing appeals decisions 83% 3 C36 Call cntr foreign language interpret 83% 4 C37 Enrollmt timeliness 90% 4

170 CMS Quality STAR Measures example C15 Diabetes Care Eye Exam for damage from DM 1 Star <47% 2 Star >47%-<54% 3 Star >54%-<64% 4 Star >64%-<81% 5 Star >81%

171 CMS Quality STAR Measures example C05 Glaucoma testing - % members over 65 without prior diag glaucoma or suspect who received glauc test 1 Star <54% 2 Star >54%-<62% 3 Star >62%-<70% 4 Star >70%-<74% 5 Star >74%

172 Principles of Healthcare Reform HEDIS Healthcare Effectiveness Data & Information Set Widely used set of performance measures in managed care industry developed & maintained by National Committee on Quality Assurance (NCQA) Consumable data allows humans to read and also allows ability for computer systems to automatically extract specific data and populate different EHRs, allowing sharing of data but also sharing the effort to enter data. It increases efficiency and lowers costs

173 Principles of Healthcare Reform ACO Accountable Care Organization is network of providers to provide full continuum of care, accountable for quality and cost of care and incentives for success Chronic Care Management coordinates healthcare and supportive services to improve health status of patients with chronic diseases like DM and asthma, focusing on EBM and patient education to improve self management and increase quality & decrease costs Comparative Effectiveness Research - analyzes the impact of different options for treating a condition in a particular group of patients, focusing on medical risks and benefits and cost risk and benefits of each option

174 Principles of Healthcare Reform MU Meaningful Use is a timeline created for providers to be able to incorporate all features necessary to practice in a coordinated environment where reimbursement is based on outcomes. Total patient experience addresses the psychology of the patient. Studies show satisfaction affects compliance. More of the focus of new quality measures is directed at patient total experience than it is the care providers deliver

175 Principles of Healthcare Reform Transparency process of reporting provider quality scores to public to allow patients to select providers ARRA allows payers to create incentives up to 20% out of pocket to patients who select high scoring providers Medicare is required by law to establish a provider quality reporting webpage and outcomes of all medicare billing is now being completed in preparation for reporting to public via Medicare Physician Quality Compare Website under delvelopement

176 Dry Eye Disease (DED) CC: Foreign body sensation HPI: OU / 2 yrs / mod / 44 year old perimenopausal female / CL intolerant (SCL), mild blepharitis and MGD VA = 20/70 OU SLE: + SPK diffuse / corneal stains (both), conj stains (both), TBUT = 5 sec, Schirmers = <3mm IOP = 12 Fundus = Normal

177 Dry Eye Disease (DED) Assessment = DED Plan Lid scrubs bid AFTs q2h (PF) Lotemax gel qid Restasis bid EyePromise EZ Tears PO D/C SCL Humidifier Letter PCP

178 Case Study: Dry Eye Disease Coding First visit E/M = ($168.00) or ($125.00) Ant Photo = ($27.00) Second E/M = ($85.00) or ($72.00) Total $ (excludes revenue from supplements)

179 DED - HCR Principles Demonstrated Engage Pt involved in decision making; understands options of prescription vs palliative treatments; nonocular therapies reviewed; potential for systemic medication involvement; co-morbidities reviewed Clinical Decision Support - discussion of evidence based approach to definitive treatment of DED Patient education examination summary Standardized communications coordinated care

180 Monitor Compliance with Audits Develop a Documentation team Monthly Assessment 10 charts/provider Report your Results All staff, residents, students Acknowledge positive & negative variances RETRAIN, RETRAIN..

181 Thank you Missouri Eye Associates McGreal Educational Institute Excellence in Optometric Education