Download November 2003 3rd Party Newsletter

November
2003
Third Party Newsletter
NEBRASKA OPTOMETRIC ASSOCIATION
Volume 3 Issue 11
Medicare's
National Correct Coding Initiative
On September 23, 2003 the Centers for
Medicare & Medicaid Services (CMS)
posted the National Correct Coding
Initiative edits on its web page. NCCI
was prepared to promote national correct coding methodologies and to
eliminate improper coding. CCI edits
are developed based on coding conventions defined in the AMA’s's CPT
Manual, current standards of medical
and surgical coding practice, input
from specialty societies, and analysis
of current coding practice. The AOA
recently mailed the 100 page section
applicable to optometry to Dr. Quack.
The edits are arranged by two sets of
tables. Each table is arranged in two
columns. Column 2 codes in both tables are not payable with the column 1
codes unless the edit permits the use of
a modifier associated with CCI.
One table contains the column 1/
column 2 correct coding edits
(formerly known as comprehensive/
component edits). The column 1/
column 2 correct coding edit table contains two types of code pair edits.
• One type contains a column 2
(component) code which is an integral part of the column 1
(comprehensive) code.
• The other type contains code pairs
that should not be reported together where one code is assigned
as the column 1 code and the other
code is assigned as the column 2
code. If two codes of a code pair
edit are billed by the same pro-
vider for the same beneficiary for
the same date of service without
an appropriate modifier, the column 1 code is paid. If clinical circumstances justify appending a
CCI-associated modifier to the
column 2 code of a code pair edit,
payment of both codes may be allowed. (Appropriate modifiers include: E1 E2 E3 E4 LT RT 25 58
59 78 79 91)
The other table contains the mutually
exclusive edits. "Mutually exclusive"
codes represent procedures or services
that could not reasonably be performed
at the same session by the same provider on the same beneficiary.
The CCI Edits Manual may be obtained in two ways.
1. Through the CMS website at
HTTP://WWW.CMS.HHS.GOV/PHYSICIANS/
CCIEDITS/DEFAULT.ASP.
The CMS
website contains a listing of the
CCI edits, by specific CPT sections, and is available free for
downloading to the public.
2. The CCI Edits Manual may be obtained by purchasing the manual,
or sections of the manual, from the
National Technical Information
Service (NTIS) website at HTTP://
WWW.NTIS.GOV/PRODUCTS/FAMILIES/CCI ,
or by contacting NTIS at 1-800363-2068 or 703-605-6060.
More on CCI next issue.
Information in this article was obtained from http://www.cms.
gov/medlearn/ncci.asp
Inside this issue:
Compliance: Civil monetary Penalties Law
Optometric Postoperative Care
2
3,4
Modifier 24: E&M not related to Post-op care
5
UPIN numbers: finding other doctor’s...
5
Dr. Quack
6
November 2003
Note: Abstracts of all articles
in this newsletter are found at
the top of page six.
Compliance: Civil Monetary Penalties
The following information was recently published in the Federal Register and entitled “Compliance
Program Guidance for Individual and Small Group Physician Practices”. It directly impacts optometrists. A lengthy document, it has been distilled here for readability, and will be presented as a series of
articles in this publication.
Civil Monetary Penalties Law
(42 U.S.C. 1320a-7a)
Description of Unlawful Conduct
The Civil Monetary Penalties Law (CMPL) is a comprehensive statute that covers an array of fraudulent and
abusive activities and is very similar to the False Claims
Act. For instance, the CMPL prohibits a health care provider from presenting, or causing to be presented, claims
for services that the provider ``knows or should know''
were:
♦ Not provided as indicated by the coding on the
claim;
♦ Not reasonable or necessary;
♦ Furnished by a person who is not licensed as a physician (or who was not properly supervised by a licensed physician);
♦ Furnished by a licensed physician who obtained his
or her license through misrepresentation of a material fact (such as cheating on a licensing exam);
♦ Furnished by a physician who was not certified in
the medical specialty that he or she claimed to be
certified in; or
♦ Furnished by a physician who was excluded from
participation in the Federal health care program to
which the claim was submitted.
Additionally, the CMPL contains various other prohibitions, including:
♦ Offering remuneration to a Medicare or Medicaid
beneficiary that the person knows or should know is
likely to influence the beneficiary to obtain items or
services billed to Medicare or Medicaid from a particular provider; and
♦ Employing or contracting with an individual or entity that the person knows or should know is excluded from participation in a Federal health care
program.
The term ``should know'' means that a provider: (1)
Acted in deliberate ignorance of the truth or falsity of
the information; or (2) acted in reckless disregard of the
truth or falsity of the information. The Federal Government does not have to show that a provider specifically
intended to defraud a Federal health care program in or-
Page 2
der to prove a provider violated the statute.
Penalty for Unlawful Conduct
Violation of the CMPL may result in a penalty of up
to $10,000 per item or service and up to three times the
amount unlawfully claimed. In addition, the provider
may be excluded from participation in Federal health
care programs. The regulations defining the aggravating
and mitigating circumstances that must be reviewed by
the OIG in making an exclusion determination are set
forth in 42 CFR Part 1003.
Examples
1. Dr. X paid Medicare and Medicaid beneficiaries
$20 each time they visited him to receive services and
have tests performed that were not preventive care services and tests.
2. Dr. X hired Physician Assistant P to provide services to Medicare and Medicaid beneficiaries without
conducting a background check on P. Had Dr. X performed a background check by reviewing the HHS-OIG
List of Excluded Individuals/Entities, Dr. X. would have
discovered that he should not hire P because P is excluded for a period of 5 years from participation in Federal health care programs.
3. Dr. X and his oximetry company billed Medicare
for pulse oximetry that they knew they did not perform
and services that had been intentionally up-coded.
The Civil Monetary Penalties Law is a
comprehensive statute that covers an
array of fraudulent and abusive activities
and is very similar to the
False Claims Act.
November 2003
THIRD PARTY NEWSLETTER
AMERICAN OPTOMETRIC ASSOCIATION’S SUGGESTED VOLUNTARY GUIDELINES
OPTOMETRIC POSTOPERATIVE CARE
This paper is provided for informational purposes.
It suggests voluntary guidelines, which are not enforceable by AOA, for consideration by an individual
practitioner in determining what co-management
relationships are in his or her patients’ best interests
and are appropriate. Practitioners should exercise
their professional judgment in applying these guidelines to the particular circumstances of their practice
and to the specific needs of individual patients. This
paper is not intended to, and does not, provide legal
advice or a legal opinion with respect to Federal or
state laws regulating co-management, or any specific
co-management circumstances. Practitioners should
consult with their own attorneys regarding any questions with respect to such legal matters.
The American Optometric Association believes that referrals for specialty services should be based on
achieving the best possible outcome
for the patient and not on financial
relationships between providers.
OPTOMETRIC
POSTOPERATIVE CARE
Approved AOA Board of Trustees, April 27, 2000
This paper discusses the proper role and responsibilities of providers in co-managing patients, consistent with federal regulations and ethical standards.
For purposes of the paper, co-management is defined
as two or more independently licensed health care
professionals sharing responsibility for the diagnosis, treatment and management of a patient’s medical
or surgical condition.
Background
Doctors of optometry have been successfully comanaging patients with ophthalmic surgeons for
many years. The federal government has long
recognized the role of optometrists in providing this
care. In 1980, Congress amended the Medicare
statute to allow payment to doctors of optometry for
cataract post-operative care. The report from the
then Department of Health, Education and Welfare
(HEW) upon which this legislation was based
concluded, “The services appear to be effective in
patient management, including the management of
aphakic and cataract patients. They are reasonable,
non-experimental, safe and generally acceptable to
the vision/eye care community and the public.”
VO L U ME 3
I S SU E 1 1
Recently, the American Academy of Ophthalmology
(AAO) and the American Society of Cataract and
Refractive Surgery (ASCRS) have issued a joint position paper on this issue. The paper purports to offer
guidelines on when co-management is ethical and
proper and concludes that such situations should be
an exceptional occurrence. This conclusion is not
grounded in law, regulation, or the American Academy of Ophthalmology’s own Code of Ethics. At
the same time, government regulation of referral relationships does require providers to carefully assess
such relationships to assure both compliance with
federal requirements as well as good patient care.
This paper seeks to offer guidance in this area.
Suggested Guidelines
Co-managed care should always adhere to the basic
tenets of good patient care, the ethical responsibilities of providers, and governmental rules. The following suggested guidelines are offered to help providers meet these objectives.
♦
The selection of an operating surgeon for patient
referral should be based on providing the best
potential outcomes for that patient. Financial relationships between providers should not be a
factor.
November 2003
(Continued on page 4)
Page 3
OPTOMETRIC POSTOPERATIVE CARE...CONTINUED
ciary’s record”. This may be accomplished by including the appropriate information in the referral letter from the
ophthalmic surgeon to the optometrist at
the time of transfer of care.
All health care professionals have an
ethical obligation to patients for
whom they are responsible to insure
that medical and surgical conditions
•
The operating surgeon and the comanaging optometrist should communicate during the post-operative period to
assure the best possible outcome for the
patient.
•
Compensation for care should be commensurate with the services provided. Cases
involving care for Medicare beneficiaries
should reflect proper use of modifiers and
other Medicare billing instructions.
are appropriately evaluated and
treated.
(Continued from page 3)
•
The patient’s right to choose the method of
postoperative care should be recognized
consistent with the best medical interest
of the patient.
•
Co-management of post-operative care
should be determined on a case-by-case
basis and not prearranged. For example,
agreements to refer all patients back on a
date certain should be avoided. The patient should be advised prior to surgery of
potential postoperative management options.
•
The transfer of post-operative care must be
clinically appropriate and depend on the
particular facts and circumstances of the
surgical event.
•
Following surgery, transfer of care from
the operating surgeon to an optometrist
should occur when clinically appropriate
at a mutually agreed upon time or circumstance; and such time should be
clearly documented via correspondence
and be included in the patient’s medical
record. For example, Section 4822 of the
Medicare Carriers’ Manual states that
“Both the surgeon and the physician providing the postoperative care must keep a
written transfer agreement in the benefi-
Page 4
Conclusion
The American Optometric Association believes that
referrals for specialty services should be based on
achieving the best possible outcome for the patient
and not on financial relationships between providers.
All health care professionals have an ethical
obligation to patients for whom they are responsible
to insure that medical and surgical conditions are
appropriately evaluated and treated. Decisions to
co-manage should be made on an individual basis
and should always include proper and complete
documentation and communication between
providers. Co-management should occur only when
these basic principles are followed.
Decisions to co-manage should be
made on an individual basis and
should always include proper and
complete documentation and com-
November 2003
munication between providers.
THIRD PARTY NEWSLETTER
Dr. Quentin Quack’s Queries and Questionable Quotes
~~~~~~~~~~~~~~~~~~~~~~~~~~
Third Party Questions from NOA Doctors and Staff
Dr. Quentin Quack
~~~~~~~~~~~~~~~~~~~~~~~~~~
Modifier 24: E&M Services Unrelated to Post-Op Care
Dear Dr. Quack,
When, exactly, can I use modifier 24
during a cataract post-op period? We
have had payment denials I feel are unjustified.
Dr Quack’s Quote:
Yours is the third question I have had
on modifier 24 in the last two months.
And apparently other professions have
had similar frustrations since Medicare
recently printed an article on the use of
modifier 24. Excerpts follow.
Modifier 24 = Unrelated evaluation and
management service by same physician
during a postoperative period. The physician may need to indicate that an evaluation and management service was performed during the postoperative period for a
reason unrelated to the original procedure.
This circumstance may be reported by adding the modifier "24" to the appropriate level
of evaluation and management service.
Services Included in the Approved
Amount for the Procedure--Payment for
the following services related to the surgery
when furnished by the physician who performs the surgery are included in the approved amount for the procedure. These
services should not be billed with the 24
modifier.
• Complications Following Surgery--All
additional medical or surgical services
required of the surgeon during the postoperative period of the surgery because
of complications, which do not require
additional trips to the operating room.
• Postoperative Visits--Follow-up visits
during the postoperative period of the
surgery that are related to recovery from
the surgery.
• Post-surgical Pain Management--By the
surgeon.
• Miscellaneous Services--Items such as
dressing changes; local incisional
care; ... removal of ... sutures …
Services Not Included in the Approved
Amount for the Procedure.--These services may be paid for separately. These
services should be billed with the 24 modifier.
• Visits unrelated to the diagnosis for
which the surgical procedure is performed, unless the visits occur due to
complications of the surgery.
• Treatment for the underlying condition
or an added course of treatment, which
is not part of normal recovery from surgery;
• Critical care services (codes 99291 and
99292) unrelated to the surgery where a
seriously injured or burned patient is
critically ill and requires constant attendance of the physician.
Services submitted with the "24" modifier must be sufficiently documented to
establish that the visit was unrelated to
the surgery. An ICD-9-CM code that
clearly indicates that the reason for the
encounter was unrelated to the surgery is
acceptable documentation and will be used
to support payment. The medical record
should support the ICD-9-CM code selected.
HTTP ://WWW . NEBRASKAMEDICARE. COM / PART _ B / MED _REVIEW /
ARTICLES/110303MODIFIER24.HTM
Finding Another Doctor’s UPIN Number
Dear Dr. Quack: Occasionally
I need a doctor’s UPIN number
for a claim, and at times it is
bothersome to contact that doctor’s office. Is there any Internet
source for UPIN numbers that is
easily accessible?
Dr. Quack’s Quote: Yes. Just recently Dr. Quack found, by way
VO L U ME 3
I S SU E 1 1
of Cigna Medicare’s web site
under “helpful links”, a site that
provides UPIN numbers at no
charge. The web address is
HTTP://UPIN.ECARE.COM/.
With a
minimum amount of information
Dr. Quack could find the UPIN
numbers of every doctor I queried.
Hope this helps!
November 2003
UP
IN
#
Page 5
NEBRASKA OPTOMETRIC ASSOCIATION
201 N. 8TH Street, Suite 400
P.O. Box 81706
Lincoln, NE 68501
ABSTRACTS OF THIS MONTH’S ISSUE
society meetings was corrected.
NATIONAL CORRECT CODING INITIATIVE
On September 23, 2003 the Centers for Medicare & Medicaid
Services (CMS) posted the National Correct Coding Initiative
edits on its web page. NCCI was prepared to promote national
correct coding methodologies and to eliminate improper coding. The AOA recently mailed the 100 page section applicable
to optometry to Dr. Quack.
The edits are arranged by two sets of tables. Each table is arranged in two columns. Column 2 codes in both tables are not
payable with the column 1 codes unless the edit permits the
use of a modifier associated with CCI.
OPTOMETRIC POSTOPERATIVE CARE
Approved AOA Board of Trustees, April 27, 2000
This AOA suggested voluntary guideline discusses the proper
role and responsibilities of providers in co-managing patients,
consistent with federal regulations and ethical standards. For
purposes of the paper, co-management is defined as two or
more independently licensed health care professionals sharing
responsibility for the diagnosis, treatment and management of a
patient’s medical or surgical condition.
MODIFIER 24
COMPLIANCE: CIVIL MONETARY PENALTIES
The Civil Monetary Penalties Law (CMPL) is a comprehensive statute that covers an array of fraudulent and abusive activities and is very similar to the False Claims Act. For instance, the CMPL prohibits a health care provider from presenting, or causing to be presented, claims for services that the
provider ``knows or should know” were: Not coded correctly,
Not reasonable or necessary; Furnished by a person who is not
licensed or has misrepresented their license…
INSERT: 3RD PARTY WEB PAGE REFERENCE
A page is inserted on the correct method of accessing and
using the NOA 3rd party web page. A recent handout used at
Unrelated evaluation and management service by same
physician during a postoperative period. The physician may
need to indicate that an evaluation and management service
was performed during the postoperative period for a reason
unrelated to the original procedure. This circumstance may be
reported by adding the modifier "24" to the appropriate level of
evaluation and management service. Payment for services related to the surgery when furnished by the physician who performs the surgery are included in the approved amount for the
procedure. Other services are not included in the approved
amount for the procedure.--These services may be paid for
separately. Examples of each are given.
Dr. Quentin Quack’s Queries...continued
O
and we are small and insignificant.
Meteorologically, it seems we will
have a beautiful day tomorrow.
What it tell you, Kemo Sabe?"
The Lone Ranger is silent for a
moment, then speaks.
"Tonto, you idiot, someone has
stolen our tent."
ccasionally Dr. Quack’s fax
machine or email contains a question or story that is interesting, but
may not pertain directly to third
party care. Dr. Quack feels that he
should share some of these humorous thoughts.
The Lone Ranger and Tonto
camped in a clearing of the forest,
set up their tent, and are asleep.
Some hours later, The Lone Ranger
wakes his faithful friend.
"Tonto, look up at the sky and
tell me what you see."
Tonto replies, "Me see millions
of stars."
VO L U ME 3
I S SU E 1 1
"What does that tell you?" ask
The Lone Ranger.
Tonto ponders for a minute.
"Astronomically speaking, it tells
me that there are millions of
galaxies and potentially billions of
planets. Astrologically, it tells me
that Saturn is in Leo. Time wise, it
appears to be approximately a
quarter past three. Theologically,
it's evident the Lord is all powerful
November 2003
The NOA Third Party Newsletter is published monthly by the
Nebraska Optometric Association with the assistance of
Ed Schneider, O.D., Third Party Consultant.
To reach Ed (aka Dr. Quack):
Fax & Voicemail: 402-466-7470
Email Address: [email protected]
To reach the NOA:
Nebraska Optometric Association
201 North Eighth Street, Suite 400
P.O. Box 81706 (68501)
Lincoln, Nebraska 68508
Phone: 402-474-7716 Fax: 402-476-6547
Page 6