Bradford Scott Medical

The decision to stop recognizing Current Procedural Terminology® (CPT) codes 99241–99245 and 99251–99255 in the Medicare program as of January 1, 2010, took many by surprise. In justifying its decision, CMS cited a 2006 Office of Inspector General report that 75 percent of consultations were billed incorrectly.

Offsetting the elimination of those payments, the codes CMS directs physicians to use instead received modest increases in the work relative value units (wRVUs). The small boost to units associated with these E/M codes, espouses CMS, means the decision to eliminate payment for consults is budget neutral for the Medicare program.

CMS’ exclusion of consultation codes for Medicare patients will certainly affect physician revenue, especially if private payers follow suit. Physicians must also devise new strategies for coding and documentation to continue getting reimbursed for seeing these Medicare patients, or else just decline to see them at all.

Here are answers to common questions physicians are asking about the new Medicare consultation policy:

How do I code consults for Medicare patients? 
Use the appropriate E/M code. For a patient in the hospital, code from the series CPT 99221-99223 for the initial encounter and 99231-99233 for subsequent encounter(s).

Can I ask the patient to sign an Advance Beneficiary Notice (ABN), and collect directly from the patient? 
CMS no longer recognizes the consultation codes as valid, as opposed to non-covered; therefore, you cannot use an ABN and bill the Medicare patient.

If physicians are directed to use the initial hospital visit code, how is an admission identified? 
To report an admission for Medicare, append AI (“a” – “eye”), the principal physician of record, to the initial hospital care code (99221-99223) or initial nursing facility care code (99304-99306). The new modifier is informational only; no additional remuneration is provided.

How will I get paid when a referring physician requests my opinion? 
CMS directs physicians to use the appropriate E/M code and will reimburse the physician even when services are requested within a practice within given parameters: “Medicare may pay for an inpatient hospital visit or an office or other outpatient visit if one physician or qualified NPP in a group practice requests an evaluation and management service from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.” Remember, this policy relates to Medicare, so you can continue using the consultation codes for non-Medicare patients.

Should physicians stop using consult codes altogether? 
It may be the easiest path from a process perspective but most payers, other than Medicare, continue to pay for consults. Because the payment differential is significant – consults pay up to 30 percent more than a visit code at the corresponding level – experts don’t advise dropping them altogether.

How do I handle Medicare as a secondary payer (MSP)? 
This may be the most confusing situation of all because CMS essentially authorizes you to change codes when it is the secondary payer. CMS instructs: “Bill the primary payer using a consultation code that is appropriate for the service, and then report the amount actually paid by the primary payer, along with an E/M code that is appropriate for the service [our emphasis], to Medicare for determination of whether a payment is due.” Develop processes for “crosswalking” codes on MSP claims, catching MSP claims before they are submitted to Medicare, and re-working any denied claims that miss your crosswalk process.

Does this policy change apply to Medicare Advantage plans? 
Medicare Advantage plans aren’t required to embrace the new payment policy, but some have. It’s important to check with the plans with which you participate.

Is it no longer necessary to send reports to referring physicians? 
Although it’s no longer necessary to follow CMS’ documentation rules specifically related to consults, CMS states: “…physicians should continue to follow appropriate medical documentation standards and communicate the results of an evaluation to the requesting physician.” Furthermore, one of the proposed “meaningful use” criteria for the HITECH Act’s electronic health record bonus program is: “Provide summary care record for each transition of care and referral”.

How can I get more information?
Review the MLN Matters 6740: Revisions to Consultation Services Payment Policy.

In jettisoning consultation codes for Medicare, CMS cited audits showing high levels of inappropriate consultation coding, physician confusion about its rules, and its own disagreements with the consultation coding guidance in the AMA’s CPT® Manual. The new day for consultation coding is here. Let’s see how it works.

Written by Elizabeth W. Woodcock, MBA, FACMPE, CPC of Woodcock & Associates.

• Albany Obstetrics and Gynecology experienced 20% fewer missed appointments
• Patient information became increasingly more up to date
• Verifying coverage for patients reduced denied claims by as much as 70%
• The days in accounts receivable has been reduced to less than 30
• Phone nurses quickly accessed/updated information - relieving front desk congestion
• With EHR, paper charts aren't needed, saving over 3 hours per day in chart pulls
• Physicians are able to view patient information from outside the office

"It's invaluable that the physicians can look at patient records when they are on call, especially being able to see lab results,"

• Survey of your site:  The representative should spend time face-to-face with you and your staff before the demo to ensure they have a clear understanding of your business objectives
• Integrity:  Does the glove fit the hand?  A company with Integrity will make sure they have a product that meets your needs instead of just selling you something.
• Customized EMR demo:  The demo should relate to the site survey and the objectives you defined
• Testimonials:  Any good company should be able to provide testimonials directly from their users
• References:  This is a user you can reach out an touch.  These references will help you gain a better understanding of the advantages of the product and vendor.   It's your opportunity to ask questions and receive honest credible feedback.
• Focus beyond the sale: The representative should be a part of the process before, during, and after the sale. 

• Medicaid - When it comes to Medicaid, it is up to each state to determine how they will pay out the ARRA EHR stimulus money.  Sure, some will most likely try to keep it as to close to the Medicare model as possible, but we'd be silly to thing that some states wouldn't go in a completely different direction. 
• Medicare - The earliest that we'll see Medicare ARRA EHR stimulus money is in the spring of 2011.  Remember, you have to prove "meaningful use" of your "certified EHR" for a minimum of 90 days to receive the incentives.

• Providers must have and use a qualified eRx system and report on his or her adoption and use of electronic prescriptions
• Providers must meet the criteria for successful electronic prescriber specified by CMS for a particular reporting period
• At least 10% of a successful eRx provider's Medicare Part B covered services must be made up of codes that appear in the denominator of the eRx measure.

• It makes insurance more affordable by providing the largest middle class tax cut for health care in history, reducing premium costs for tens of millions of families and small business owners who are priced out of coverage today.  This helps over 31 million Americans afford health care who do not get it today – and makes coverage more affordable for many more. 
• It sets up a new competitive health insurance market giving tens of millions of Americans the exact same insurance choices that members of Congress will have.  
• It brings greater accountability to health care by laying out commonsense rules of the road to keep premiums down and prevent insurance industry abuses and denial of care.  
• It will end discrimination against Americans with pre-existing conditions.
• It puts our budget and economy on a more stable path by reducing the deficit by $100 billion over the next ten years – and about $1 trillion over the second decade – by cutting government overspending and reining in waste, fraud and abuse.

In February 2009, Congress passed landmark legislation to encouage the adoption of electronic health records (EHRs).  Later President Obama signed it into law.  Part of the multi-billion dollar package, known as the American Recovery and Reinvestment Act, the Health Information Technology for Economic and Clinical Health allocates $19 billion to encourage the health care industry to adopt information technology using an EHR System.

On the other hand, if providers choose not to participate, they will receive lowered Medicare reimbursement rates.

Medicare Physician EHR Incentives

If you would like more information about the EHR Stimulus package, contact Bradford Scott Data Corporation at www.bradfordscott.com. 

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What is the biggest complaint about going to the doctor's office? The amount of time we spend in the waiting room! Everybody is busy and tries to save time. If my doctor was always late, I would find a new Doctor. But how do you as a doctor know if your patients are waiting for hours in the waiting room?

This is a feature that our Medical Software Systems offer. The system has a tracking system that will track the time the patient spends at your office. The medical software not only displays the whole time the patient is there, but where they spend the most of their time at.

The system starts with your schedule in the Medical Office Billing Software. Then as the patient works their way into a room and is actual seen by a provider that time is tracked by the Electronic Health System. Bradford-Scott's Medical Software systems are integrated allowing an overall report to be created on your patent's time.

This will not only allow you to better server your patients, it will also prove the amount of time you spend with your patent's for Medical Billing coding. If you were ever under an audit you could prove the level of office visit that you are coding at.

This is a great benefit not only for patient satisfaction, but also for you as a doctor being able to code visits at the level you deserve.

1. Use CPOE
2. Implement drug-drug, drug-allergy, drug-formulary checks
3. Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT
4. Generate and transmit permissible prescriptions electronically
5. Maintain an active medication list
6. Maintain an active allergy list
7. Record demographics: preferred language, insurance type, gender, race, ethnicity, and date of birth
8. Record and chart changes in vital signs: height, weight, blood pressure, calculate and display: BMI, and plot and display growth charts for children 2-20 years, including BMI
9. Record smoking status for patients 13 years old or over
10.  Incorporate clinical lab-test results into EHR as structured data
11.   Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities and outreach
12.   Report ambulatory quality measures to CMS or the States
13.   Send reminders to patients per the patient's preference for preventive/follow up care
14.   Implement five clinical decision support rules relevant to specialty or high clinical priority, including diagnostic test ordering, along with the ability to track compliances with those rules
15.   Check insurance eligibility electronically from public and private payers
16.   Submit claims electronically to public and private payers
17.   Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, allergies), upon request
18.   Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies) within 96 hours of the information being available to the EP
19.   Provide clinical summaries for patients for each office visit
20.   Capability to exchange key clinical information (for example, problem list, medication list, allergies, diagnostic test results), among providers of care and patient authorized entities electronically
21.   Perform medication reconciliation at relevant encounters and each transition of care
22.   Provide summary care record for each transition of care and referral
23.   Capability to submit electronic data to immunization registries and actual submission where required and accepted
24.   Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice
25.   Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities

• What kind of training do you offer? Is it classroom training, web-based training, or self training?
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• What is your implementation plan?
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• How can you offer me better service then your competitors?
• What Medical Software support is available to me on the product?
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• What kind of Back up support do you offer is something were to happen to my EMR system?

Meaningful What? Stimulus What? Who's on first?  Can somebody explain this in 500 word or less?

Let me break down Meaningful Use as simply as I can.

• $19 billion have been allocated by the federal government to encourage the health care industry to adopt information technology (more specifically an Electronic Health Records System).
• To be eligible to get some of the $19 billion you must do 3 things

1. Be an eligible professional or hospital
2. Implement a certified EHR product between 2011 and 2014
3. Use it in a Meaningful Way

Okay, are you still with me?  Then let's go one level deeper. Let's make some assumptions:

• You are an eligible professional (doctors of medicine, etc.)
• You have or will have a certified EHR system.  (All vendors in the medical software industry will have to get their software certified (including CCHIT) or go out of business.  We are going to assume your system is or will be certified)

There are two types of incentive programs (The Medicare way or the Medicaid way).  You can pick either but you can't choose both at the same time!
 

• Medicare:  Physicians that treat Medicare patients can receive up to $44,000 payable over 5 years.

• Medicaid:  Physicians that treat Medicaid patients are eligible for up to $63,750 payable over 6 years

Are there strings attached?  Of course.  And the biggest string is called 'Meaningful Use'.  The Government isn't going to just give you some cash for buying or even implementing an EHR system.  You have to prove to them that you can use it in a meaningful way that improves patient health care.  And they plan to accomplish this string by outlining 25 objectives and ways to measure those objectives.  Most of the measurements are percentage based.  (For Example:   At least 50% of all clinical lab tests whose results are in a positive/negative or numerical format need to be recorded in the EHR as structured data.)

For a complete list of these objectives, I recommend that you check out CMS or contact Bradford-Scott.  One important note:  The Meaningful Use definition is still under a proposed state and can be commented on until March.

That's it.  That's the nutshell.  Oh, and there is one more catch.  Starting in 2015, those physicians who choose to not participate will receive a 1% reduction in their Medicare allowed charges.  This reduction will increase by 1% each year up to a maximum of 5%.

So the moral of the story is that if you have plans on implementing an EHR/EMR system don't wait.  If you begin using it in a meaningful way in 2011 you are going to get more incentive payments than implementing in 2014.  And if you don't implement by 2015 you  are going to lose Medicare reimbursements.

Do you need help on what to do next?  Whether you are cardiology, orthopedics, or family practice, contact Bradford-Scott and ask about our Sage Intergy EHR system and how it can help you prove your meaningful use and improve patient care.

(and I kept it under 500 words!)
 

There has been a lot of belly aching about the recent snow storms that have hit the Midwest. Yes, snow storms do get old, but I remember what it was like growing up in the 70's and 80's with blizzards here in Indiana. In the more recent years our winters here in Indiana have been very mild compared with those of my childhood. And although I am in the Federal protected age group, I am not that old. I guess one thing that you can count on in Indiana is that there will be some snow storms each and every winter season.

• A call back within 29 minutes from when you have logged your call
• trained software and hardware support teams
• Our dedication to client satisfaction, every year we send our clients our customer satisfaction surveys and this year you rated us as a 9.52 on a 10 point scale.

• Electronic Eligibility (important in the high deductible world we now live in)
• Pre-collection of copays
• Advanced collection modules
• Clearinghouse integrations
• eStatments, eCollcetion Letters, etc.
• Claim Scrubbing
• Patient Portals via the web
• Image scanning
• and many more...

• Intergy by Sage medical claims software implementation
• Intergy EHR by Sage electronic health records implementation
• CCHIT 2008 certification for Intergy EHR by Sage v5.5
• Customer service survey score of 9.52 out of 10.