It’s everywhere. ICD-10. Are you ready? Are you ready for the transition? So apparently we have moved from “being aware” to the new “are you ready?”
And for many, the response may be well, of course. Because of the “awareness” campaign, we contacted on EMR and Practice Management vendors and they have assured us that “they will handle everything”.
Now, most of us think we have an idea of what “everything” should be….of course the EMR needs to code into ICD-10 and the claim forms, whether the 837i ( UB-04) or the (837p)CMS 1500 should be able to handle ICD-10 for billing. Isn’t that all there is?
And that is the million dollar question. To which the answer is no. A close look at the potential uses of ICD-9-CM currently in place may amaze you. Lab requisitions all require diagnostic coding, and many use the exact code, as compared to a diagnostic statement. If you still handle a paper encounter form (aka as fee slip, superbill, charge ticket etc.) many diagnostic codes are preprinted on these documents. How about your pre-certification or referral processes? And these are simply a few areas that may be impacted by a transition to ICD-10.
Know to that much of what ICD-10 is for data collection. Falling back on the original London Bill of Mortality, where in the 1600’s diseases were classified for children under the age of 5 who were dying of all sorts of diseases. ICD was created from that original premise. ICD-10 simply takes us into the 21st century.
So what’s the next step?
The transition to ICD-10 requires a tremendous effort on the part of the whole organization. You will want to start with a project plan addressing where you want to be on October 1st, 2014, the date that you will need to start submitting ICD-10 on your claim forms.
With any project plan comes a project team – and in this case, multiple teams. You will want a high level team of strategic leaders, and the teams that will need to address education training and communication. Within each department there should be a team that will work with other project teams. And don’t forget senior management, you will want their full support throughout the process.
What’s next is the “gap analysis”. Just where do all those departments use diagnostic coding? And will it require a change by October 1, 2014?
Back to the Vendors, who will take care of everything? Just when do they plan on making that happen? Will you have new systems up and running well before the deadline? Will you be able to practice and train prior to go live? You will need to have contingency plans in place if that new upgrade doesn’t go as planned.
Once the gap analysis is complete, it’s time to build your business plan or the work plan….how will each one of those departments get to October 1 unscathed? Creating the business plan will make sure that every department is heard, and accounted for within the plan. You can then group similar tasks so that everyone has the benefit of the group process.
How long will this all take? We anticipate that you should allow up to 3 months just for the gap analysis and then that business plan process will depend upon what you have uncovered and the extent of the plans for each department.
And remember, this is just leading up to the actual training. Teaching physicians to document and coders to code will be time consuming. Coders need to have a good back ground in A+P and medical terminology; it’s no longer selecting one code from a list. Fortunately many of the ICD-9-CM coding conventions and guidelines still hold true.
But you can’t train too early or all will be forgotten, and you will want a period of learning and practice. But onsite trainers are going to go for a premium so you need to reserve your trainer and the dates now.
To help out with this process, you can take the PMG ICD-10 Readiness Assessment….we can then see where you stand and what needs to get done. Good luck as we launch into the future.
It is Mother’s Day and I find myself in a wonderful position to have some all too infrequent one-on-one time with my oldest daughter. As we sit having a cup of tea together she says “Mom, can I talk to you about something important?” My spidey senses tingle and my imagination runs wild as only a mother’s imagination can run. “Sure”, I say, “you can talk to me about anything!” She says “It’s about something I downloaded from the internet.” Was this a virus, a worm, a picture, something I did not touch upon in those mother-daughter talks in middle school and high school? “Where was this going?” I asked myself with trepidation. She walks over to the computer and opens an Excel spreadsheet that contains more than 65,000 rows from CMS and asks, “Why is there so much variation from hospital to hospital in their total charges for the same service?” I breathe easier. This is not your typical mother-daughter chat. This I can handle. You see, my daughter is a data analyst for a large healthcare organization and has recently started a HealthCare MBA program. She is full of this type of question lately.
Last week CMS released a FY2011 data on Medicare Provider Charge data. This data was released as an attempt at transparency and to offer consumers some comparative buying information. Unfortunately the data came without explanation, background or healthcare finance 101. The release of data was picked up by newspapers across the nation as they tried to call higher priced hospitals on the carpet. However, this is a much more complicated issue that just consumer comparison shopping and dramatically different charges. How much a hospital charges for its services rarely has any basis in reality when considering how much a hospital (or health center) will be paid for those services. A hospital has contracts with payers by which the hospital is paid far less than the charge amount. Uninsured patients are rarely expected to pay the full amount of charges either.
Yes, health care costs are high. But we are surely the only industry to never ever expect to be paid anywhere near what we charge. The US reimbursement rules are aberrant from all other consumer product lines. What CMS did not mention is that there is a very high variability from hospital to hospital and payer to payer in what they are paid for those same services. Commercial payer contract negotiations are intense and the outcomes are confidential. In contrast, Medicare and Medicaid payments rates are formulaic and not subject to negotiation. Sliding fee scales offer uninsured and underinsured patients discounts often deeper than the payers. It is a rare uninsured patient who is expected to pay the “list” price.
As health centers we need to keep our charges at a reasonable rate. That cannot be done in a vacuum. It must be done with the full knowledge of our payer contracts and our costs. We must keep our charges standard for all parties but we also must keep charges above our highest paying payer to maximize the reimbursement from them based on our contracted rates. Fiscally, health centers must understand that charges having little bearing on the expected payments. Consumers would be wise to be more aware of their insurance contract and the subscriber liability than at the hospital rates. The payer is really the one driving their financial burden.
A quick look at our own personal explanation of benefits from recent medical visits helped me bring this into focus for my daughter. Maybe next time we can have a meaningful dialogue about love, life and the pursuit of personal happiness but for now, I will settle for a meaningful talk about CMS charge data. A mother can dream can’t she?
ICD-10… PCMH… EMR Optimization… ACA 2014 Impact… Meaningful Use… Who’s on First?
It never stops. New opportunities, new threats, changes to our personal and professional life… it is almost unceasing. The old Abbot and Costello baseball routine comes to mind as we can hardly keep pace with the meaning of the acronyms, never mind keep up with the “to do” list that keeps expanding seemingly exponentially.
This past week while performing a state wide PCA training I was asked by a CHC CEO… “How do I prioritize all that has to be done?” We had just completed a discussion about ICD-10 and the tumultuous impact this new code set will have on CHCs and health care in general. With the anticipated disruption of patient flow, expected “Y2K”-like fees from EMR and practice management system vendors (who have to spend significant money updating their products), and straight expense for training (both consultant fees and salary of staff who are not “producing” while training)… ICD-10 is daunting at best. Most CHCs have not begun and I heard a PCA leader tell me a large and well respected CHC in her market just told the head of her PCA that they were essentially going to ignore ICD-10 and “just see what happens…” This is reckless at best and a legal/fiduciary liability at worst.
We had also discussed earlier in our day the fact that the Affordable Care Act (ACA, also known as ObamaCare) would result in CHCs in most states transitioning 20% to 30% or more of their patients who were previously “uninsured” or “self pay” to now being eligible for third party billing. Not only will CHC billing teams have to be prepared to expand claim volume capacity but front desk and financial support staff will have to learn how the new health products work, what services are covered, and even what the new insurance cards will look like. This does not begin to address what Massachusetts saw happen after their healthcare reform took effect; i.e., wait times for new patients to see a doctor extended nearly six months as all these newly-insured patients suddenly wanted to use their insurance vs. before when it was a very intentional avoidance of visits which most could ill afford.
If your CHC is not one of the 500 pilot PCMH programs, you know it is coming. Between ACOs (think of these as “neighborhoods” of PCMH) and other burgeoning PCMH… it seems clear this “case management” style of practice is how the compensation system is moving. How well your teams function to manage patient panels will determine your success. Optimal efficiency of information exchange and management of patient care remotely will be areas of critical focus if you are to succeed in a world very different from the flat encounter rate and fee for service compensation in which optimal reimbursement resulted from “face to face” contact with the patient vs. managing patients from afar.
Finally, this CEO was also struggling with final Meaningful Use (MU) requirements. The MU payout opportunity began back in 2011 affording a $44,000 maximum pay out to individual doctors (NOT the CHC employer… so if the doctors work for you make certain they sign something that says the MU money will be assigned to your CHC or else (as they say) the chase is on). Even if you join as late as 2014, there is still up to $24,000 that can be earned BUT you have to meet all the performance and reporting standards or that money could be recovered by the government. Again, more to do with too little time.
So back to that question… what is first on the list??
- Take care of your staff and they in turn will take care of your patients. Sounds easy but we know it is not. Staff need to understand what your organization is doing to address these changes to the health care system. When staff are well managed and treated with respect, they in turn will take better care of your patients.
- Take care of your patients. This is not just essential to the CHC mission but critical to your longevity and survival. Make no mistake, at some level, especially if your currently uninsured patients receive ACA coverage from a plan with a reasonable fee (payment) schedule, you will be in competition with local private practices who suddenly want to see these patients (because suddenly they are a payment stream vs. a resource drain).
- Get your EMR Up to Speed. You can’t stop getting your EMR up to speed. In fact, as we’ve discussed in these pages before, making the EMR do all it is supposed to do (especially automating provider work flow such as charge capture transfer to billing) will allow your providers to make time to master ICD-10 and all the complexities that go along with it. And, aside from EMR mastery improving odds for success around ICD-10 implementation, Meaningful Use monies should follow as a result.
- ACA patient influx preparation. Not much you can do about this other than make the current revenue cycle management process as fluid and successful as able. If your billing team can’t keep up with the work now, it will NOT get better when the claim/billing volume increases by 20-30%+.
As Mark Twain said “Worrying is like paying interest on a debt you may never owe.” Making your leadership team aware of these competing priorities and assigning a designee to each with an expectation of a monthly report to the team… that can’t hurt. In the end, control the things you can control and prioritize your team’s efforts in this regard. Not much more you can do.
Optimizing reimbursement is on the forefront of revenue cycle management. Have you asked yourself or your organization: are we losing revenue because your fee schedule is not up to date? Are you capturing all the charges you could? Is your fee schedule correct and current concerning CPTs, revenue codes (Medicare encounter rate), and descriptions? Do you have any deleted CPTs or terminated services still active in your fee schedule? Is your mode of charge entry (encounter form or electronic charge capture) updated and maintained? If the answer to any of these questions is “I don’t know” or “I’m not sure”; then it’s time to consider a Fee Schedule review.
The following is a list of steps you should take in order to complete a Fee Schedule review and begin to understand whether your Fee Schedule is “healthy” or needs a clean-up. Having a complete understanding of the operations of the clinical being reviewed is critical to revenue capture improvement.
1. Download and Review Your CHC Fee Schedule.
The information downloaded should consist of at least the following:
- CPT/HCPCS code
- Charge Code Description
- Charge Amount
- Effective Date/Create Date
- Revenue Code (Medicare encounter rate)
- Current/YTD Volume (Units) and Revenue
- 2 years Prior Volume (Units) and Revenue
The downloaded Fee Schedule should be validated against a billing and coding compliance tool to check for valid CPT/HCPCS codes and Revenue Codes (if applicable). Familiarity with the services being performed in a clinical area and the associated CPT/HCPCS is critical for this part of the review.
“Surgical procedures furnished in an RHC or FQHC by an RHC or FQHC practitioner are considered RHC and FQHC services. For RHC or FQHC services, the RHC or FQHC is paid based on its all-inclusive rate and is not subject to the Medicare global billing requirements.” Medicare Benefit Manual, Chapter 13.40.4 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf
Other commercial payors would follow their global billing requirements.
For example, in a GYN setting, you may be doing endometrial biopsies, vulvar biopsies and IUD removal/insertion procedures. These should be documented according to surgical guidelines and billed as a FQHC service where appropriate.
Key Finding- A number of times there are outdated CPTs. The descriptions in the file should be compared to the current CPT/HCPCS manuals or downloaded descriptions from AMA and CMS. Deleted CPTs are sometimes missed from the Fee Schedule.
Key Finding- Review hard-coded modifiers (i.e., permanently affixed within the practiced management system) vs. manually entered modifiers. Modifiers used may not be correct or up to date causing error queue issues or denials.
Key Finding- Reviewing volumes is important for analyzing shifts in services being performed and an opportunity to clean up the fee schedule of unused charge codes.
2. Obtain copies of all encounter forms used and review against Fee Schedule download file.
Make sure that the copies of the encounter forms are the most recent and are the ones currently being used by staff.
Key Finding-Most often the charge codes in the fee schedule and the charge codes on the encounter form are not in sync. This is big potential for lost revenue. If the services are on the encounter form but not in the fee schedule charges are not going anywhere.
Key Finding- There have been a number of charges on the encounter form containing different descriptions than what is in the fee schedule, hence billing incorrect services on the claim form.
Key Finding- Deleted CPTS still existing on the encounter form. Often times there are more appropriate CPTs for services being rendered but not being used.
Key Finding- Reviewing volume sometimes reveals services no longer being performed. The encounter form should be reviewed and updated periodically for services performed. Placement of services on the encounter form should be done to create operational efficiency.
3. Review all electronic charge entry screens/printouts against Fee Schedule download file
If charges are entered from an encounter form into a charge entry screen, the encounter form should be designed to flow in a logical, efficient order and be matched against charges in the charge entry screen. Strategically designing the form and screens will help with efficiency and accuracy of charges entered.
Key Finding- Charge entry screens and encounters forms usually have discrepancies and are not design for optimal workflow.
Key Finding- Like the encounter form, the fee schedule and charge entry screens are not always in sync. A number of times, charge codes are available in the charge entry screens but are not electronically connected to the billing system. This situation also arises in physician documentation systems that are interfaced.
Summary- Understanding your operations and the process flow from scheduling through billing is key to optimizing reimbursement. At times there are inefficiencies, miscommunications and IT disconnects which may not be apparent in day-to-day operations. It is important for revenue cycle operations to stay connected with the clinical operations putting the necessary processes in place for revenue capture and compliance updates. An annual review at the Fee Schedule level should be performed around code set changes and a complete review of each clinical area in your center should be performed at least every other year.
We have all been patients at one time. Watching over the revenue cycle gives us a unique perspective on how billing processes affect the Patient Experience. I have been a patient at different hospitals, triaged in Emergency Rooms, seen by the NP when I was really sick, and have sat in waiting rooms like everyone else. Each time I needed medical service I felt lucky that the care I was receiving was top notch. I felt reassured by the providers and their staff that I was in good hands.
What separated the good experiences from the bad was how I was handled from an administrative perspective; more specifically how the billing was handled.
Walking into my PCP’s office feels like walking into some building operated by the CIA. When I arrive, automatic doors whoosh me into the building. A velvet rope ushers me to a hand sanitizer station where a sign reads, “Please have your insurance information and photo ID ready when you arrive at the scheduling desk”. Just beyond that there are 3 to 4 front desk staff sitting behind glass like you would see at a bank. Each station has a privacy partition. When I am called up I am quietly asked for my insurance information and photo ID.
The scheduler confirms the name of the Doctor I am scheduled to see and asks me to verify some other personal information she has on file. She asks for a moment to check my insurance eligibility. After a moment or two of prodding around in her computer, the printer in the back starts to rumble and she grabs the print-outs. She returns to tell me that I have a $25 copay for the visit and asks me how I would like to pay (not if I would like to pay). She swipes my debit card for me, prints a receipt and a routing form. With a sympathetic smile asks me to take the elevator to the second floor to my Doctor’s suite.
When I arrive upstairs, it is only 10 feet from the exit of the elevator to the next “guard”. When I get to the window the scheduler behind the glass simply reaches out her hand for the routing form I am holding. “Thank you” she says, “Have a seat we will call you in a moment or two”. As I sit waiting I notice how empty the waiting room is. There is only one other person sitting there with seating for at least 20. Before I get a chance to check the score of the Red Sox game on my smartphone, a nurse opens a door and quietly says “Jeffrey?” She’s looking right at me and the other person in the waiting room is a woman, so I am pretty sure she means me.
I wait a little longer in the exam room after I am weighed, meet with my Physician for my check-up and am on my way. As I am leaving I ask where I check out and am told “you don’t need to, have a nice day”. A week later I get a survey from them, and that is it.
Last summer I was vacationing at the beach and woke up with one of my eyes swollen shut. Needless to say I wasn’t really happy about it so my wife took me to the urgent care center down at the end of the beach road. It was a small building with a normal door. I walked in the front door and the place was packed with vacationers who were having their week ruined by some injury, allergic reaction or other ailment.
I found my way to the front desk where a woman was seated behind a monitor. I stood there for a few moments until she looked up at me and handed me a clipboard with a series of forms. “Have a seat and fill these out”, she asked. I filled out the forms and went back to the front desk. She took a copy of my insurance card (which lists my co-pay on the back). “You can have a seat” the woman said, “Doctor will see you in a minute”. I asked her about my co-pay. “Don’t worry about it, we’ll just bill you” she replied. I offered to pay again and was told to just sit and wait. So I did.
Eventually it was my turn and a woman emerged from the back bellowing “Jeff Di, Di… Dilidiolodio? Swollen Eye?” Thanks for broadcasting that, I thought as got up from my chair. The Nurse Practioner kindly washed some sand out from under my eyelid and said I would be good as new in a day.
A month or two later I started to get bills in the mail from them. Turns out their claims got denied. Despite having copied my insurance card and my filling out their form, they sent out the wrong number and then transferred the balance to me when it wasn’t paid. This was almost as annoying as the sand in my eye. I called the office to help get them the right insurance information, they agreed to resubmit the claim, and they went silent again. Sometime later I got a bill for my co-pay. There was an interest charge on it dating back to when they originally transferred the balance to me the first time. For some reason that was never removed once they got their claim paid. Figures. I called to protest, sitting on hold for quite some time before someone got it straightened out.
Mission… sort of accomplished
Two different visits and what set them apart was the annoyance of dealing with billing issues after the fact. My PCP’s office takes a little bit more work to get into, and some of the process feels very “sterile” but in the end it makes the experience better for me. I go in, I know what to expect, I get top notch care, and then I leave. There isn’t this belly ache after the fact and they don’t have to put with me calling them back about two separate invoices.
Comparing an urgent care setting in a seasonal vacation spot to my PCP’s office might not be a totally fair comparison, but it highlights the process differences. My PCP’s office makes it clear to me where I need to go and what information they need from me to get bills out correctly the first time and then they double check the info I gave them. I know when I go there that the billing office is in good order so I can just worry about my visit. Sure, they ask more of me, but I would prefer to handle it then rather than having to sit on hold later on.
Billing process controls (like checking a patient’s eligibility while they are in the office) make it easier on all of us, but it has to start when the patient walks in the door.
Yes, the risk is real. As you work through your day to day operations, managing a never ending stream of patients, some with greater needs than others, you may wonder why compliance is such a major part of your day. Compliance has many faces, it involves not only the quality of care that your provide to your patients, but also how you handle the myriad of government regulations. From HIPAA, Privacy to CLIA, OSHA and billing and RAC reviews, Quality care initiatives and HIPAA Security, CHC’s are inundated with rules.
Medicare has been actively working high-producing providers who appear to be the recipient of higher than usual funds from the government. When the government shows up on your doorstep with a subpoena, it’s after they have reviewed the available data thus a reasonable belief that the provider is a problem. Who’s knocking at your door? Typically Federal Agents from more than one department. FBI, DOD, CMS may all be represented. Do your employees have a protocol to follow in the event someone comes knocking?
Why are they knocking? It could be that someone (usually unhappy or disgruntled) from your organization told the government, usually through a whistleblower action, that your billing is less than stellar. Or the government may just be running the numbers. Reasons the government gave in recent cases include the extreme: “we suspect that the provider is using his Medicare practice to fund terrorist activities”, to the mundane: your provider was excluded from billing Medicare due to criminal activity in another court (such as embezzlement), and the law is clear, that if you are convicted in another criminal issue, you cannot be a provider with CMS.
Some of the most common actions are for billing, usually because it’s easy for the government to quantify and audit. In the larger or more serious cases, Medicare will employ a forensic accountant to review data. But, it doesn’t mean that the people employed are experts in the field. In one case in which I participated, the FBI asked if we wrote the 1995 and 1997 E+M Guidelines, which as just about everyone knows were a joint production by the government with the AMA!
Responding to the government in all cases is time consuming and detracts from your day to day operations. You can anticipate that if the government is going to knock on your door that the next 2-7 years are going to be spent answering to the concerns of the government and defending your positions.
Your compliance programs need to be able to address with a timely investigation and response just about any issue that is brought forward to you. Serious infractions that put the organization at risk must be dealt with immediately and appropriately. This means that your compliance plan cannot be templated from a kit and made to sit on the shelf. Each year you need to review the plan as written and update it to the current climate of the industry. Work plans for billing and other areas allow you to conduct periodic reviews of high risk areas and providers. And for any adverse findings, you will need to be able to set disciplinary measures and processes to action.
Does it really make a difference? Absolutely, if your efforts are sincere, Medicare will see it in the data. In one case presented by a whistleblower, the government reviewed the issue. Numbers were run, and the government could see that changes had occurred in response to the billing problem, and as a result the billings related to the problem decreased. The government said that because the efforts of the organization, to find and correct the issue, was apparent and successful, they would not pursue the case.
If you belong to a large healthcare system, you have probably met, worked with and been trained by the Compliance Department. Smaller organizations may not have all the processes in place to address all issues. A yearly review of your compliance initiatives, policies and training is recommended. Included in the review should be a close look at your billing initiatives, updates to coding and billing regulations, and training for staff. While Compliance may seem like an added expense, the efforts by your compliance professionals may well result in major savings such as: time saved from having to address government actions, resolving small problems before they become a major concerns, and in keeping staff trained and current, so that problems are avoided and appropriate reimbursements maintained.
Linda Howrey, EJD
Managing Director, PMG Consulting
Every Spring and Fall I reorganize my closet. Although I do get some satisfaction from the chore it doesn’t change the content of the closet. It is the same stuff I had in there the last time this season rolled around. It just makes it feel new and easier to find things. Next time I am ready to reorganize my closet; I am going to have CMS do it. That way not only will it be all new and easier to find things, I think it might very well have new things in there that were never there before.
On January 31, 2013 CMS published an MLN Matters article about CR 7824. It was titled merely “Reorganization of Chapter 13”. By Chapter 13, CMS was referring to the Medicare Benefits Policy Manual for RHCs and FQHCs. This is our bible for Medicare billing in an FQHC. In the “What you need to know” section this article simply stated;
This article is based on Change Request (CR) 7824, which updates and reorganizes Chapter 13 of the “Medicare Benefit Policy Manual.” a.k.a. MBPM. This chapter deals with Medicare RHCs and FQHCs. Chapter 13 is reorganized for easier use and updated to include more comprehensive information. There are no new policies contained in the manual.
I have added the bold font to the last sentence. When I read this, as I read all the MLN Matters articles, I said to myself, “this is great, I love reorganization”….a little Sheldon Cooper-like but still true. Then I read the newly reorganized chapter.
While it is reorganized, CMS has reused numbering for completely different topics. Section 40.1 was always one of my most used sections. Previously, 40.1 defined FQHC Primary Preventive Services. The new 40.1 describes the locations in which an FQHC visit may occur. The publications do not give any roadmap about where to find the information previously in 40.1. So I went on a scavenger hunt.
I found what I was looking for in the newly minted section 210.2.1 – Preventive Health Services in an FQHC; General. When I compared the sections, I got confused. Section 40.1 (in the previous manual) stated in part (bold emphasis added by me):
The following preventive primary services may be covered and billed to the intermediary when provided by FQHCs to Medicare beneficiaries:
● Medical social services;
● Nutritional assessment and referral;
● Preventive health education;
● Children’s eye and ear examinations;
● Prenatal and post-partum care;
● Prenatal services;
● Well child care, including periodic screening;
● Immunizations, including tetanus-diphtheria booster and influenza vaccine;
The new 210.2.1 section states:
FQHCs must provide preventive health services on site or by arrangement with another provider. These services must be furnished by or under the direct supervision of a physician, NP, PA, CNM, CP, or CSW. Other services that must be provided directly by an FQHC or by arrangement with another provider include: preventive dental services, mental health and substance abuse services , transportation services necessary for adequate patient care, hospital and specialty care.
Section 330(b)(1)(A)(i)(III) of the Public Health Service (PHS) Act required preventive health services can be found at http://bphc.hrsa.gov/policiesregulations/legislation/index.html, and include:
• prenatal and perinatal services;
• appropriate cancer screening;
• well-child services;
• immunizations against vaccine-preventable diseases;
• screenings for elevated blood lead levels, communicable diseases, and cholesterol;
• pediatric eye, ear, and dental screenings to determine the need for vision and hearing correction and dental care;
• voluntary family planning services; and
• preventive dental services.
NOTE: The cost of providing these services may be included in the FQHC cost report but they do not by themselves constitute a billable visit.
Do you understand my confusion? By way of an example, previously Preventive Well Child Care, including periodic screening when performed in an FQHC was billed to the intermediary (Part A). Now this manual states that although we are required to provide “well-child services” they do not constitute a billable visit. These are services provided by a core provider, usually an MD but sometimes an NP. Yet they are not billable visits? These statements are contradictory to each other. I needed help. We sent a question to CMS regarding the changes in the MBPM. The reply was “What exactly do think has changed?” Yikes. I guess we need to be more specific with our questions. This will take some more conversations with CMS. We will keep you posted about our progress with this new manual.
But in the meantime, my closet needs some “reorganization”, I could use some new shoes for spring.
After reading the Geiger Gibson /
RCHN Community Health Foundation Research Collaborative Policy Research Brief # 32, a product from the George Washington University School of Public Health, it is clear that CHCs should be bracing for the impact of sequestration.
Recent releases from CMS about sequestration make it clear that fee-for-service (FFS) Medicare will see a 2% pay cut but hope has prevailed that perhaps the CHC Encounter Rate (funded by Medicare Part B but adjudicated via Medicare Part A) might be spared. However, if the suppositions set forth in the Geiger Gibson report become reality, a 2% cut would be a blessing.
What Geiger proposes is that community based organizations will see the biggest hit. In fact, CHCs are expected to see in 2013 alone more than $120 million in cuts to grant funding. Further, as they expect this loss to occur over the latter part of 2013, there is really no way to respond except by dramatically reducing program offerings. Part of the residual consequence is an additional loss of $230 million in 3rd party (billing revenue) due to a decrease volume of patient visits resulting form an inevitable inability to offer a full complement of services. In other words, if you cannot pay the staff to render services there are no bills to send so no incoming money from such. That is truly a double whammy.
So how does your CHC respond? Are you maximizing every penny available from third party payers? Are you still accepting substandard performance from your billing and clinic operations? Can you really afford to do this on the precipice of such a daunting financial shortfall?
Key KPI. Know your Key Performance Indicators (KPI) and how you stand. For years we have heard CHCs boast that they maintain at or below 50 days of accounts receivable (DAR or Days Sales Outstanding (DSO) to some). Frankly, this is unacceptable and in most markets (save states like Illinois in which claims are cleanly adjudicated and “paid” but the state government only releases funds intermittently), sub 30 DAR/DSO is realistic. Further, knowing your “blended encounter rate” (i.e., how much money you are paid per visit vs. the state and national averages) is essential. Take your total payments divided by your total visits and that is your blended encounter rate. Not only should you be able to benchmark against national/regional norms, you should know this KPI by clinic location and quarter over quarter.
Finally, how are you planning to deal with a theoretically HUGE influx of new patients in January 2014 (only 9 months away) when the ACA (a.k.a., ObamaCare) descends with the majority of your self pay patients suddenly being “insured” and therefore becoming more demanding because they are now “paying customers.” This not only impacts clinic operations (also theoretically running on an even thinner staffing levels due to this sequestration hit) but the need for your billing team to absorb up to 30%+ more work. Again, are you ready?
Thank God we don’t have to implement ICD-10 until next October.
CHCs have the opportunity to maximize Medicaid reimbursement for obstetrical care due to the unique encounter rate reimbursement afforded during the antepartum period. For non-CHC providers, AND for commercial payers compensating a CHC, payment is made primarily via a “global surgical package” which essentially means payment is a lump sum. This singular “global payment” is intended to cover all services related to “normal and uncomplicated” service revolving around the antepartum visits, delivery, and a post-partum follow visit. Commercial payers can pay from $2,000 to $2,500 for a vaginal delivery while “global OB” for Medicaid can be as little as $1,200. However, as a CHC each outpatient/clinic based encounter (i.e., all antepartum and the post-partum follow up) should be paid the full Medicaid encounter rate.
For example, if a CHC had a Medicaid encounter rate of $130 a visit, and assuming only ten antepartum encounters, this CHC should be paid $1,300… and this is just for antepartum care. Additionally, CHCs who perform the delivery are also eligible for “delivery only” service (e.g., CPT code 59409, vaginal delivery only). Medicaid payment for the ”delivery only” can range from $600-$900. This results in CHCs receiving for Medicaid Obstetrical care, as much or more than what most commercial payers compensate for the identical services; i.e., total Medicaid compensation can be well in excess of $2,000 vs. the more typical “Medicaid OB Global” payment of $900 to $1,200. Certainly, this disparity cannot last but for the time being, CHCs would be foolish to not maximize this revenue opportunity.
To be clear, some Medicaid Managed Care Entities (MCEs) today pay the global obstetrical package fee vs. paying individual antepartum and postpartum visits. However, most states with MCE market penetration still afford, based on state specific CHC manuals/guidance, Medicaid “wrap payment” for all Medicaid eligible encounters. As such, CHCs are entitled to encounter rate dollars for all antepartum/postpartum visits and not just the global OB. Resolution of any disparity is often a matter of explaining to, and at times lobbying against, the MCE to assure capture of all payments for which the CHC is eligible. It is not unheard of to witness some strong-arming by the primary care association or a sympathetic elected official.
There is always the logistical challenge of getting providers and ancillary staff to adequately “code” the services and the obstacle of correctly establishing “edits” or table updates which output the necessary encounter rate coding (e.g., T1015). However, in the end, these are worthwhile and manageable tasks necessary to achieve PMG’s motto of “get paid as much as possible when able so you can give it away when you want or need to.”
Anyone who has been through compliance training regarding documentation and coding of physician services has learned that Medical Necessity is the overarching criteria for meeting the Medicare coverage requirements. What does that really mean in this day of Electronic Health Records (EHR)? Practically speaking, it means that regardless of the vigor of your documentation and regardless of the fact that the documentation technically supports the code selection, if the nature of the presenting problem does not support the level of service documented and coded, then the service has been over-coded.
As more EHRs are implemented and providers become more savvy in ways the EHR can save administrative time, the likelihood of cloning or templating notes becomes increasingly common. Properly used templates are not banned or illegal or even frowned upon. When templates turn into a cloning agent for notes, CMS and the OIG get their dander up. I have performed medical record review for thousands and thousands of charts in the course of my career. Identical or nearly identical notes for completely different presenting problems have never been so prevalent.
On September 24, 2012, Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services (HHS) and Eric Holder, the U.S. Attorney General for the Department of Justice (DOJ), issued a letter to five of the largest health care organizations in the country. The letter states in part “there are troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled.” Evidence shows that there is “potential cloning of medical records in order to inflate what providers get paid”. This letter is another warning shot. “False documentation…is illegal. This practice will not be tolerated. Providers in violation will be pursued.
Take this letter seriously. Review your documentation. Review your EHR templates. Could you be mistaken for a gamer or a cloner? Be careful. Be cautious. Be prudent. Be safe so that you can continue your admirable mission.