Legs/Regs. Basic Medicare rules. Quality. Audits

Transcription

1 SPEAKER DISCLOSURE SHOWCASING VALUE: MAXIMIZE PAYMENT FOR AUDIOLOGY SERVICES Lisa Satterfield, M.S., CCC-A ASHA director of health care regulatory advocacy Lisa Satterfield, M.S., CCC/A is ASHA's director of health care regulatory advocacy. She is ASHA s liaison to the Centers for Medicare and Medicaid (CMS). In that role, she consults with members on reimbursement, coding, and CMS policy practices, and represents the professions at CMS and other related regulatory agencies. Financial: She is ASHA staff Non-financial: She participates in meetings with CMS, MedPAC, and other federal agencies related to health care policies. ISHA, October 2014 TOPICS: Legs/Regs Basic Medicare rules Quality LEGISLATION AND REGULATIONS Audits

2 LEGISLATION VERSUS REGULATION REGULATORY CYCLE MEDICARE PHYSICIAN FEE SCHEDULE Legislation is: Issued by governmental body (Congress) Enacted as law Voted on by representatives Requires vote for amendment, repeal or new law to change Can be specific or broad Regulation is Issued by government departments or agencies (Dept. of Health and Human Services, Centers for Medicare and Medicaid Services) Implementation of the intent of the legislation Issued in rule making, with proposed rules, comment period, and final rules Feb-June Proposed rule development July Proposed rule release September Comments due November Final rules published January Rules implemented for calendar year KEY LEGISLATION MEDICARE PROVIDER PAYMENT MODERNIZATION ACT Repeals Sustainable Growth Rate (SGR) and changes payment for fee-for-service Stabilizes SGR from the ~-25% threatened cut each year to 0.5% annual update from Maintains 2018 rates through 2023, but offers payment adjustments based on new Merit-Based Incentive Payment System (MIPS) Sunsets current penalties end of 2017

3 AUDIOLOGY SERVICES BASIC MEDICARE RULES As defined in the Social Security Act, section 1861(ll)(3), the term audiology services specifically means such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under State law This is for Medicare services only This means Medicare will only reimburse audiologists for diagnostic services PERFORMING AUDIOLOGY SERVICES Qualified audiologist Nurse practitioner or clinical nurse specialist authorized to perform the tests under applicable State laws Physician in an office or hospital outpatient department Support staff under the appropriate level of supervision of a physician PHYSICIAN ORDERS The SSA (Section 1861) requires orders for the purpose of Obtaining information necessary for the physician s diagnostic medical evaluation OR To determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem. No order = No coverage Order must be received/documented before the testing begins A physician, nurse practitioner, clinical nurse specialist, physician assistant must: Write and sign an a document OR Call and clearly document, in the medical record, the intent that the test be performed OR , with the same clear intention Only orders for a technician must specify which test is to be furnished by the technician under the direct supervision of a physician. When the qualified physician or NPP orders diagnostic audiology services furnished by an audiologist without naming specific tests, the audiologist may select the appropriate battery of tests.

4 REASON THE TEST WAS PERFORMED OPT-OUT? Suspected change in hearing, tinnitus, or balance Cause of disorders of hearing, tinnitus, or balance; Effect of medication, surgery, or other treatment; Reevaluation for that place the patient at probable risk for a change in status Failure of a screening test Diagnostic analysis of cochlear or brainstem implant and programming; and Audiology diagnostic tests before and periodically after implantation of auditory prosthetic devices. The type and severity of the current hearing, tinnitus or balance status needed to determine the appropriate medical or surgical treatment is known to the physician before the test; or The test was ordered for the specific purpose of fitting or modifying a hearing aid. If a physician refers a beneficiary to an audiologist for testing related to signs or symptoms associated with hearing loss, balance disorder, tinnitus, ear disease, or ear injury, the audiologist s diagnostic testing services should be covered even if the only outcome is the prescription of a hearing aid. NOPE The opt out law does not define physician or practitioner to include audiologists;; therefore, they may not opt out of Medicare and provide services under private contracts Therefore, if an audiologist charges or attempts to charge a beneficiary any remuneration for a service that is covered by Medicare, then the audiologist must submit a claim to Medicare. INCIDENT TO STUDENTS Audiological diagnostic tests are not covered under the benefit for services incident to a physician s service The NPI of the audiologist must be indicated on the claim as the rendering provider The test must be performed by the audiologist listed as the rendering provider on the claim Other services performed by the audiologist may be billed incident to Other electrophysiologic studies Audiology treatment Doctor of Audiology (AuD) 4th year student with a provisional license from a State does not qualify unless he or she also holds a master s or doctoral degree in audiology In order to bill Medicare the audiologist must: Be present and in the room for the entire session Guiding the student in service delivery Signs all documentation Is responsible for the services

5 PHYSICIAN QUALITY REPORTING SYSTEM (PQRS) PHYSICIAN QUALITY REPORTING SYSTEM Mandated in 2007 as an incentive-driven quality reporting program Affordable Care Act included transition from incentive to penalty for non-participation Proposed legislation sustains current program through 2018, and transitions to mixed bonus/penalty system Rates providers on participation and quality Bonus or penalty dependent on score Non participation penalty is steeper WHY PARTICIPATE? PQRS ELIGIBILITY 2014 participation = -2.0% on all Medicare Part B services provided in 2016 Proposed 2015 participation = -6.0% on all Medicare Part B services provided in 2017 Congress is looking at further expansion Providers Private Practice Group Practice University clinics NOT Hospitals Skilled Nursing Facilities Medical centers ACOs Patients Medicare Part B Outpatient Fee-for-service Measure requirements Age (e.g. 18 and older) Denominator CPT codes ICD codes

6 AUDIOLOGY REFERRAL FOR DIZZINESS (#261) #261 MEASURE CODES Must be reported for 50% of eligible Medicare patients to avoid the penalty Audiologists who do not report qualifying patients will not pass the MAV process Reported one time per calendar year per Medicare patient Patient must qualify with both procedure code and diagnosis code Patient referral occurs when the patient is not under the care of a physician for dizziness Dizzine ss ICD CPT Reportin g Required! #REPORTING #261 DOCUMENTATION OF MEDICATION (#130) CMS considered this a best practice for all providers, regardless of specialty Referred to physician for further evaluation G8856 Patient already seen by physician for dizziness G8857 Referral not made, reason not specified G8858 ASHA Preferred Practice Patterns Audiology: Consider effects of medications, surgery, and other interventions SLP: Relevant case history, including medical status Institute of Medicine (IOM), Agency for Healthcare Research and Quality (AHRQ), and others consider it a patient safety issue

7 #130 Perform on 50% of the Medicare eligible patient visits to avoid penalties Ask the patient to bring a list of current medications: dosage, frequency, route Make a copy or scan it into the patient s chart Provider must document he/she reviewed the list Not a pharmacological assessment For every patient visit, ask the patient if there have been changes to medications and document If the patient reports no medications, document #130 PROCEDURE CODES Audiology Vestibular: Comprehensive audiology: Impedance/Reflex: ABR/OAE: Auditory rehab assessment: Speech-Language Pathology Speech/language treatment: Swallowing treatment: Auditory rehab assessment: Cognitive treatment: REPORTING MEASURE #130 Medications obtained, updated, or reviewed G8427 Medications not obtained, updated, or reviewed, reason unspecified G8428 Patient not eligible due to emergent situation G8430 SCREENING FOR DEPRESSION (#134) Must use standardized tool for screening clinical depression Tool must be normalized and validated for population for which it is used Must document a follow-up plan for positive findings This measure should not be reported by audiologists/slps who are not familiar with or do not regularly use standardized screening tools in their clinical practices State scope of practice should be confirmed for including screen for depression Should be reported one time per calendar year

8 #134 PROCEDURE CODES Audiology and Aural Rehabilitation Comprehensive audiology: Impedance/Reflex: Assessment of tinnitus: REPORTING MEASURE #134 Positive screen for clinical depression and follow-up plan documented G8431 Negative screen for clinical depression, no follow-up plan necessary G8510 No screen for clinical depression documented, reason unspecified Positive screen for clinical depression, no follow-up plan, reason unspecified G8511 Patient not eligible due to emergent situation or mental capacity Auditory rehab assessment: G8432 G8433 AUDIOLOGY QUALITY CONSORTIUM Collaborative group of representatives from 10 audiology organizations working on PQRS: Measure development Currently drafting 5 measures for future use, and consideration of more Inclusion in current PQRS measures Smoking Cessation counseling Blood pressure measurement Pain assessment Investigating registry options BARRIERS TO OVERCOME Diagnostic-only profession Measuring standard of care Cost of code development Identify need, concepts, and candidate measures Develop Technical Specifications Alpha testing for feasibility First submission Testing Reliability and Validity Final endorsement Moving profession towards outcome/quality reporting

9 PQRS IN YOUR PRACTICE STEP BY STEP Step 1: What are you already doing that you can report? Documentation of medications in the medical record Screening for clinical depression with follow-up plan Evaluating patient with dizziness Step 2: Visit ASHA website for all the codes Quality-Measures--A-Step-by-Step-Guide/ STEP 3 : Add the codes to your superbill or create a simple form for submission Don t forget to record the audiologist who performed the services! PQRS codes for 2014 Patient dizzy (Diagnosis 780.4, ) G8856 G8857 G8858 Medication Documentation G8427 G8430 G8428 Screening for Depression G8431 G8510 G8433 G8432 G8511 Referral to MD for dizziness Patient already under care of MD for dizziness Referral not performed, reason unspecified Documented medications OR patient not taking medications Medications not documented; patient in emergent situation Medications not documented; reasons not given Positive screen; follow-up plan Negative screen Screen not appropriate No screen performed Positive screen, no follow-up plan STEP 4: TRAIN THE STAFF GET PLUGGED IN Report on Part B Medicare beneficiaries Benchmark requires 50% of: Every visit for medication documentation Once a year for dizziness and depression Not reporting affects the bottom line Reporting is tracked by individual provider number Non-compliance by one provider in a practice will result in their future charges receiving the penalty Report accurately Better to report reason not given codes than wrongly attest to measure being performed Do not perform screening for depression if: A standardized tool is not being used The provider is not comfortable or trained ASHA ethics states Individuals shall provide all services competently. Register for ASHA Headlines to get up to date information about policy changes and legislation, including PQRS Watch your ASHA Leader in December/January for an update on Medicare rules

10 FRAUD Making false statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person s own benefit or for the benefit of some other party. FRAUD, ABUSE, AND AUDITS Examples of Medicare fraud may include: Knowingly billing for services that were not furnished and/or supplies not provided, including billing Medicare for appointments that the patient failed to keep Knowingly altering claims forms and/or receipts to receive a higher payment amount. -Medicare Fraud & Abuse: Prevention, Detection, and Reporting ABUSE Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced. Examples of Medicare abuse may include: Misusing codes on a claim Charging excessively for services or supplies Billing for services that were not medically necessary OTHER TYPES OF FRAUD AND ABUSE Unreported income or insurance Drug seeking behavior or incarceration Services never provided Provider billing irregularities or errors Over utilization of health care services Misrepresentation of credentials -Medicare Fraud & Abuse: Prevention, Detection, and Reporting

11 MEDICARE FRAUD AND ABUSE LAWS RECOVERY AUDIT CONTRACTOR DEMONSTRATION PROJECT False Claims Act Civil liability who knowingly submits a false or fraudulent claim, including by deliberate ignorance or reckless disregard Anti-Kickback Statute Criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program. Physician Self-Referral Law (Stark Law) Prohibits a physician from making a referral for certain designated health services to an entity in which the physician has an ownership/investment interest or a compensation arrangement 2005: Florida, New York, California 2007: South Carolina, Massachusetts & Arizona added : Expansion nationwide 2011: $939.3M improper payments $797.4 million in overpayments $141.9 million in underpayments Recovered Millions $ MEDICARE CLAIMS AUDITORS MEDICAID AUDITS Medicare Administrative Contractors (MACs) Regionally manage policy and payment Use data from other contractors to target improper payment and vulnerabilities Can perform medical reviews for all claims at their discretion Recovery Audit Contractors (RACs) Detect and correct improper payments Review claims where improper payments have been made or there is a high probability that improper payments were made Incentivized for recovery of funds Comprehensive Error Rate Testing (CERT) contractors Statistically analyze and establish error rates and estimates of improper payments by claims randomly selected for review Not required to notify providers of their intention to begin a review National Medicaid Provider Audit program Went to full implementation in 2009 Medicaid Integrity Contractors Review the actions of Medicaid providers, audit providers claims, identify overpayments, and educate providers and others on Medicaid program integrity issues $10.7 million recovered in overpayment Zone Program Integrity Contractors (ZPICs) and Program Safeguard Contractor (PSCs) Identify and stop potential fraud Refers cases to the Department of Health and Human Services (HHS) Office of Inspector General (OIG) Office of Investigations (OI). Private health plans are jumping on the audit wagon

12 HAS THIS HAPPENED TO US? Audiologist in visited skilled nursing facilities throughout Northern California and billed Medicare for hearing tests in skilled nursing facilities performed without a referring physician s order. He also did not perform all of the tests for which he billed Medicare and forged physician referrals to justify his Medicare billings. Audiologist in Missouri found guilty of three counts of Medicaid fraud, charged with submitting false claims of more than $12,000 to Medicaid for audiology services never performed. Audiologist in Southern California made arrangements with a nursing facility and affiliated physicians to get orders for hearing exams that were not medically necessary. The audiologist used this access to residents exclusively to market hearing aids. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) TOP 5 HIPAA PRIVACY RULES 1. Impermissible uses and disclosures Cannot use or disclose PHI unless: 2. Safeguards Authorized by patients OR Necessary for access to quality health care OR Needed for public benefit or national priorities. Reasonable efforts made to prevent uses and disclosures 3. Access Individuals right to access their PHI that is contained in their designated record sets. 4. Minimum Necessary PHI must be limited to only necessary items 5. Notice Must inform patients of the privacy practices and their privacy rights with respect to PHI HIPAA PENALTIES Willful neglect and is not corrected Willful neglect, but corrected within required timeframe Reasonable cause but not due to willful neglect Unknown, and would not have known even with reasonable diligence $50,000 $1.5 million $10,000 - $50,000 $1,000 - $50,000 $100 - $50,000

13 RELATED CASES Minimum Necessary UCLA $865,500 and corrective action plan Response to complaint Unauthorized employees repeatedly looked at the electronic PHI of celebrity and other UCLA patients. Breach Unencrypted Laptop Massachusetts Eye and Ear Infirmary (MEEI) $1.5 million and corrective action plan Breach report by MEEI Missing laptop included patient prescriptions and clinical information. Management was aware and found negligent for: No risk analysis No security measures No HIPAA policies and procedures DOCUMENTATION If you didn t document it, it didn t happen! CMS & DOCUMENTATION In order for services to be paid, CMS requires that Medical Necessity be established and documented: Services must be reasonable and necessary for the treatment of illness, injury, disease, disability, or developmental condition The service is consistent with the symptoms or diagnoses of the condition under treatment The service is necessary and consistent with generally accepted professional standards (i.e., not experimental or investigational) CMS & DOCUMENTATION More Medical Necessity Requirements: The service is not furnished primarily for the convenience of the patient, the attending physician, or another physician or service provider (that means you!) The service is furnished at the most appropriate level that can be provided safely and effectively to the patient

14 MEDICARE REQUIREMENTS Reason for the test Test results are required by physician to: Confirm a prior diagnosis Post-evaluation diagnosis OR Determine treatment after diagnosis, including hearing aids Reevaluation Schedule is determined by the ordering physician Evaluation of treatment Monitor changes in hearing, such as progressive hearing loss Patient/Caregiver reports perceived change in condition MEDICARE REQUIREMENTS Qualifications for payment Physician order Reason for the test Furnished by a qualified individual (i.e. within the professional s scope of practice) Signed ABN (Advanced Beneficiary Notice) when testing is not ordered by physician Payment for audiological diagnostic tests is determined by the reason the tests were performed, rather than by the diagnosis or the patient s condition BEST DOCUMENTATION PRACTICES Describe the reason for the test Describe the procedures that were completed Describe the outcomes of procedures Clinical assessment of the findings Recommendations Signature (real or electronic not a stamp) Date of service. SOAP note Subjective findings Objective findings Assessment Plan AUDIT PROOF DOCUMENTATION Insufficient documentation has been cited by Medicare as the 2 nd highest cause for improper payment Documentation did not match the claim or was not detailed enough to justify the services that were billed Match the claim!!!

15 CONNECT THE DOTS Coding = Documentation If it wasn t documented, it wasn t done! Date of service on the claim must match DOS on the report, or else the patient was never seen Each provider is ultimately responsible for the correct coding of the services they provide Healthcare Common Procedure Coding System (HCPCS) Level II devices L8614 cochlear implant V5261 binaural hearing aid, BTE Current Procedural Terminiology (CPT) Level I Basic vestib eval Comprehensive audiology The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) CODES PROCEDURE CODES CODING WITH MODIFIERS Current Procedural Terminology Codes (CPT) Contact Codes Billed once per date of service, regardless of time Comprehensive audiology evaluation Timed Codes Billed by first hour, then 15 minute increments Start and end time must be documented in the record Evaluation of Auditory Rehabilitation Status, first hour, and additional 15 minutes Unit Codes Each element of procedure is reported as one unit Caloric testing, each irrigation (max of 4) Auditors will pull claims based on patterns of modifier use -22 modifier Increased procedural service Used when you perform a service above and beyond what is customarily done -52 modifier Reduced services Used when the work required to perform the service or procedure is significantly less than usually required Do not use on timed codes Use for only one side in a normally bilateral procedure, such as performing pure tone audiometry in only one ear.

16 CORRECT CODING PRACTICES National Correct Coding Initiative (NCCI) Developed by Medicare, utilized by all payers Coding rules that minimize abusive coding Lists codes that cannot be reported together on same date of service (speech audiometry) cannot be billed with (speech audiometry with recognition) Medically Unlikely Edits (MUEs) Limits number of units for a date of service Osseointegrated devices (BAHAs) L8690, limit 1 per DOS Caloric testing, limited to 4 ADVANCED BENEFICIARY NOTICE (ABN) ABNs notify the Medicare beneficiary of financial liability ABNs must be used for services: That are a benefit but do not meet Medicare coverage policies (mandatory ABN) ABN can be used for services: That are excluded from coverage (voluntary ABN) dits_aud.htm ABN EXAMPLES Mandatory: Audiologic and/or vestibular testing that is more frequent than the norm or what was ordered by the physician Unlisted code (92700) is used Voluntary: Audiologic and/or vestibular testing where a physician order was not obtained prior to testing Treatment services such as cerumen removal, canalith repositioning, tinnitus management, and aural rehabilitation AUDIT RULES FOR ABN You cannot Issue an ABN routinely Complete the entire ABN for the patient Issue the ABN after the service has been provided Use the Government form ABN for non-medicare beneficiaries Use and ABN to charge a Medicare beneficiary for services that would be paid under the Medicare benefit The beneficiary may requests under their own free will that the claim is not submitted, but They can change their mind You must submit a claim for a Medicare beneficiaries if asked even if previously they asked you not to submit

17 GREATER SPECIFICITY = MORE CODES! ICD-10-CM ICD-9-CM ICD-10-CM ABRUPT CHANGE Claims with date of service September 30, 2015 require ICD-9 Claims with date of service October 1, 2015 require ICD-10 New paper CMS-1500 required for use April 1, 2014 Includes space to indicate ICD-9 or ICD-10 Additional diagnosis options PRINCIPLES OF ICD-10 CODING Most principles remain the same as ICD-9. For example: Always code to the highest degree of specificity available Primary and secondary diagnoses Primary: condition chiefly responsible for the visit (reason you are seeing the patient) Secondary: Co-existing conditions, symptoms, or reasons Normal test results: code signs or symptoms to report the reason for the test/procedure

18 ICD-10 CODING CONVENTIONS Not otherwise specified (NOS) and unspecified codes (usually a code with a 4 th digit 9 or 5 th digit 0 for diagnosis codes) Use only when the information in the medical record is insufficient to assign a more specific code H91.9- Unspecified hearing loss May be appropriate for newborn diagnostics, when type of hearing loss has not yet been determined F80.9 Developmental disorder of speech and language, unspecified THE ICD The International Classification of Diseases (ICD) Format for reporting causes of death on the death certificate. Assigns codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the U.S. Updated annually ICD-9-CM codes are 3-, 4-, and 5-digit codes Number of digits indicates level of code specificity Codes are arranged by categories There are levels within each category 7 0 ICD-10 BEGINS OCTOBER 1, 2014 U.S. Dept of Health & Human Services has set October 1, 2015 as the new compliance date for implementation of ICD 10-CM ICD-10 includes ICD-10-CM diagnosis codes for all settings ICD-10-PCS procedure codes for hospital inpatients ICD-10 diagnostic code set contains more than 68,000 codes Combined with other ICD-10 code sets about 150,000 ADVANTAGES OF ICD-10-CM 3-7 alphanumeric characters instead of ICD-9 with 3-5 digits to allow for more specificity Combination codes represent multiple conditions so that the need to determine primary and secondary codes is eliminated Clearer instructions than ICD-9 ICD-10 code descriptions contain detail, less room for error

19 ICD-9-CM to ICD-10-CM FOR SNL ICD-9-CM to ICD-10-CM FOR BPPV ICD-9-CM ICD-10-CM ICD-9-CM ICD-10-CM Sensorineural hearing loss, bilateral Sensorineural hearing loss, unilateral H90.3 Sensorineural hearing loss, bilateral H90.41 Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side H90.42 Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side Benign paroxysmal positional vertigo Benign paroxysmal positional nystagmus H81.10 Benign paroxysmal vertigo, unspecified ear H81.11 Benign paroxysmal vertigo, right ear H81.12 Benign paroxysmal vertigo, left ear H81.13 Benign paroxysmal vertigo, bilateral 74 ICD-9-CM to ICD-10-CM FOR APD ICD-10-CM IS EVEN MORE SPECIFIC ICD-9-CM Abnormal auditory perception, unspecified ICD-10-CM H Other abnormal auditory perceptions, right ear H Other abnormal auditory perceptions, left ear H Other abnormal auditory perceptions, bilateral H Other abnormal auditory perceptions, unspecified ear 75 Noise induced loss due to dolphin encounter? H83.3X3 - Noise effects on inner ear, bilateral W Struck by a dolphin Repeated injury by pet bird? H Hematoma of pinna, left ear W Bitten by a macaw W61.11XD subsequent encounter

20 BE AN ADVOCATE! Read the ASHA Leader Sign up for ASHA Headlines: Use ASHA s Take Action! tool: State Medicare Administrative Contractor (SMAC) Network Paula Simon (SLP) State Advocates for Reimbursement (STARs) Brandon Viet (SLP) State Education Advocacy Leaders (SEALs) Darla Sharar And me Lsatterfield@asha.org YOUR STATE ASSOCIATION RESOURCES Thank You!