VAD Professiona. al Reimbursement Wb 12/13/211

Transcription

1 VAD Professiona al Reimbursement Web Wb binar Peter K. Sm mith, MD Professor and Chief Thoracic Surgery Duke University 12/13/211

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3 Relative Value Distribution in the Physician Fee Schedule RV PLI, 0.03 RV PE, 46% RVW, 51%

4 Importance of Evaluation and Management Billing in Cardiothoracic Surg gery E&M Payments 17% $110,000,000 Procedural Payments 83% $549,000,000

5 Length of Stay Template for E&M Services Percent of Patients Mitral Repair N=7985 E&M Median Mean Length of Stay (days)

6 Length of Stay Template for E&M Services Percent of Patients Mitral Repair N=7985 E&M Median Mean Length of Stay (days)

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8 Payment Policy Paid for physician services that are described by CPT (Current Proceduree Terminology) and are assigned Relative Value Units (RVU) by CMS Many services are assigned Global Periods which are either 90, 10 or 0 days For many other services, no global periods are assigned. These are calle ed XXX globals Some services are intended to be add-ons to specific codes, and are called ZZZ codes

9 Global Period A global period is initiated when a CPT code is billed, and defines a peri iod of time where other billing related to the service described by the CPT code is prohibited. This is due to the fact that the RVU of the global code already contains th he value of the typical physician services provided during the global period.

10 90 Day Global This is the most common designation for surgical procedures and prohibits billing for related services 1 day before and 90 days after the procedure. For example, this is a 90 day global: Coronary artery by ypass, single, arterial

11 33533 RVU Build Includes Time 60 minutes of pre-service evaluation 15 minutes to position p atient in OR 20 minutes of scrub, dress and wait time 151 minutes to perform the procedure skin-to-skin 40 minutes of immediatee postop time to stabilize and transfer the patient, dictate, communicate, etc And

12 33533 RVU Build Includes Visits 1 X Critical Care 3 X Hospital Visit 1 X Hospital Visit 1 X Hospital Visit 1 X Hospital Visit 1 X Discharge 1 X Office Visit 1 X Office Visit

13 Global Period Exce eptions-additional Procedures Performed Post Op Must be performed in OR or treatment room Best example is Re-exploration exploration for Bleeding or Infection CPT modifier -78 must be appended to indicate that it is performed in the global period, related to the principal procedure. This results in a discount in payment Procedures performed by others are paid full value and not subject to global period rules

14 Global Period Exceptions: Evaluation and Management of a New and dunrelated ltdproblem Example: Patient has CABG with pre-existing DVT and suffers a pulmonary embolism requiring multiple days of critical care services to recover. You would bill several critical care E&M codes and append CPT modifier -24 or -25 to indicate that you are billing for a new problem wihi ithin the existing i global l period for the CABG There are few legitimate t examples of this, as most tissues that arise are related to the CABG procedure. The use of -24 and -25 modi ifiers frequently lead to audits.

15 CPT Modifiers -51: Another procedure performed at the same time as a higher valued procedure, pays 50% to account for overlap and duplication in global period payments. Orthotopic Heart Tx/VAD Removal Pays full value of higher valued code, Heart Tx Pays 50% of VAD Remo oval

16 Summary of VAD Changes VAD removal codes Global changes from 90 day to XXX global Reimbursement goes down Offset cuts by billing for E/M services VAD replacement codes Have established Values All VAD codes Have XXX global l Related E/M services should be separately billed Additional i services should be separately billed Physician Documentation of services ESSENTIAL

17 Impact of 5 Year Review VAD Changes 2010 Global Period Global Period Current New Current Percent CPT Descriptor RVW RVW Medicare New Payment Payment Difference Freq Insert Single Extracorporeal XXX XXX $296,038 $352,930 19% Insert Double Extracorporeal XXX XXX Remove Single Extracorporeal 90 XXX Remove BiVAD Extracorporeal 90 XXX Insert Single Intracorporeal XXX XXX Remove Single Intracorporeal 90 XXX Change Pump Et Extracorporeal XXX XXX Change Pump Intracorporeal XXX XXX Change Intracorporeal with CPB XXX XXX $55,333 $74,075 34% $118,791 $122,188 3% $30,337 $33,382 10% $1,237,349 $1,010,246 18% $493,042 $253,365 49% NA Unknown $4,215 NA NA Unknown $4,245 NA NA Unknown $31,322 NA Grand Total $2,230,889 $1,885,967 15%

18 Ventricular Assist Devices - Replacements Replacement of extra acorporeal ventricular assist device, single or biventricular, pump(s), single or each pump p Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass implantable intracorporeal, single ventricle, with cardiopulmonary bypass ALL ARE XXX GLOBAL PROCEDURES

19 VAD Rep lacements Procedure component in ncludes Replacement and insertion of pump ONLY Connection of new pump De-airing of new pump Initiation of new pump

20 Services Include ed in VAD XXX Valuation Same day pre-op E/M Procedure (insertion, rep placement or removal) Care through stabilization

21 VAD Removals Problem #1 You will receive less automatic payment for the procedures that have been revalued from 090 Globals to XXX codes Solution: Develop plans to capture (perform, document and bill) medically necessary E&M services for these and all l other XXX codes

22 33977 Remove Single VAD Extracorporeal Cd Code RVW Surveyed dvisitsit Total RVW 9291 (critical care first mins) (critical care each add 30 mins) (subsequent hospital visit) (subsequent hospital visit) (subsequent hospital visit) (discharge 30 minutes or less) (discharge >30 minutes (established patient office visit) (established patient office visit) (established patient office visit) otal E&M Services RVW rocedure RVW otal Potential RVW omparable Code Mitral Valve Replacement 50.93

23 Code Remove BiVAD Extracorporeal RVW 9291 (critical care first mins) (critical i care each add 30 mins) (subsequent hospital visit) (subsequent hospital visit) (subsequent hospital visit) (discharge 30 minutes or less) (discharge >30 minutes (established patient office visit) (established patient office visit) (established patient office visit) 0.48 Total Surveyed Visits RVW otal E&M Services RVW rocedure RVW otal Potential RVW omparable Code AVR with Annulus Enlargement

24 33980 Remove Single VAD Intracorporeal Code RVW Surveyed Visits Total RVW (critical care first mins) (critical care each add 30 min ns) (subsequent hospital visit) (subsequent hospital visit) (subsequent hospital visit) (discharge 30 minutes or less) (discharge >30 minutes (established patient office visit) (established patient office visit) (established patient t office visi it) Total E&M Services RVW Procedure RVW Total Potential RVW Comparable Code Current Value as

25 VAD Remova al Problem #2 Value of has been reduced by 8.43 RVW or 18% Solution No solution if you are alr ready billing appropriate E&M However, value would be restored with two services (9.0 RVW) if you have not been taking advantage of the XXX global period to this point.

26 VAD Removal Problem #3 When VAD removal codes are performed with Heart Transplant, the reduced value will still be reduced 50%, but you will be within the Heart Transplant 090 global. This prevents billing additional E&M related to the Heart Transplant procedure Solution (minimal): Bill for new Dx related to VAD, use -24 or -25 Mo odifier

27 Unrelated VAD Care Examples Rare that will be able to removal care same day Wound care issues - Drive line site Bleeding related to the VAD pocket separate out VAD Residual medical compli cations from the VAD Care for embolus that occurred during explantation

28 Necessary Documentation To report any VAD related post op E/M Care All services MUST be cle early documented d Separate out care specific to VAD in op note and use that t documentation ti to sele ect codes Code levels and category selected based on VAD specific documentation Diagnosis for VAD should be different from 90 day global procedure diagnosi is Use appropriate modifiers to pull out of bundle

29 Possible E/M Codes for Follow-up VAD Care Established Patient Outpati ient Visits ( ) 99215) Initial Hospital Care ( ) Subsequent Hospital Care ( ) Critical Care ( ) VAD Interrogation Code (93750): Interrogation of ventricular assist device (VAD), in person, with physician analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow and volume status, septum status, recovery), with programming, if performed, and report

30 Coding Based on Time Use instead of fkey Components ONLY WHEN OVER 50% of visit spent in face-to-face patient counseling or coordination of care Documentation includes time of overall visit Documentation includes time spent in counseling or coordination of care Documentation includes summary of the discussion Some codes are time based Follow CPT for time increments instead of component based

31 Critical Care Codes Critical care, evaluation and management of the critically ill or critically injured patient; first minutes each additional separately in addition to 30 minutes (List 30 minutes (List code for primary service)

32 Critical Care Definitions Medicare and CPT Definition Care delivered directly by a physician for a critically ill or injured patient. A critically ill or injured patie ent tis defined das one that thas an illness or injury impairing one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient s condition. Vital organ systems include (but are not limited to) failure of the central nervous system circulatory failure shock failure of the renal, metabolic, and/or respiratory systems

33 Critical Ca are Criteria The critical care codes are time based for each date and encounter. The critical i care time provided d to the patient does not need to be continuous; it can be cumulative over the course of the day. Time counted towards critical care must be time where the physician s s care is de evoted solely to the critically ill or injured patient. NO Care be provided to any other patients during time that is counted towards critical care.

34 Critical Care Considerations Considerations More than one physician can provide critical care at another time and be paid. Only one physician may bill for critical care during any single period of time, even if more than one physician i is present and providing care to a critically ill or injured patient. Use of fdifferent tdiagnosi is codes by different physicians involved in the patient s care, if appropriate, clarify that th he care does not overlap

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36 E/M Modifiers Decision for Surgery Significant, Separa ately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service Unrelated Evaluati on and Management Service by the Same Physician During a Postoperative Period

37 Post-VAD Procedures No modifier necessary if not in global of another procedure Additional procedure starts new global period Once in new global, mod difiers to isolate care related to VAD if appropriate

38 Example - VAD Removal Patient no longer needs VAD supp port. Biventricular extracorporeal VAD is removed, The patient is moved to ICU in critical condition. Surgeon spends 90 minutes providing critical care services to patient throughout h the day and evening. Report 33978, 99291, Code would be reported extracorporeal device. for the removal of fthe biventricular i would be used for the fir rst 74 minutes of critical care services (minimum 31 minutes, otherwise use 99233) would be used for the additional 16 minutes of critical care services NOTE: documentation in coding scenario is not sufficient for reporting the critical care visits, detailed documentation must be provided

39 Example - VAD Removal with Transplant Implantable intracorporeal VAD removed, heart transplant performed, ASD on the donor heart repaired. Patient seen for level three subsequent hospital visit three days postop p in the ICU for bleeding along the suture line. Report 33945, , , is reported at 100% for the heart transplant is reported with the 50% reduction for the ASD repair on the donor heart is reported for the intracorporeal VAD removal is reported for the subsequent hospital visit. A different dx from the heart transplant or ASD repair is required

40 Example VAD Insertion Patient has left ventricular failure, an intracorporeal VAD is placed. Patient is seen later that day in the ICU for 60 minutes of critical care. The next day the pa atient taken back to OR for bleeding. Report: First Day: 33979, Second Day: 35820

41 Example VAD Insertion with CABG Patient with CAD has tripl le CABG single arterial and two venous grafts. Patient has left ventricular failure and a single ventricular ex tracorporeal VAD is placed. Patient is seen later that day in the ICU for 90 minutes critical care. The next day patient is taken back to the OR for bleeding Report: First Day: 33533, , 33518, , Second Day: Note: Payers may not recognize the critical care isolated to VAD care on the same day, even with the -25 mo odifier since in the global of another procedure and it is related to the same organ system

42 You Must Develop a Plan Details of E&M coding and documentation beyond scope of our talk Work with your compliance officers and local educators Usually do not need to re-invent the wheel, as many physicians i in your organi ization derive all lltheir income from E&M Services Pay attention to other procedures and how effects VAD care and reporting Utilize modifiers to identify separately billable care