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EisnerAmper Blog

An EisnerAmper Health Care Services Blog

CMS Introduces Modifiers to Combat Abuse

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October 22, 2014
 

By Nancy Clark, CPC, CPC-H, CPB, CPMA, CPC-I


Clark_NancyThe Office of Inspector General (OIG) has identified continued abuse of modifier 59, Distinct Procedural Service.  This modifier indicates when physicians’ services that are usually considered integral to each other may be reported separately for additional payment.  Frequently, this modifier is applied to services that should not be billed separately and the provider inappropriately receives reimbursement.  Transmittal 1422 states that the 2013 Comprehensive Error Rate Testing (CERT) data projected a $320 million error rate in physician claims and $450 million in facility claims appended with modifier 59. The Centers for Medicare and Medicaid Services (CMS) indicate that four new modifiers will be implemented in January 2015 in an attempt to better identify inappropriate claims. 

These new Healthcare Common Procedure Coding System (HCPCS) modifiers, referred to collectively as -X{EPSU} modifiers, are considered subsets of modifier 59:

  • XE indicates a Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter  
  • XP indicates a Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner    
  • XS indicates a Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure  
  • XU indicates an Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

CMS believes that by identifying specific reasons for utilizing modifier 59, it will be easier to filter claims that may be billed inappropriately.  Provider education is crucial for submitters to understand when a service can be appropriately “unbundled.”  Nonetheless, we can expect frequent audits of claims with both modifier 59 and the new subset modifiers.  Ensure that documentation substantiates distinct services whenever claims are submitted, or expect to forfeit payment and undergo potentially time-consuming audits.

Physician Open Payments Are Online at the CMS Website

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October 7, 2014

 

By Michael J. McLafferty, CPA, MBA, FACHE, FHFMA, FACMPE

McLafferty_MikeThe first batch of Open Payments data connecting your physicians to financial arrangements with certain businesses was published online September 30. Your physicians’ financial data may not be on the CMS website now even if it was collected, but that doesn’t mean it won’t be there eventually.

The data collection mandated by the federal Sunshine Act and performed from Aug. 1 to Dec. 31, 2013, is broken into three categories:

  • General payment details including all payments or other transfers of value from applicable group purchasing organizations (GPOs) or manufacturers to physicians and teaching hospitals that have nothing to do with research agreements or protocols;
  • Research payment details for those payments or transfers of value that do involve research agreements or protocols; and
  • Physician ownership information about physicians who have an ownership or investment interest in a manufacturer or GPO.

Your data could be there but ‘de-identified’

The data your doctors’ financial partners submitted may not be identifiable, or tied to your providers, in this edition of Open Payments.

About 4.4 million records have been collected, but CMS estimates that 40% of them — which would come to 1.76 million records — have been stripped of identifying details, or “de-identified,” while 199,000 other records are not published at all.

All the records were checked against the National Plan & Provider Enumeration System (NPPES); the Medicare Provider Enrollment, Chain and Ownership System (PECOS); and a private database to confirm the connection between the physicians and teaching hospitals and the payment information, CMS explained on a press call September 30. Records that were fully confirmed against physician names, national provider identifiers (NPIs) and licenses are published and the physicians are identified; those that were not confirmed have been published without identifying the physician.

Also de-identified are records for which providers entered a dispute in the review period but did not have 45 days to pursue it as the law allows


Of the unpublished records, 190,000 are not available because the GPOs or manufacturers requested that the information be held for reasons relating to ongoing research, as the law allows, while 9,000 are unpublished because a dispute lodged by a provider is ongoing.

CMS says the agency expects the de-identified 2013 data will be updated during the next reporting cycle in 2015 so that the physicians are identified.

Beware of Big Files

The Open Payments website has a download library and a “data visualization” tool to help you navigate the data — including a search feature for looking for individual doctors or teaching hospitals.

The online files are big. The largest identified data for general payments is 1.4 gigabytes, and CMS warns that you may have trouble importing these large files into regular spreadsheet programs such as Excel.

If you have an IT team, you can use a database server such as MySQL to put the big file into a database and then develop a simple user interface for you to view and work with the files, suggests Sean Vogt, director of operations at Greenview Data in Ann Arbor, Mich. Alternately, you can use a commercial file editor such as Vedit which Greenview developed, to split the files into parts that can fit into Excel, he says.

Resource:

Meaningful Use Deadline

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By Steven Bisciello, MBA, CMPE

Bisciello_StevenWith the October 1, 2014 deadline for eligible professionals to attest to the meaningful use EHR Incentive Program rapidly approaching, attention has been turned to the CMS attestation website. 

Recently, the reporting options were expanded by CMS, allowing eligible professionals to utilize either the 2011 or 2014 Certified EHR Technology (CEHRT), or a combination of the two, to be able to secure the 2014 payment and avoid the Medicare payment adjustment which will go into effect in 2015.

However, there is an issue with the current website used to report. It does not allow new eligible professionals to attest using these new options until after the October 1 date has passed (the site actually won’t allow reporting until mid-October).  Reporting in mid-October results in the eligible providers being unfairly subjected to the 2015 payment adjustment.  Eligible Providers have begun to lobby CMS to oppose the utilization of this website. 

Professional organizations such as the Medical Group Management Association have joined the protest, and recently sent a letter to CMS on behalf of the eligible providers and its members.  The letter requested that CMS Immediately modify their attestation website, extend the attestation deadline for new eligible providers and communicate these changes to the provider community immediately.

We will pay close attention to CMS’s response and any changes to the reporting period and its subsequent website.

As a reminder, if you are a Medicare provider in your second year of Stage 1 Meaningful Use in 2014, you must select a three-month reporting period in a respective quarter.  The only start date left would be October 1.
If you are starting Stage 2 in 2014, again the only start date left is October1 and there are additional core measures that were not required in Stage 1. For more information on the Stage 2 requirements, check out the CMS guide to Stage 2 criteria changes .

For more specifics overall on Meaningful Use and the quality measure, please click here

Auditors to Review Physician Fees ‘Related’ to Denied Hospital Claims

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September 16, 2014

By Michael McLafferty, CPA, MBA, FACHE, FHFMA, FACMPE

McLafferty_MikeAccording to AIS’s Medicare Compliance newsletter, if hospitals suddenly find that more physicians embrace compliance and documentation improvement, it’s probably because Medicare auditors are now authorized to rebuff professional fees “related” to hospital payment denials, according to the Center for Medicare and Medicaid Services (CMS). As of Sept. 8, auditors may deny physicians’ claims based on hospital records, upping the ante for the quality of documentation outside their offices.

Medicare Transmittal 534 issued by CMS on Aug. 8, gives Medicare administrative contractors (MACs), recovery audit contractors (RACs) and zone program integrity contractors (ZPICs) the authority to review physician payments “related” to hospital and other claims that are rejected because they are not considered medically necessary for various reasons.

Transmittal 534 says MACs and ZPICs will soon have the discretion to deny physician claims before or after related hospital versions are submitted. “If documentation associated with one claim can be used to validate another claim, those claims may be considered related,” according to the transmittal, which provides two examples of claims that can be denied as related:

  • Inpatient vs. outpatient: The MAC reviews Part B payments from admitting physicians and/or surgeons if the inpatient admission is denied as not reasonable and appropriate for Part A payment because the services could have been provided in an outpatient or observation bed. If the MAC decides the physician service was “reasonable and necessary,” it will be recoded “to the appropriate outpatient evaluation and management service.”
  • Medical necessity of the procedure: The MAC recoups Part B payments from admitting physicians and/or surgeons post-payment when the patient’s history and physical, physician progress notes or other hospital documentation doesn’t back up the medical necessity of the procedure.

CMS has recently replaced Medicare Transmittal 534 with Transmittal 540 to adhere to CMS’s inpatient recording policy standards.

IRS releases draft of employer reporting form for health reform law compliance

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August 26, 2014

By:  Michael McLafferty CPA, MBA, FACHE, FHFMA, FACMPE

McLafferty_MikeBased on an article in BusinessInsurance.com,  the Internal Revenue Service has issued draft versions of the reporting forms most employers will begin using next year to show that their group health insurance plans comply with the health care reform law.

The long-awaited draft forms, posted late Thursday afternoon to the IRS' website, are the first practical application of employers' health care coverage and enrollment reporting obligations under the Patient Protection and Affordable Care Act since the regulations were finalized in March of this year.

The forms are the primary mechanism through which the government intends to enforce the health care reform law's minimum essential coverage and shared responsibility requirements for employers.
Beginning in 2015, employers with at least 100 full-time employees will be required to certify that benefits-eligible employees and their dependents have been offered minimum essential coverage and that their employees' contributions to their premiums comply with cost-sharing limits established under the reform law. Smaller employers with 50-99 full-time employees are required to begin reporting in 2016.
Additionally, self-insured employers will be required to submit documentation to ensure compliance with minimum essential coverage requirements under the reform law's individual coverage mandate.

“In accordance with the IRS' normal process, these draft forms are being provided to help stakeholders, including employers, tax professionals and software providers, prepare for these new reporting provisions and to invite comments from them,” the IRS said in a statement released Thursday.

The IRS said it expects to publish draft instructions for completing the reporting forms by late August and that both the forms and the instructions would be finalized later this year.

Proposed Changes to the Medicare Physician Fee Schedule for 2015

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July 31, 2014

 

By Nancy Clark, CPC, CPB, CPMA, CPC-I

Clark_NancyEarlier this month, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would update payment policies and rates for services furnished under the Medicare Physician Fee Schedule (MPFS) in calendar year 2015.  Significant proposed changes include additional payments for chronic disease management, greater transparency in setting fee schedule amounts and a major revision to the global periods of procedures.

Currently, Medicare pays physicians for chronic care management services as part of a face-to-face visit.  In 2013, Current Procedural Terminology (CPT) codes were introduced for the complex chronic care coordination of services.  These codes include services provided outside of a face-to-face visit for managing two or more chronic conditions. Medicare will continue to emphasize primary care management by beginning to make separate payment for non-face-to-face chronic care management services for beneficiaries under certain conditions.   Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.

For 2015, CMS is proposing a new process for establishing MPFS payment rates that will be more transparent and allow for greater public input prior to payment rates being selected. Under the new process, payment changes will go through a notice and comment period before being adopted.  These changes will begin for the establishment of the 2016 MPFS.

Recent amendments to the Affordable Care Act have directed CMS to identify potentially “misvalued codes.”  These codes have been identified by reviewing high-expenditure services by specialty that have not recently been reviewed.  Additional measures include a public nomination process through which misvalued codes could be identified by external parties.  Approximately eighty codes will be added to this year’s list.

Directly relating to this initiative, CMS is proposing to transform all 10- and 90-day global codes to 0-day global codes beginning in 2017.  The Office of Inspector General has identified many surgical procedures that include payment for more visits in the global period than are being furnished.  In order to address potential misvaluation of services, it is proposed that visits prior and subsequent to a surgical procedure be billed separately, not inclusive to the surgery.  This initiative could have a profound effect on Medicare reimbursement and billing procedures for surgeons and their staff.

The complete rule can be found here.  

Surgical Checklists Unused in 10% of Hospitals, CMS Data Shows

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July 28, 2014

By Michael J. McLafferty, CPA, MBA, FACHE, FHFMA, FACMPE

McLafferty_MikeHealthLeaders recently published a disturbing article about new data available on the Centers for Medicare & Medicaid Services' (CMS) Hospital Compare website.  Given the evidence of how surgical checklists can reduce deaths and complications, it's a mystery why nearly 10% of hospitals still don't mandate their use and why another 12% can't say for certain whether or not checklists are being used.

One week ago, the CMS Hospital Compare website started publically reporting which of 4,136 hospitals across the country use surgical checklists and which ones don't.

That, one would think, is a pretty big deal, introducing a level of transparency that would please Brigham & Women's Hospital surgeon Atul Gawande to no end. Gawande's work has shown that a Safe Surgery Safety Checklist can reduce by up to one-third deaths and complications resulting from retained objects, infections, unplanned reoperations, and other procedural horrors such as wrong-site or, heaven forbid, wrong-person surgery.

Amazingly, despite so much evidence showing the importance of using such checklists, the website shows that, for the calendar year 2012 when the reports were collected, 366 hospitals said they still don't use them and 497 couldn't say whether they did or not.

Specifically, CMS is now reporting on whether hospitals use a 12-point version of the checklist, one that stops everything at three "critical points" of an operation: before anesthesia, before skin incision, and after surgical site closure but before the patient leaves the operating room.

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