2014 Reimbursement Update Impact on education and clinical practice for communication Sciences and Disorders- Part tw

1. 2014 Reimbursement Update Impact on education and clinical practice  for communication Sciences and Disorders- Part two Robert C. Fifer, Ph.D. Mailman Center for Child Development, University of Miami

2. Disclosures • Program evaluator for Duke University Medical School and University of Texas Medical Branch • Presenter at New Mexico Speech and Hearing Association, North Carolina Academy of Hearing Rehabilitation • Member Genetics and Newborn Screening Advisory Council, Florida Department of Health • Consultant to Children’s Medical Services Audiology Review Committee • Member ASHA’s Health Care Economics Committee

3. Documentation Requirements1997 Documentation Guide for E/M Coding • History (Soap): • Medical necessity for why the patient is there • “Referred by” is not medical necessity • Requires a history covering the following areas as appropriate • Chief Complaint • Duration of symptoms • Family history • Social / occupational history • Prior medical history • Relevant diagnoses • This section justifies all that is done

4. Documentation Requirements • Actions and results (sOap) • Describing what was done • The test forms cannot stand on their own • Most professionals don’t know what it is or what the raw results mean • Description of procedures and observations • Procedure description can be “canned” • Description of what was found (results)

5. Documentation Requirements • Clinical Assessment (soAp) • Must have a clear statement of practical and clinical significance • Must flow logically from the history and the findings • Recommendations (soaP) • Logical conclusion to the matter. • Based on these outcomes, the following recommendations are offered:………… • Each recommendation must be supported by history, findings, and interpretation • Do not list unsupported recommendation

6. Additional Notes on Recommendations • Medical Necessity • All recommendations must be supported by the concept of “medical necessity” • Recommendation should not be offered that is for the convenience of health care provider or patient • Transfer to plan of care • Use of report • Separate document (Recommended)

7. Other Requirements • Signature • If a paper report, must be an original signature • Facsimile or stamped signature is not appropriate • If electronic medical record (EMR), your login constitutes your signature • Date • Date of service must be specified and prominent in report • Other dates may include date of review, date of “signing”, date of dictation. These must be distinguished from date of service.

8. Impact of ICD-10 on Documentation • ICD-10 allows greater specificity in diagnosis coding and will be even more so if functional scales are added • Description of patient status in report will need to be more detailed in order to complement and justify the specific ICD-10 code selected • Will affect descriptions of what was found and clinical assessment statement. • BE CLEAR IN WHAT YOU WRITE!

9. Say What You Mean – Clearly! • I saw your patient today, who is still under our car for physical therapy • The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week." • Patient has chest pain if she lies on her left side for over a year. • Discharge status: Alive but without permission. Patient needs disposition; therefore we will get Dr. Blank to dispose of him

10. Say What You Mean – Clearly! • The patient was to have a bowel resection. However, he took a job as stockbroker instead. • The patient is tearful and crying constantly. She also appears to be depressed. • The patient refused an autopsy. • The respiration tube was disconnected and the patient quickly expired.

11. Personal Observations • Consists of audiogram with some notes • Ex: Referred by Dr. Razzelfratz for hearing test. • Recommend hearing aids • Fails to meet federal guidelines for minimum documentation standards for covered services • Therapy notes incomplete or has sign-in sheets only

12. Diagnosis Coding • October 1, 2014 • To International Classification of Diseases, 9th Revision, Clinical Modification ICD-10-CM • ICD-9-CM: Approximately 18,000 codes • ICD-10-CM: Approximately 64,000 codes • Provides more flexibility for adding new codes

13. Clinical BillingCoding “Normal” Diagnosis • Medicare guidelines on code selection • Not allowed to be “normal” within the ICD-9 or ICD-10 coding system • Code signs / symptoms that caused you to do the test • Some recommend use of a V code for test encounter following (for example “Examination following a failed screening”

14. ICD-10-CM • H90 Conductive and Sensorineural Hearing Loss • Includes: • Congenital deafness • Excludes: • Deaf mutism NEC (H91.3) • Deafness NOS (H91.9) • Hearing loss NOS (H91.9) • Noise-induced (H83.3) • Ototoxic (H91.0) • Sudden (idiopathic) (H91.2)

15. ICD-10-CM • H90.0 Conductive hearing loss, bilateral • H90.1 Conductive hearing loss, unilateral with unrestricted hearing on the contralateral side • H90.2 Conductive hearing loss, unspecified • Conductive deafness NOS • H90.3Sensorineural hearing loss, bilateral • H90.4Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side

16. ICD-10-CM • H90.5Sensorineural hearing loss, unspecified • Congenital deafness NOS • Hearing loss: • central } NOS • neural } NOS • perceptive } NOS • sensory } NOS • Sensorineural deafness NOS

17. Emphasis on Outcomes • Congress is eager to do away with the therapy caps and the exceptions process and go to a simpler system. • Now requires CMS to collect functional status and outcomes measurements • Seven-level functional outcome system to be phased in this year for therapy services • Similar to NOMS in structure

18. Changing Landscape • International Classification of Functioning, Disability and Health (ICF) • Describes body functions, body structures, activities, and participation • Useful for understanding and measuring outcomes • ASHA has information available online

19. ICF Levels

20. ICF Levels

21. Documentation and Audits • Greatest problem in audits • Often inadequate and over-simplified • Often not clear • Mismatch between CPT and diagnosis codes unsupported by documentation

22. Audits • To protect the Medicare Trust Fund • Medicare QIO (Quality Improvement Organization) • CERT (Comprehensive Error Rate Test) • RAC (Recovery Audit Contractor) • ZPIC (Zone Program Integrity Contractor) • MAC (Medicare Administrative Contractor) • PSC (Program Safeguard Contractor) • OIG (Office of Inspector General Audits)

23. Audits • To protect Medicaid funds • MIP (Medicaid Integrity Program) • MFCU (Medicaid Fraud Control Unit) • RAC (Recover Audit Contractor) • IMRO (Independent Medical Review Organization

24. “In Your Presence” Audits • QIO: Improve effectiveness, efficiency, economy, and quality of services provided to Medicare patients • MAC Audits: Sampling of patient records to ensure quality of service delivery and completeness • MIC reviews: Looking for overpayments and billing errors • MIC Audits: Looking for fraud often with local law enforcement (can also be behind the scenes)

25. “Behind the Scenes” Audits • ZPIC oversees the RACs and approves their CPT code selection for data-mined audits • RAC searches the Medicare and Medicaid data bases for inappropriate billing patterns that violate principles of code reporting • PSC obtains information from RACs regarding possible fraud and abuse

26. Recovery Achievements • RAC Pilot Project • 3 year demonstration • 6 states • $1.3 billion recovered in overpayments • Overpayments • Medicare: $49.9 billion in 2013 • Medicaid: $14.4 billion in 2013 • Point of comparison • Deficit reduction bill by Rep. Ryan cut $20 from budget

27. Attributes of Overpayments • Administrative and documentation errors • Medically unnecessary services • Diagnosis coding errors • Inappropriate procedure code reporting

28. Prevention of Bad Outcomes • KNOW THE RULES!!!!! • Correct coding • Types of codes • Don’t go “code fishing” • Be truthful in code selection • Documentation • “If it wasn’t documented, it never happened” • The audiogram cannot stand alone, not even with notes • Six elements of documentation – EVERY TIME • Medical necessity – justify ALL procedures

29. Clinical BillingCode Selection • With rare exception, do not go outside of our family of codes for SLP and Aud services • Do not code shop for what sounds good without understanding the procedure represented by that code • If a procedure does not have a code, use the unspecified/unlisted code 92700 • Know the difference between a unit code, contact code, and timed code

30. Clinical BillingCode Type • Contact code • Untimed code reported once per date of service • Will have no unit or timed designation in the descriptor • Unit code • Report the code up to a maximum number of times per date of service • Designated by maximum number of units in descriptor • Timed code • Designated in descriptor by “1st hour” or “each successive 15 minutes”

31. Clinical BillingTimed Codes • Usually the report preparation is included in the intra-service time. It will be designated “with report” if that is true • Be conservative when reporting the portion of time devoted to report writing • Document in progress notes the start time and stop time for the face to face contact

32. Clinical BillingSupervision • Medicare requires 100%, in the room supervision • Medicare pays for the licensed professional’s time and not the student’s effort • Decision-making must be by the professional • Cannot be involved with care of a second patient • Medicaid • Supervision may vary from state to state • Typically professional contact with family and student to ensure appropriate procedures, outcomes, and decision-making • Depending on the student, may not require 100% supervision

33. The Question of Whether to See Medicare Patients • Depends on supervision level and medical necessity • Practice patients / clients • If supervision CAN be met and the decision is to see Medicare patients, then must use an ABN if medical necessity is not met (more on ABNs momentarily) • If decision is to NOT see Medicare patients, then a sign must be posted informing all patients / clients that Medicare is not accepted because level of student supervision cannot be done in accordance with Medicare regulations

34. 38 years of per capita spending by country Per Capita Spending for Health Care; Source: Kaiser Family Foundation

35. Health Care Costs for American FamiliesSource:Milliman Medical Index

36. Health Care Costs for American FamiliesSource: Milliman Medical Index

37. Health Care Costs for American FamiliesSource: Milliman Medical Index • Miami most expensive at $24,965.00 • Phoenix least expensive at $18,365.00 • Primary utilization factors influencing out of pocket and overall expenses: • Inpatient facility care • Outpatient facility care • Professional services • Pharmacy • Other

38. Health Care Economics • Cost inflation • Risen 78% since 2000 vs. 20% for salaries • Average 9% per year with range of 7%-13% • Defensive medicine (malpractice) • Unnecessary procedure/treatment (fee for service) • Ineffective treatment • Inefficient service delivery models • Pharmaceuticals • End of life care

40. Factors Affecting Reimbursement • Sustainable Growth Rate (SGR) • PQRS • New models of reimbursement • Procedure reviews • New Challenges

41. Sustainable Growth Rate • Part of the 1997 Balanced Budget Amendment to keep Medicare budget neutral • Includes several factors to calculate the reimbursement of Medicare services • Independent from RVU assignments from AMA • Annual budget allocation from Congress

42. Sustainable Growth Rate • Intended to control the growth of Medicare costs • Payments for services not withheld if SGR targets are exceeded • If target expenditures exceed budget, the next year’s update is reduced • If target expenditures are below budget, the next year’s update is increased

43. Sustainable Growth Rate: How does it work? • The estimated percentage change in fees for physicians’ services. •  The estimated percentage change in the average number of Medicare fee-for-service beneficiaries. • The estimated 10-year average annual percentage change in real gross domestic product (GDP) per capita. (from 2008 forward) • The estimated percentage change in expenditures due to changes in law or regulations.

44. SGR Adjustments: 1990-2011

45. The “Doc Fix”: Introduced February 2014 • Immediate repeal of SGR • Transition period with 0.5% increase annually for 5 years • Merit Based Incentive Program • PQRS • Value Based Modifier • Meaningful Use for Electronic Medical Records • 5% added incentive payment to physician payment under new Alternative Payment Models • Increased funding for technical assistance to small physician practices (<15 physicians) • Creation of a technical advisory panel to review and recommend Alternative Payment Models

46. Noteworthy Features of “The Fix” • Consolidates quality programs (e.g., PQRS, Value Based Modifier, Meaningful Use) into one. • Payments based on achieving performance thresholds • Introduces the concept of alternative payment models • Incentivizes care coordination and shared responsibility of patient care • Requires ongoing development of quality measures to evaluate performance

47. Other Noteworthy Features of “The Fix” • Increases transparency of metrics and quality • Physician Compare website • Posts quality and utilization data for patients to make informed decisions about their care • Allows qualified clinical data registries to purchase claims data for purposes of quality improvement and patient safety

48. Latest News on Doc Fix 3/31/14 • Congress passed a bill to delay to freeze the current situation for one year. • Suspend 24% reduction in payments • Extend the therapy caps exceptions until March 2015 • Delay implementation of ICD-10 for one year

49. Other Factors Affecting Reimbursement • CMS Screens of billed codes looking for • Codes frequently reported together • Codes that have never been surveyed by the RUC or HCPAC • Codes believed to be overvalued based on utilization increases • AMA Responses to CMS • Overseeing survey process • Facilitating potential methods of payment revision

50. Physician Quality Reporting Initiative (PQRS) • One of three performance based reimbursement factors affecting physicians – the primary performance based factor for audiologists at present • Began as an enticement to physicians to abide quality of care standards • Participation is now a requirement to maintain full Medicare reimbursement • Each health care discipline / specialty will develop performance standards