Download Financing Health Care

Medicare Update
March 11, 2008
Debra L. Patterson, M.D.
J4 MAC Medical Director
TrailBlazer Health Enterprises, LLC
TrailBlazer Part B Paid Claims Error Rates
16%
TX
14%
MD/DC/DE/VA
Gross Error Rate
12%
National
10%
8%
6%
4%
2%
0%
November 2004
Report
(Claims 1/1/0312/31/03)
January Update
November 2004
Report
(Claims 1/1/0312/31/03)
April Update
November 2004
Report
(Claims 1/1/0312/31/03)
July Update
November 2005 May 2006 Report November 2006 May 2007 Report November 2007
November 2004
Report
(Claims
Report
(Claims
Report
Report
(Claims 1/1/20410/1/2004(Claims 4/1/2005
10/1/2005 (Claims 4/1/2006
(Claims 1/1/0312/31/2004)
9/30/2005)
- 3/31/2006)
9/30/2006)
- 3/31/2007)
12/31/03)
November 2007 CERT Report - Part B
Carrier Combined Error Rate by Type of Error
Claims Submitted 4/1/2006 - 3/31/2007
20.8%
2.1%
2.1%
22.9%
Incorrect Coding
Insufficient Documentation
No Documentation
Medically Unnecessary Services
Other
52.1%
Paid Claims Error Rate
4.8%
November 2007 CERT Report - Part B
TrailBlazer TX Top 10 BETOS on Projected Improper Payments
Claims Submitted 4/1/2006 - 3/31/2007
16.7%
6.0%
$40,000,000
8.2%
$35,000,000
Projected Improper Payments
$30,000,000
$25,000,000
$20,000,000
13.1%
$15,000,000
10.8%
10.0%
$10,000,000
$5,000,000
$0
Consultations
Office visits - established
Hospital visit subsequent
Office visits - new
Emergency room visit
Nursing home visit
Evaluation and Management Services
Correct coding based on two distinct but
related sets of criteria
• Medical reasonable and necessity criteria set
the following
– Appropriate frequency
– Upper and lower limits of appropriate
intensity of service
• Key component “work” defined by the correct
medically reasonable and necessary must be
demonstrated
Medical Necessity Defined
Medical Necessity
• Statute
• National Coverage Decisions
• Local Coverage Determinations
• Clinical judgment considering the “rules”
– Safe and effective
– Meet but not exceed patient’s need
– Accepted standard of medical practice
• Medical literature
• Practice guidelines
• Respected textbooks
• Authoritative opinion
Medical Necessity – Beyond E/M
• Medical literature
Medical Necessity – Beyond E/M
• Medical literature
Medical Necessity – Beyond E/M
• Medical literature
Medical Necessity – Beyond E/M
• Medical literature
Medical Necessity – Beyond E/M
• Medical literature
Medical Necessity – E/M
The nature of presenting problem(s)
•
•
•
•
•
•
Severity
Acuity
Number
Diagnostic complexity
Therapeutic complexity
Counseling and coordination
Medical Necessity – E/M
Medical Decision Making
•
# of diagnoses and/or management
options
•
Amount and complexity of medical records,
diagnostic
tests, and/or other
information
•Diagnostic
complexity
•
Risk of significant complications, morbidity,
and or mortality due to
– Nature of Presenting problems
– Diagnostic tests performed or ordered
– Therapeutic options chosen
Medical Necessity
Frequency
• Acute problems – generally frequency
not an issue
• Sub-acute problems (with or without
physician intervention)
–Incomplete resolution
–Potential for worsening, recurrence or
negative consequences
–Acute problem resolved but outcome
was still questionable when last seen
Medical Necessity
Frequency
• Chronic conditions
–For stable, well controlled, or inactive
conditions
• Consider likelihood for problem to
deteriorate or become uncontrolled
based on the nature of the problem and
documented patient behavior/past
history
• Use published guidelines regarding
accepted standards of care for specific
problems (when available)
–Treat poorly controlled,
decompensated, or exacerbated
problems as acute
Medical Necessity
Intensity of service
•
•
Nature of the presenting problem
Severity
– CPT Medical Necessity Guidance
– Contributory factor statements known as
“Nature of Presenting Problems” (NPP)
contained in most CPT E/M codes.
Medical Necessity in Evaluation and
Management Services
• 99201
“Usually the presenting problems are self-limited or minor.”
• 99202
“Usually the presenting problems are of low to moderate
severity.”
• 99203
“Usually the presenting problems are of moderate severity.”
• 99204
“Usually the presenting problems are of moderate to high
severity.”
• 99205
“Usually the presenting problems are of moderate to high
severity.”
Medical Necessity in Evaluation and
Management Services
• 99231
“Usually the patient is stable, recovering, or
improving.”
• 99232
“Usually the patient is responding inadequately
to therapy or has developed a minor
complication.”
• 99233
“Usually, the patient is unstable or has
developed a significant complication or a
significant new problem.”
Medical Necessity in Evaluation and
Management Services
“self-limited or minor”
“low severity”
A problem that runs a
definite and prescribed
course, is transient in
nature, and is not likely to
permanently alter health
status or has a good
prognosis with
management/compliance
A problem where the
risk of morbidity
without treatment is
low; there is little to no
risk of mortality without
treatment; full recovery
without functional
impairment is expected
.
Medical Necessity in Evaluation and
Management Services
“moderate severity”
A problem where the
risk of morbidity without
treatment is moderate;
risk of mortality without
treatment; uncertain
prognosis OR
increased probability of
prolonged functional
impairment
.
“high severity”
A problem where the
risk of morbidity
without treatment is
extreme; there is
moderate to high risk
of mortality without
treatment OR high
probability of severe,
prolonged functional
impairment
Medical Necessity in Evaluation and
Management Services
CPT Appendix C – Clinical Examples
•
99231
Subsequent hospital visit for 50-year old male with an
uncomplicated myocardial infarction who is clinically stable and
without chest pain.
•
99232
Subsequent hospital visit for an 54-year old female admitted for
myocardial infarction , but who is now having frequent premature
ventricular contractions.
•
.
99233
Subsequent hospital visit for a 65-year old male, following an
acute myocardial infarction, who complains of shortness of breath and
new chest pain.
Medical Necessity
Other characteristics of the encounter
•
•
•
•
Number of problems
Diagnostic complexity
Therapeutic complexity
Counseling and coordination
Medical Necessity
Other characteristics of the encounter
•Appropriate for the problem/complaint
•Supports conclusions
•Supports evaluations and treatments
chosen
•Well documented
Medical Necessity
Medically reasonable Medical Decision Making
regarding one or more problems out of proportion
to severity of illness
• Large number of lower severity problems
or clearly defined co-morbidities
evaluated/managed during one encounter
• Extensive medically necessary data
review
• Extensive medically necessary diagnostic
and/or therapeutic interventions
Medical Necessity
Medically reasonable Medical Decision Making
regarding one or more problems out of proportion
to severity of illness
• Extensive medically necessary data
review
• Extensive medically necessary diagnostic
and/or therapeutic interventions
Medical Decision Making
MDM in CPT and CMS E/M Documentation
Guidelines
• Number of diagnoses or management options
• Amount and/or complexity of data to be
reviewed
• Risk of significant complications, morbidity,
and/or mortality
– Presenting problem
– Diagnostic procedures ordered
– Management options selected
Common E/M Coding Errors
Typical MDM Errors
•No documentation of medical decision
making at all
•MDM limited to a list of old and current
diagnoses
•No indication that diagnoses/problems
listed led to increased physician work
•No key component information to support
diagnostic conclusions and/or
diagnostic/therapeutic plans
Medical Decision Making
“Broad Brush” MDM
• Typical E/M CPT code includes descriptions of
multiple levels of key component work
• For History and Physical, CMS Guidelines
further describe and quantify CPT key
component levels and descriptors
• CMS Guidelines do not quantify MDM
descriptors except in the area of “Risk”
Common E/M Coding Errors
CPT and EM Guideline MDM Definitions
• High complexity MDM
–Extensive diagnoses evaluated or problems
managed
–Extensive amount and complexity
diagnostic evaluation ordered or reviewed
–High risk problem(s), diagnostic
intervention(s), or treatment option(s)
Medical Decision Making
MDM in CPT and CMS E/M Documentation
Guidelines
99222
HX = Comprehensive
HPI
EX =•Extensive
Comprehensive
•Complete
ROS
MDM
= Moderate
•Complete PFSH
Medical Decision Making
MDM in CPT and CMS E/M Documentation
Guidelines
CPT
E/M Guidelines
99222
Moderate MDM
• Extensive numbers of diagnoses and/or
MDM = Moderate
management options (extensive not
defined)
•Extensive data reviewed (extensive not
defined)
•High risk of complications (table of risk
provided)
Medical Decision Making
No National Standard Method
• Many physicians and other providers use no
logical mechanism for coding MDM
• Some use commercially and otherwise
available score-sheets
–Use without reasonability testing
–Undefined terms included
–Inherent shortcomings
MDM Rationale – Marshfield Clinic
Medical Decision Making
1. Uncomplicated rib fracture with
chest x-ray and no treatment
4 points
2. Uncomplicated rib fracture with no
imaging but treated with analgesic
3 points
3. Chronically uncontrolled diabetic with comorbid conditions started on insulin
therapy
1 point
MDM Auditing - TrailBlazer
MDM Auditing - TrailBlazer
MDM Auditing - TrailBlazer
MDM Rationale – TrailBlazer
http://www.trailblazerhealth.com/partb/tx/evalmgmt.asp?
Medical Decision Making
What’s a doc to do?
Keep in mind what E/M coding is all
about
• Medical Necessity
•
Physician Work
–Number and nature of problems
–Diagnostic complexity
–Therapeutic complexity
Medical Decision Making
Diagnostic complexity
• Differential diagnoses
• Constellations of symptoms and signs
• Appropriate H and P to support
diagnostic conclusions
• Appropriately complex diagnostic
evaluation ordered, scheduled, or
performed
Medical Decision Making
Therapeutic complexity
–Therapeutic modalities
 Medications
 Surgical procedures
 Radiological interventions
 Many, many others
–Patient instruction
–Referrals to other practitioners for treatment
–Hospital admission
Medical Decision Making
• Pick a method for coding MDM and apply it
– Be consistent
– Define quantitatively as many terms as
possible
• Validate that it does not lead to irrational
coding considering physician work and medical
necessity
• If a method results in codes that it look too
good to be true….they probably are
Consultations
• All consultations require the following
–Request for opinion or advice from
another physician (for that physician to
use in his or her care of the patient)
– A written report of the consultant’s
findings, opinions, and
recommendations to the requesting
physician
• Documentation must demonstrate both the
request and the report
Consultations
• Opinion requested is specific to the patient’s
condition
• Referring physician will use the consultant’s
report to manage the patient (ie, has not
transferred sole care for the problem to the
consultant)
• Service performed by an appropriate
practitioner adequately trained to provide the
opinion requested
• Adds to the quality or scope of medical care
reasonably available from the requesting
physician
Consultations
• Pre-operative clearance must be medically
reasonable and necessary considering the
patient’s health history and the nature of the
proposed operation
• Pre-operative visits whose sole purpose is
performing or recording the mandatory admission
H/P for a surgical admission are not separately
payable and are not consultations
• Continuation of care by the consultant for an
established clinical problem of an established
patient in a different clinical setting but with no
significant change in health status (ie, postoperative concurrent care) is not a consultation
Consultations
• May not be reported as a split/shared service
with a non-physician practitioner in the same
group
Consultations
• Orthopedist seeing patient with elbow pain at
request of family practitioner
• Internist seeing patient for hypertension at
request of orthopedist
• Cardiologist seeing patient for chest pain at
request of neurosurgeon
• Dermatologist seeing patient with melanoma at
request of internist
Medicare Contracting Reform
Why?
Section 911 of the Medicare prescription
Drug, Improvement, and Modernization Act of
2003 (MMA)
• Replaces current contracting authority with
the new Medicare Administrative Contracting
(MAC) authority.
• Requires CMS to compete and transition all
work to MACs by October 2011
Medicare Contracting Reform
• Carriers
• Fiscal Intermediaries
• Durable Medical Equipment Contractors
Medicare Contracting Reform
“Functional” Contractors
• Process Claims
MAC
• Fraud and Abuse
PSC
• Fair Hearings
QIC
• Post payment review
RAC
• Beneficiary Call Center
1-800Medicare
Medicare Contracting Reform
Medicare Contracting Reform
14
2
3
13
6
12
8
1
5
15
11
4
10
7
3 = Start-up
2
9
1
N = Cycle One
N = Cycle Two
Medicare Contracting Reform
Local Policy
• A Contractor Medical Director required for each MAC
(not each state)
• LCD Consolidation during Implementation
• Following full MAC implementation, Local Policy
development returns to “normal” (Program Integrity
Manual instructions)
– Contractor Advisory Process (i.e. CAC)
– Comment and Notice
– LCD Reconsideration processes
Medicare Contracting Reform
“Least Restrictive” LCD
• Other than “least restrictive” permitted when significant
program vulnerability exists (CMS approval required)
• “No policy” not necessarily “least restrictive” (CMS
approval required)
Medicare Contracting Reform
J4 MAC Policy Consolidation
• 800+ legacy contractor policies
• 138 “consolidated policies”
– 50% are Trailblazer LCDs with or without limited
changes
– Remaining 50% are Noridian and Pinnacle policies
(mostly Noridian) with or without limited changes
– Some LCDs underwent major revision and now
consist of provisions from 2 or more legacy policies
Medicare Contracting Reform
J4 LCD Consolidation Lessons-Learned
• “Less restrictive” is often very subjective
• Huge volume of work with very short turn-around time
(ie, potential to not fully appreciate all “less restrictive”
provisions)
• Implementation approach not evident in the text of the
policy
• Not everything that affects claim payment is R&N
– Variations in interpretation of national policy
– Coding requirements
Medicare Contracting Reform
LCD “Gotchas”
• Drugs and Biologicals
• Non-covered Services
• Routine Foot Care
• Ambulance (ground) Services
• Wound Care
• Bariatric Surgery
TrailBlazer Website
TrailBlazer Website
Questions?