Empirical Risk Management
Empirical Risk Management

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17.07.2018
Empirical Risk
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Evaluation and management (E/M) coding and documentation burden could lighten in 2019 under CMS proposed rule The rule also proposes a single payment rate for level 2 through level 5 office visits. The July/August issue of FPM addressed strategies for distinguishing between 99213 and 99214 office visit codes. That distinction may soon become easier to document but essentially irrelevant to payment. On July 12, the Centers for Medicare & Medicaid Services (CMS) released its proposed changes to the Medicare Physician Fee Schedule for 2019(www.federalregister.gov). The proposed rule contains, among other updates, significant revisions to the coding and documentation of office visit evaluation and management (E/M) services (see page 331 of the proposed rule(s3.amazonaws.com)). While Medicare is only proposing changes to the Office and Other Outpatient Services category of codes (99201-99215) for 2019, Medicare indicates it intends to use a stepwise approach and expand its finalized policy to other E/M code categories (see pages 331-332 of the proposed rule). The changes follow years of auditing from Medicare contractors and widespread concerns from the medical community that existing E/M documentation guidelines no longer reflect current practices and result in unnecessarily burdensome documentation requirements. New time reporting option In selecting a level of service for office or other outpatient services, beginning Jan. 1, 2019, physicians would have increased options available. In addition to using the current 1995 and 1997 documentation guidelines, physicians could select the level of service based on time or by using medical decision-making alone, regardless of the level of history or physical exam performed (see page 335 of the proposed rule). The option to select a level of service based on the duration of the visit relaxes existing requirements. Currently, selecting a visit based on time requires documentation of the duration of face-to-face time with the patient and greater than 50 percent of the visit must be spent in counseling or coordination of care. Medicare’s proposal would eliminate this second requirement, simply allowing physicians to select a code based on the total length of the visit even if counseling did not dominate the service time. (see page 338 of the proposed rule). Medical decision making as the driving factor Especially for new patient visits, which currently require meeting requirements for all three key components of history, examination, and medical decision-making, satisfying requirements for higher levels of service can be difficult. Physicians have long complained that the points system for history and examination components result in unnecessary documentation that does not contribute to patient care. As a result, Medicare proposes to allow physicians to select their level of service for both new and established patient office visits using only the medical decision-making component. The requirements for medical decision making would remain the same. Reducing unnecessary requirements Recognizing several common E/M documentation guideline complaints, Medicare proposes to no longer require physicians to re-record information regarding the chief complaint and history of present illness previously documented by ancillary staff (see pages 343-345 of the proposed rule). Single payment rate The method of supporting your level of service, in some respects, may be a distinction without a difference under the proposed rule. Level 2 through level 5 new and established office visits, respectively, would have a single payment rate regardless of the code reported (see page 349 of the proposed rule). New patients (99202-99205) would be paid at approximately the midpoint between a 99203 and 99204 (see page 349 of the proposed rule), assigning 1.9 work RVUs to new patient visit codes. (Compare that to the 2018 rates for 99203 at 1.42 work RVUs and 99204 at 2.43 work RVUs, with a midpoint of 1.925.) Established patient visits (99212-99215) would be paid just under the midpoint between 99213 and 99214 (see page 349 of the proposed rule), assigning 1.22 work RVUs to established patient visit codes. (Compare that to 2018 rates for 99213 at 0.97 work RVUs and 99214 at 1.5 work RVUs, with a midpoint of 1.235.) The following tables from the proposed rule illustrate the potential financial impact using 2018 work RVU and conversion factor values. Primary care payment bump Visits with a focus on primary care can receive a bump in payment by reporting a new add-on code (specific code to be determined), with a proposed work RVU of 0.07. Impact to physicians Physicians should note that these modifications, if finalized, would only apply to office visit codes and only for Medicare. As a result, the existing 1995 and 1997 E/M guidelines will continue to apply for other services such as hospital visits, and for commercial payers. Note: The release is scheduled for official publication in the Federal Register July 27, 2018. Page references are subject to change upon publication of the Proposed Rule in the Federal Register. – Richelle Marting, JD, an attorney practicing with Forbes Law Group in Overland Park, Kan., where she focuses on regulatory compliance and health care reimbursement https://www.aafp.org/journals/fpm/blogs/gettingpaid/entry/em_coding_proposed_changes.html
National Health Care Fraud Takedown Results in Charges Against 601 Individuals Responsible for Over $2 Billion in Fraud Losses Largest Health Care Fraud Enforcement Action in Department of Justice History Resulted in 76 Doctors Charged and 84 Opioid Cases Involving More Than 13 Million Illegal Dosages of Opioids Attorney General Jeff Sessions and Department of Health and Human Services (HHS) Secretary Alex M. Azar III, announced today the largest ever health care fraud enforcement action involving 601 charged defendants across 58 federal districts, including 165 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving more than $2 billion in false billings.  Of those charged, 162 defendants, including 76 doctors, were charged for their roles in prescribing and distributing opioids and other dangerous narcotics.  Thirty state Medicaid Fraud Control Units also participated in today’s arrests.  In addition, HHS announced today that from July 2017 to the present, it has excluded 2,700 individuals from participation in Medicare, Medicaid, and all other Federal health care programs, which includes 587 providers excluded for conduct related to opioid diversion and abuse.  Attorney General Sessions and Secretary Azar were joined in the announcement by Acting Assistant Attorney General John P. Cronan of the Justice Department’s Criminal Division, Deputy Director David L. Bowdich of the FBI, Assistant Administrator John Martin of the Drug Enforcement Administration (DEA), Deputy Inspector General Gary Cantrell of the HHS Office of Inspector General (OIG), Deputy Chief Eric Hylton of IRS Criminal Investigation (CI), Centers for Medicare and Medicaid Services (CMS) Deputy Administrator and Director of the Center for Program Integrity Alec Alexander and Director Dermot F. O’Reilly of the Defense Criminal Investigative Service (DCIS). Today’s enforcement actions were led and coordinated by the Criminal Division, Fraud Section’s Health Care Fraud Unit in conjunction with its Medicare Fraud Strike Force (MFSF) partners, a partnership between the Criminal Division, U.S. Attorney’s Offices, the FBI and HHS-OIG.  In addition, the operation includes the participation of the DEA, DCIS, IRS-CI, Department of Labor, other various federal law enforcement agencies, and State Medicaid Fraud Control Units.   The charges announced today aggressively target schemes billing Medicare, Medicaid, TRICARE (a health insurance program for members and veterans of the armed forces and their families), and private insurance companies for medically unnecessary prescription drugs and compounded medications that often were never even purchased and/or distributed to beneficiaries.  The charges also involve individuals contributing to the opioid epidemic, with a particular focus on medical professionals involved in the unlawful distribution of opioids and other prescription narcotics, a particular focus for the Department.  According to the CDC, approximately 115 Americans die every day of an opioid-related overdose.    “Health care fraud is a betrayal of vulnerable patients, and often it is theft from the taxpayer,” said Attorney General Sessions.  “In many cases, doctors, nurses, and pharmacists take advantage of people suffering from drug addiction in order to line their pockets. These are despicable crimes. That’s why this Department of Justice has taken historic new steps to go after fraudsters, including hiring more prosecutors and leveraging the power of data analytics. Today the Department of Justice is announcing the largest health care fraud enforcement action in American history.  This is the most fraud, the most defendants, and the most doctors ever charged in a single operation—and we have evidence that our ongoing work has stopped or prevented billions of dollars’ worth of fraud. I want to thank our fabulous partners with the FBI, DEA, our Health Care Fraud task forces, HHS, the Defense Criminal Investigative Service, IRS Criminal Investigation, Medicare, and especially the more than 1,000 federal, state, local, and tribal law enforcement officers from across America who made this possible. By every measure we are more effective at finding and prosecuting medical fraud than ever.” “Every dollar recovered in this year’s operation represents not just a taxpayer’s hard-earned money—it’s a dollar that can go toward providing healthcare for Americans in need,” said HHS Secretary Azar.  “This year’s Takedown Day is a significant accomplishment for the American people, and every public servant involved should be proud of their work.” According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare, Medicaid, TRICARE, and private insurance companies for treatments that were medically unnecessary and often never provided.  In many cases, patient recruiters, beneficiaries and other co-conspirators were allegedly paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare.  Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of submitting a total of over $2 billion in fraudulent billings.  The number of medical professionals charged is particularly significant, because virtually every health care fraud scheme requires a corrupt medical professional to be involved in order for Medicare or Medicaid to pay the fraudulent claims.  Aggressively pursuing corrupt medical professionals not only has a deterrent effect on other medical professionals, but also ensures that their licenses can no longer be used to bilk the system. “Healthcare fraud touches every corner of the United States and not only costs taxpayers money, but also can have deadly consequences,” said FBI Deputy Director Bowdich.  “Through investigations across the country, we have seen medical professionals putting greed above their patients’ well-being and trusted doctors fanning the flames of the opioid crisis.  I want to thank the agents, analysts and our law enforcement partners in every field office who work each and every day to stop these criminals and hold them accountable for their actions.” “DEA is committed to ending the opioid crisis occurring in our communities and preventing prescription drug misuse,” said DEA Assistant Administrator Martin.  “DEA will continue to work with our partners every day to protect our citizens while ensuring that patients have adequate access to these critical medications.” “This year’s operations, focusing on opioid-related schemes, spotlight the far-reaching impact of health care fraud,” said HHS Deputy Inspector General Cantrell.  “Such crimes threaten the vitally important Medicare and Medicaid programs and the beneficiaries they serve.  Though we have made significant progress in our fight against health care fraud; our efforts are not complete.  We will continue to work with our partners to protect the health and safety of millions of Americans.” “It takes a special kind of person to prey on the sick and vulnerable as happened in many of these health care fraud schemes,” said Deputy Chief Hylton.  “Medical professionals and others callously placed individuals and vital healthcare services in harm’s way simply because of greed.  IRS-CI special agents continue to work side-by-side with other federal, state and local law enforcement officers to uncover these schemes and hold these criminals accountable for their actions.” “CMS makes it a top priority to protect the health and safety of millions of beneficiaries who depend on vital federal healthcare programs,” said Alec Alexander, deputy administrator and director of the Center for Program Integrity.  “CMS’ Center for Program Integrity collaborates closely with our law enforcement partners to safeguard precious taxpayer dollars. Under Administrator Seema Verma, we will continue to strengthen this partnership with law enforcement in order to ensure the integrity and sustainability of these essential programs that serve millions of Americans.” “Heath care fraud wounds our service members and veterans alike, as they rely upon and rightfully expect uncompromised care through the Department of Defense’s TRICARE Program,” said DCIS Director O’Reilly.  “Investigations that culminated in enforcement actions over the past several days underscore the steadfast commitment of the Defense Criminal Investigative Service and our investigative partners to vigorously investigate fraud impacting TRICARE.  We remain vigilant in our efforts to ensure the high standards of care our service members, military retirees, and their dependents deserve while safeguarding American taxpayer dollars.”  The Medicare Fraud Strike Force operations are part of a joint initiative between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country.  The Medicare Fraud Strike Force operates in 10 locations nationwide.  Since its inception in March 2007, the Medicare Fraud Strike Force has charged over 3,700 defendants who collectively have falsely billed the Medicare program for over $14 billion. ********* For the Strike Force locations, in the Southern District of Florida, 124 defendants were charged with offenses relating to their participation in various fraud schemes involving over $337 million in false billings for services including home health care and pharmacy fraud.  In one case, an owner, medical director, and two employees of a sober living facility were charged with conspiracy to commit health care and wire fraud, substantive counts of health care fraud, and substantive counts of money laundering.  The indictment alleges a scheme that illegally recruited patients, paid kickbacks, and defrauded health care benefit programs for widespread fraudulent urine testing.  During the course of the fraudulent scheme, the facility submitted more than $106 million in claims for substance abuse treatment services.  In the Central District of California, 33 defendants were charged for their roles in schemes to defraud insurance programs out of more than $660 million.  For example, one indictment in a compounding pharmacy fraud case alleges an attorney/marketer paid kickbacks and offered incentives such as prostitutes and expensive meals to two podiatrists in exchange for prescriptions written on pre-printed prescription pads, regardless of the medical need for the prescriptions.  Once the prescriptions were filled, members of the conspiracy submitted approximately $250 million in fraudulent claims to federal, state, and private insurers for the compounded drugs.  In the Southern District of Texas, 48 individuals were charged in cases involving more than $291 million in alleged fraud.  Among these defendants are a pharmacy chain owner, managing partner, and lead pharmacist charged with a drug and money laundering conspiracy. According to the indictment, the coconspirators used fraudulent prescriptions to fill bulk orders for over one million pills of hydrocodone and oxycodone, which the pharmacy, in turn, sold to drug couriers for millions of dollars.  In the Northern District of Texas, a home health agency owner was arrested on a criminal complaint for a $2.6 million health care fraud scheme. In the Eastern District of Michigan, 35 defendants face charges for their alleged roles in fraud, kickback, money laundering and drug diversion schemes involving approximately $197 million in false claims for services that were medically unnecessary or never rendered.  In one case, a physician was charged in separate kickback conspiracies with two home health agency owners, which resulted in more than $12 million in fraudulent insurance billings. In the Northern District of Illinois, 21 individuals were charged for various fraud schemes involving home health and dental services.  These schemes involved allegedly over $54 million in fraudulent billing.  One case alleges a home health fraud and kickback conspiracy, which resulted in more than $6.2 million paid by Medicare based on the fraudulent billings. In the Eastern District of New York, 13 individuals were charged with participating in a variety of schemes including kickbacks, services not rendered, identity theft and money laundering involving over $38 million in fraudulent billings.  For example, the owner of a Brooklyn ambulette company was charged in a $7 million conspiracy stemming from the alleged payment of kickbacks for the referral of patients, who subjected themselves to purported physical and occupational therapy and other services, and were transported by the ambulette company. In the Middle District of Florida, 21 individuals were charged with participating in a variety of schemes involving more than $21 million in fraudulent billings.  In one case, a physician and clinic owner were charged with a conspiracy to defraud Medicare of more than $2.8 million for fraudulent home health billings. In the Southern Louisiana Strike Force, operating in the Middle and Eastern Districts of Louisiana as well as the Southern District of Mississippi, 42 defendants were charged in connection with health care fraud, drug diversion, and money laundering schemes involving more than $16 million in fraudulent billings.  One case alleges that three pharmacy owners and a nurse practitioner conspired to unlawfully dispense controlled substances and defraud TRICARE and private insurance companies out of $12 million. In the Corporate Strike Force, five defendants were charged in the Middle District of Tennessee with a kickback conspiracy at a durable medical equipment company, which allegedly resulted in more than $1 million in kickbacks and over $2.5 million in fraudulent billings to Medicare.  ********* In addition to the Strike Force locations, today’s enforcement actions include cases and investigations brought by an additional 46 U.S. Attorney’s Offices, including the execution of  search warrants in various investigations conducted by the Central and Northern Districts of California, Middle District of Florida, Southern District of Georgia, Western District of Kentucky, Eastern District of Michigan, Western District of North Carolina, Eastern and Western Districts of Texas, Eastern and Western Districts of Virginia, and Western District of Washington. In the Northern and Southern Districts of Alabama, 15 defendants were charged for their roles in eight health care fraud schemes involving compounding pharmacy fraud and unlawful distribution of controlled substances. In the Eastern District of California, four defendants were charged for their roles in two health care fraud schemes, one of which included forged prescriptions. In the Southern District of California, seven defendants, including a physician, were charged for their roles in three health care fraud schemes and one scheme involving identity theft and services that were not rendered.  In the District of Colorado, a defendant was charged with health care fraud related to billings to Medicaid and Medicare. In the District of Connecticut, three defendants, including two medical professionals, were charged for their roles in two schemes involving compounding drugs and unlawful distribution of Schedule II and IV controlled substances.  In the District of Delaware, a physician/owner of a pain management clinic was charged with unlawfully prescribing more than two million dosage units of Oxycodone products. In the District of Columbia, a durable medical equipment company owner was charged with defrauding Medicaid of $9.8 million. In the Northern District of Florida, four defendants were charged in a scheme to defraud TRICARE and other private insurance companies out of over $8 million for medically unnecessary compounded creams and pills.  In the Northern, Middle, and Southern Districts of Georgia, 12 defendants, including two physicians, were charged in nine health care fraud, drug diversion, or compounding pharmacy schemes involving over $13.5 million in fraudulent billings.  In the District of Idaho, three defendants, all of who are medical professionals, were charged for their roles in three separate fraud schemes involving controlled substances. In the Central and Southern Districts of Illinois, seven defendants were charged in six separate schemes to defraud the Medicaid program. In the Northern District of Indiana, eight defendants were charged in various health care fraud schemes to defraud both the Medicare and Medicaid programs.  In the Northern District of Iowa, two defendants – both medical professionals – were charged for their roles in two opioid-related schemes. In the Districts of Kansas and the Northern and Western Districts of Oklahoma, 12 defendants, including four physicians, were charged in various unlawful distribution of controlled substances schemes.  In the Western District of Oklahoma, one case marks the district’s first time charging unlawful distribution of controlled substances resulting in a death. In the Eastern and Western Districts of Kentucky, 12 defendants, including five medical professionals, were charged in various schemes involving health care fraud, unlawful distribution of controlled substances, aggravated identity theft, and money laundering.  One case involved the operation of two false-front medical clinics. In the Districts of Maine and Vermont, two defendants were charged for their roles in two schemes to defraud various government programs including Medicare, Medicaid, and ones run by the HHS’ Administration for Children and Families. In the District of Nebraska, seven defendants, including one physician, were charged in five separate schemes to defraud Medicare, Medicaid, and various HHS programs. In the District of Nevada, four defendants, including three medical professionals were charged with conspiracies to commit health care fraud and distribute controlled substances.  In the District of New Jersey, eight defendants, including a New York doctor, an anesthesiology technologist for a Philadelphia hospital, and the owner of a medical billing company, were charged for their roles in five schemes to defraud private insurance companies of over $16 million.  In the Southern District of New York, two defendants were charged in schemes involving health care fraud or drug diversion. In the Middle District of North Carolina, two defendants were charged with a conspiracy to defraud Medicare out of over $4 million. In the Southern District of Ohio, three defendants – all medical professionals – were charged for their roles in two health care fraud schemes, one of which involved illegal drug distribution and kickbacks. In the Eastern and Middle Districts of Pennsylvania, 12 defendants were charged for their roles in three drug diversion schemes. In the Western District of Pennsylvania, four defendants – all physicians – were charged in various health care fraud and drug diversion schemes. One scheme involved 32,000 dosage units of buprenorphine. In the District of Rhode Island, one defendant was charged for participating in a theft and aggravated identity theft scheme. In the District of South Carolina, three defendants were charged for their separate roles in a conspiracy to possess with the intent to distribute fentanyl. In the District of South Dakota, two defendants were charged in separate cases, one of which involved a scheme to defraud the Indian Health Service. In the Middle District of Tennessee, 10 defendants were charged in two separate schemes, including a conspiracy to fraudulently obtain oxycodone. In the Eastern District of Texas, two defendants were charged for their role in health care fraud schemes to defraud the Medicare and Medicaid programs. In the District of Utah, two defendants were charged in two cases, one of which involved a $31 million scheme to defraud Medicare and Medicaid. In the Western District of Virginia, eight defendants were charged for their alleged roles in health care fraud schemes.  One $45 million scheme to defraud Medicaid involved falsification of documents in patient files. In the Eastern District of Washington, a dentist and another individual were indicted for distributing and conspiring to distribute hydrocodone and tramadol without a legitimate medical purpose.  In the Eastern District of Wisconsin, three defendants were charged in a scheme involving the unlawful distribution of controlled substances and aggravated identity theft. In addition, in the states of Arizona, Arkansas, California, Connecticut, Delaware, Florida, Hawaii, Illinois, Indiana, Kansas, Louisiana, Maine, Michigan, Missouri, Mississippi, Nevada, New York, Oklahoma, Pennsylvania, Texas, Vermont, and Washington, 97 defendants have been charged with defrauding the Medicaid program out of over $27 million.  These cases were investigated by each state’s respective Medicaid Fraud Control Units.  In addition, the Medicaid Fraud Control Units of the states of California, District of Columbia, Florida, Georgia, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Nevada, North Carolina, Ohio, Texas, Tennessee, and Virginia participated in the investigation of many of the federal cases discussed above.  The cases announced today are being prosecuted and investigated by U.S. Attorney’s Offices nationwide, along with Medicare Fraud Strike Force teams from the Criminal Division’s Fraud Section and from the U.S. Attorney’s Offices in the Southern District of Florida, Eastern District of Michigan, Eastern District of New York, Southern District of Texas, Central District of California, Eastern District of Louisiana, Northern District of Texas, Northern District of Illinois, Middle District of Louisiana, and the Middle District of Florida; and agents from the FBI, HHS-OIG, DEA, DCIS, IRS-CI, Department of Labor, other various federal law enforcement agencies, and state Medicaid Fraud Control Units. A complaint, information, or indictment is merely an allegation, and all defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law. Additional documents related to this announcement will shortly be available here:  https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-charges-against-601-individuals-responsible-over This operation also highlights the great work being done by the Department of Justice’s Civil Division.  In the past fiscal year, the Department of Justice, including the Civil Division, has collectively won or negotiated over $2 billion in judgements and settlements related to matters alleging health care fraud. 
04.05.2018
Empirical Risk
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CMS-HCC Coding Cards – 12 Pack You will love these 5x7 HCC Coding Cards! This 12 pack is perfect your next risk adjustment project. 1.Diabetes: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 2.COPD: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 3.Heart Failure: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 4.Major Depressive Disorder: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 5.Malnutrition and Morbid Obesity: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 6.Complications with Internal Devices and Dependence: •ICD-10 Coding Tips for Complications (side 1) includes RAF •ICD-10 Coding Tips for Dependency (side 2) includes RAF 7. Infectious Disease: •ICD-10 CDI / Coding Tips for HIV and Sepsis (side 1) includes RAF •ICD-10 Coding Tips for Liver Disease (side 2) includes RAF 8. Heart Failure: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 9. Chronic Kidney Disease: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 10. Seizures and Neurological Disorders: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 11. Diseases of the Digestive System: •ICD-10 ICD-10 Coding Tips (side 1) includes RAF •ICD-10 ICD-10 Coding Tips (side 2) includes RAF 12. Primary and Secondary Neoplasms: •ICD-10 ICD-10 Coding Tips (side 1) includes RAF •ICD-10 ICD-10 Coding Tips (side 2) includes RAF Post one to your bulletin board, stick one near the EHR or tape it to your workstation HCC Coding Cards are made to last all year on thick 16 pt cardstock with a gloss finish. Order one for your whole team and SAVE 25% here Visit our store to see more risk adjustment tools.
26.04.2018
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Are you looking for the best education available in risk adjustment? Good News - You have found it! Join us for a day of risk adjustment, catch up with colleagues over lunch, and get the best tools in the industry for FREE! Do you need CMEs or CEUs? We have that too! All Workshops are approved by the American Medical Association, American Academy of Family Practice and the American Academy of Professional Coders. Register your team ( 3 or more) today to save 10% on Tampa and Ft. Lauderdale. Take advantage of Early Bird pricing for Fall Workshops and Save $100! Improve the Accuracy of your Risk Scores... Overview: What is changing for risk adjustment in 2019? New ICD-10 codes and HCC categories are coming. What should your team be doing now to prepare? Review the different risk adjustment models and their impact on medical practice management for 2019 and beyond. Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims? Take a deep dive into HCC Coding and Documentation. Review real documentation examples to see what validates, what doesn’t, and why.  Learn how to leverage frontline staff to be successful in the world of risk adjustment and value-based payments. Download the Agenda Here Who Should Attend? Medical Coders and Billers Providers, Managers and Frontline Staff CDI Specialists Executive Leaders ACO, MSO and IPA Teams Rural Health Centers Health Alliance Members Medicare, Medicaid and Commercial Plans REGISTER BELOW: Fort Lauderdale, Florida CYPRESS CREEK EXECUTIVE CENTER 1451 W. Cypress Creek Road, Fort Lauderdale, FL, 33309 Wednesday - May 9, 2018 9:30 AM - 3:30 PM SOLD OUT Thursday November 8, 2018 9:20 AM - 3:30 PM Early Bird Pricing $100 Register Here Tampa, Florida HILTON GARDEN INN TAMPA RIVERVIEW 4328 Garden Vista Drive, Riverview, FL 34747 Wednesday - October 24, 2018 10:00 AM - 4:00 PM Early Bird Pricing $100 Register Here Visit www.ermconsultinginc.com for more details
15.04.2018
Empirical Risk
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You will love these 5x7 HCC Coding Cards! This 6 pack includes all the basics to jump start you risk adjustment project. 1.Diabetes: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 2.COPD: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 3.Heart Failure •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 4.Major Depressive Disorder: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 5.Malnutrition and Morbid Obesity: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 6.Complications with Internal Devices and Dependence •ICD-10 Coding Tips for Complications (side 1) includes RAF •ICD-10 Coding Tips for Dependency(side 2) includes RAF Post one to your bulletin board, stick one near the EHR or tape it to your workstation! HCC CodingCards are made to last all year on thick 16 pt cardstock with a gloss finish.  Order yours today!
03.04.2018
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Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter    April 2, 2018 For payment year 2019, CMS will implement the updated CMS-HCC model without count variables that was provided in Part I of the Advance Notice for comparison. "This model incorporates the proposed additional Chronic Kidney Disease, mental health, and substance use disorder conditions, updates the data years used to calibrate the model from 2013 diagnoses predicting 2014 cost to 2014 diagnoses predicting 2015 cost, and selects 2014 diagnoses for calibration with the CPT/HCPCS-based methodology that is used to select risk adjustment eligible diagnoses submitted to the encounter data system. " See New Coefficients Below: Encounter Data CMS is also finalizing the proposal to calculate 2019 risk scores by adding 25% of the risk score calculated using encounter data and FFS diagnoses (with inpatient RAPS data to supplement encounter data) and 75% of the risk score calculated using RAPS and FFS diagnoses.  Download the entire Call Letter here
30.03.2018
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What will define those who claim victory and those who are defeated in the battle towards value based care? Will it be those organizations with the most money, power and seats at the table? Or will it be those who are nimble, flexible and open to change?  I believe it will be both. As victory will not be defined by the owners and head coaches but instead by how the players execute on the field. It will be the game time decisions that matter most. A quarterback who can read the defense and adjust accordingly will provide far greater value to the offense than the most athletic quarterback who misses the blitz every time. Perhaps Napoleon said it best, “Battles are won by the power of the mind.” For in a game of inches, the winners and losers will be defined by those who can execute in the moments that matter most. Prepare your team for victory with information at the point of care! ERM Consulting has developed the industries best tools for players on the frontline. Order yours today! Clinical Documentation Guide for Providers and Coders This 42 page guide includes proper ICD-10 coding and clinical documentation for the most common diagnoses included in the risk models. A complete list of CMS-HCCs with RAF and demographics included. Order 1 for your entire team! Orders of 100 or more can be white labeled with your logo at no charge. Please email logo to kgifford@ermconsultinginc.com after purchase. CMS-HCC Quick Coder This 36 page guide contains a list of the most common HCC codes in the Medicare (CMS-HCC) model. Includes both medical (HCC) and pharmacy (RxHCC) codes. Orders of 100 or more can be white labeled with your logo at no charge. Please email logo to kgifford@ermconsultinginc.com after purchase.  Visit our online store for a full list of available tools. https://erm.ecwid.com/
By Shannon DeConda   CPC, CPC-I, CEMC, CMSCS, CPMA® Three key takeaways from this effort by healthcare giant UnitedHealthcare UnitedHealthcare (UHC) is continuing its quest to revamp many facets of our healthcare industry. Last year, they adapted mandatory policies for the use of the SA modifier to indicate that a professional service was performed as incident-to, and now the company is introducing a mandatory review of high-level ED facility-based service codes. The newest UHC policy took effect March 1 and applies to both UHC’s commercial plans and its Medicare Advantage plans, as well as claims submitted to UHC from non-participating facilities. Organizations that submit claims to UHC have begun to see a dramatic change in coding policy, with emergency department (ED) service codes of Level 4 and 5 now undergoing review for adjustment or outright denial. Let’s review the policy change and the explanation posted by UHC, and then we will walk through concerns providers have including the following: Simply selecting ED codes 99284 and 99285, which represent moderate-complexity and high-complexity cases, will result in the claim being reviewed by UHC using its Optum Emergency Department Claim (EDC) Analyzer tool, which is a software module that supposedly “systematically evaluates each ED visit level code in the context of other claim data (i.e., diagnosis codes, procedure codes, patient age, and patient gender) to ensure that it reasonably relates to the intensity of hospital resource utilization as required per CMS (Centers for Medicare & Medicaid Services) guidelines.” UHC stated in its December 2017 bulletin, that the other ED codes, 99281-99283 (in the same family of codes) will not be subject to this automatic review by the EDC tool. UHC further stated that those facilities submitting claims with 99284 or 99285 will have those claims “adjusted” in level, which is to say downcoded, or completely denied, based on “the reimbursement structure within their agreements with UnitedHealthcare,”. There are some exceptions to the automatic EDC review, which include: Admissions from the ED; Critical care patients; Patients younger than 2 years of age; Certain diagnoses requiring greater-than-average resource use when performed in the ED; Patients who die in the ED; and Facilities whose billing of Level 4 and 5 evaluation and management (E&M) codes does not abnormally deviate from Optum's EDC Analyzer tool determination. Facilities that see either a reduction in their ED code levels or denials will be able to submit reconsideration or appeal requests if they disagree with the EDC analyzer’s findings and the subsequent “adjustments,” according to the UHC bulletin. The massive increase in scrutiny created by this new policy is needed, UHC said, to “support UnitedHealthcare’s commitment to the triple aim of improving healthcare services, health outcomes, and overall cost of care.”  Now, let’s break it all down:  Facility coding guidelines are different from professional coding guidelines. Therefore, although the codes used to bill and support the facility-based services are the same, the utilization of these codes are quite different. When reported for Facility services codes are chosen based on the volume and intensity of resources utilized by the facility to provide patient care. In fact, while physicians pay homage to documentation guidelines with every single service they provide, CMS has yet to create a standard by which facility ED codes are applied to an encounter. ACEP has created a set of standards than many ED’s across the country have adopted, and therefore has become somewhat of an industry standard, but again- previously no formal process has been adapted. Therefore, many would stay that there is no definitive correlation between facility and professional coding and therefore no rational basis for the application of one set of codes for the determination of the other on a case-by-case basis.  However, when we begin to review the steps the EDC analyzer will evaluate the line between facility services, and the professional use of the code set begins to get lost in the sand. According to the EDC analyzer (https://edcanalyzer.com/EDCAnalyzerGuide/Overview), Step one is a consideration of the level of risk of the patient’s presenting problem to drive the standard resource valuation for the presenting problems in that ED visit level and include the costs associated with the following: Nursing and ancillary staff time (for a routine arrival, triage, registration, basic patient/family communications, and a routine discharge) The room Creation of a medical record Coding and billing These four resource valuations are driven by the risk associated with the patient’s presenting problem as referenced within the MDM scoring process for professional based services. So, while these coding systems are supposed to be different, we begin to see how the facility service is also driven by the complexity of care of the patient identifying their stated medical necessity. While medical necessity should be the determination of what is billed and why it should be reimbursed, the problem in UHC’s step one determination is the initial weighted costs related to the presenting problem. For clarity, this methodology is better explained with an example. The weight of a patient presenting for a blood pressure check may seem anteriorly low, but if their blood pressure is severely high, then our presenting problem just increased 1-2 levels to a higher level of severity, which depending on the severity may pose imminent threat to support the highest cost weight category. Step two within the EDC provides for a review of all line-level services on the claim to identify diagnostic tests as follows:  Laboratory tests X-ray tests (film) EKG/RT/other diagnostic tests CT/MRI/ultrasound tests Consideration was allowed to provide for costs of creating orders, time and staffing to provide the testing, and communication with the patient. These cost weights are then added together per each category to find the total weighted consideration. WOW, this sounds much like the data and complexity section of MDM scoring of professional services but extending them beyond the scope of the physician service and realizing the facility burden associated with each category of service. Step 3 will then take into all diagnoses assigned to the patient that may impact utilization of resources based on complicating factors, i.e., the risk imposed by the patients care level needed. UHC has indicated that they have Patient complexity cost weights that were developed for each complicating condition by analyzing the additional services typically provided to patients with that complicating condition. UHC provides examples of diagnoses and conditions that they have weighted. However, they do not provide the weighted costs associated with each. UHC’s final step, once again, sounds suspiciously comparative to professional services as we will use the 3 categories to assess our service collectively. The formula they have published is the following: Total Weight = Standard Cost Weight (Step 1) + Extended Cost Weight (Step 2) + Patient Complexity Cost Weight (Step 3) Translation: Pricing = resources required based on presenting problem + resources expended based on Categories of service used + the potential resources consumed based on the diagnoses of the encounter There is one curiosity that the EDC by UHC does not indicate and that is the weighted cost of each step. This information has been redacted from their website and not published, and therefore we do not know exactly the scoring process that has been implemented. At least on the professional services side, the scoring process of the medical decision making (MDM) —again comparative in nature— does provide us with the guidance of the weight of each element to support the overall service. However, UHC has chosen to keep this information confidential. So let’s apply this to a condition. There are two words that when put together, escalate care in the ED: chest pain. I do realize that facilities have protocol requirements for this type of scenario, but before we engage in a debate, please be reminded that is a facility’s protocol and not the carrier’s. Unless the medical necessity can support the appropriateness of the services rendered, the carrier may decline reimbursements. However, let’s proceed. Patient reports to the ED for chest pain and of course lab, radiology, and diagnostic testing is performed, but ultimately it is determined that the patient’s problem is merely heartburn and they are discharged to home. The UHC EDC would consider our formula as follows: Remember your algebra rules for this one: Total Weight = Chest pain + (lab + Radiology + EKG) + GERD Translation: Pricing = Extensive resources needed for chest pain presenting problem + 3 categories of service line resources + a lower resource consuming formal diagnosis of the encounter In conclusion, three final points: Industry Modeling: UHC has created a “scoring methodology” through what they consider an analytics program, but what it really seems like is they have tried to use E&M Documentation Guidelines for Professional Services to create an industry modeling scoring of these facility-based services. Now come on, everyone knows how gray and ambiguous E&M Guidelines are, and let’s get serious… the MDM is one of the MOST troublesome parts! Therefore, it seems this may end up causing more confusion as opposed to providing valued guidance. UHC Mandatory Automatic Reviews: This policy has provided some basis for facilities to better apply the proper ED service code, but it will likely raise overhead expenses on both sides. As we pointed out through this article, much of this scoring process is based on MDM related scoring principals which are gray and ambiguous at best and part of Marshfield Guidelines, which “technically” have never been formally adopted as part of the official guidelines. Now facilities will be required to produce proof to substantiate every single level 4 and 5 encounter through an appeal process. Additionally, UHC is now going to have to review every single appealed encounter. Who loses? Patients! This increased overhead will affect them on both sides: as a consumer and an insured. Data Analytics Reviews: It’s the new buzz-phrase in healthcare. Not only has data analytics created new avenues in which carriers can track all services by facilities and providers, but more importanty, facilities and providers can now analyze their own risk and focus on their compliance dollars. However, analytics cannot assess medical necessity regardless of the type of service- be it facility or professional. Keep in mind that UHC essentially has an algorithm that raises red flags of alert, but that should only be a flag, as it truly takes a reviewer to analyze services for medical necessity. Is the point of this policy to encourage undercoding? Maybe, but rather than point fingers in this way, let’s ponder for just a moment what this policy still does not do. It does not provide an avenue to educate the masses on the proper use of these codes. Instead, this policy will increase labor by driving unnecessary medical reviews. We need the carriers to back educational efforts to help improve code usage, rather than introducing burdensome policies that increase healthcare costs to all involved. READ MORE
07.03.2018
Empirical Risk
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The American Journal of Accountable Care. 2018;6(1):29-32 Much has been written about the crippling effect of America’s overreliance on opioids and the country’s ongoing chronic pain crisis.1 Major news outlets have chronicled the tragic individual circumstances, often focusing on rural communities and overwhelmed primary care providers (PCPs). Simultaneous to this pain and opioid crisis, there has been an expansion in alternative payment models, such as accountable care organizations (ACOs), in which providers take on some degree of financial risk for the total cost of care for a population based on outcomes and quality metrics. As a result of taking on financial risk, the hope is that providers will care for patients using a more holistic approach and may be increasingly involved in treating conditions that pay poorly in a fee-for-service (FFS) environment but have a significant impact on the total cost of care (eg, behavioral health conditions). At University of California, San Francisco (UCSF) Health, we currently participate in a number of commercial ACOs. This arrangement motivated us to understand what conditions drive the total cost of care. Chronic pain has been a hot topic, but this is the first exploration of chronic pain in the ACO context at a major academic medical center. As a result of clinical expertise on our ACO team, we asked the question: Do our patients with chronic pain have greater-than-​expected healthcare utilization? If so, can we design interventions that improve the quality of care while simultaneously decreasing costs? Anecdotally, providers felt that patients with uncontrolled pain often sought care in the emergency department (ED) and perhaps had longer lengths of stay when they were admitted to the hospital.  To answer these questions, we analyzed both the prevalence of chronic pain in the UCSF Health ACO population and its link to utilization. Using the Tian et al algorithm,2 we identified that nearly 20% of the UCSF Health commercial ACO populations had chronic pain. The rate of chronic pain at UCSF Health was nearly identical to the rate of hypertension and 3 times the rate of diabetes there. This algorithm was based on billing coding, pain scores, and prescription medications and was validated with reported sensitivity and specificity of 84.8% and 97.7%, respectively. Tian et al reported more accurate identification of patients with chronic pain using their algorithm than estimates based on pain scores or International Classification of Diseases, Ninth Revision codes alone. Given the high specificity of the Tian algorithm, the 20% chronic pain prevalence may be conservative. Epidemiologic estimates of the prevalence of chronic pain have historically varied, ranging from 2% to 45% of primary care populations.3 Most recently, an analysis of the 2012 National Health Interview Survey estimated 126.1 million American adults as reporting pain in the previous 3 months and 25.3 million adults suffering daily pain.4 Substantiating clinicians’ instincts, subsequent analysis of utilization patterns among UCSF Health ACO patients indicated that patients with chronic pain had 2 to 3 times the rates of ED, inpatient, urgent care, and primary care visits compared with patients without chronic pain (Table 1). Utilization was used as a proxy for cost.5  Given the finding that chronic pain was highly prevalent in our ACOs and was associated with increased overall utilization of healthcare services, we considered the current state of pain management and possibilities for improvement. We interviewed over 30 internal stakeholders and external experts, including PCPs, pain management specialists, alternative medicine providers, general and pain-specific psychiatrists, physical therapists, opioid specialists, inpatient pain nurses, and representatives from a local integrated pain treatment center. We found that pain management was divided into silos of excellence within UCSF, with limited communication or coordination of services between providers. Providers described limited integration and misaligned expectations between PCPs and specialists. Guided by these interviews with clinicians at the front lines and based on evidence in the literature and proposals suggested by the individuals we interviewed, we identified the following opportunities for redesigning chronic pain management (specific solutions are outlined in Table 2): Education Physicians and other healthcare providers need education and training in pain management. Less than half of US medical schools dedicate more than 10 teaching hours to pain management, resulting in underprepared physicians.6 Similarly, the goals of pain education could be reframed to focus on patient communication and multimodal treatment while approaching medications as just one part of a broader plan. In addition to provider education, patients must understand the risks of pain management and be informed so they can set realistic expectations and be active participants in shared decision making. As chronic pain has not been a point of emphasis in the past, changing medical education would require both individual institution- and national-level changes in curriculum development.  Communication and Coordination of Care Improvement in clinical chronic pain management could involve change at 2 levels: primary care and specialty centers. Integrating pain management into primary care could take the form of embedded psychiatric and physical therapy services within primary care centers.7 The specialty pain center could also be integrated by offering patients with complex pain management needs joint evaluations by a pain specialist, psychiatrist, and physical therapist during longer visits.8 Integrating chronic pain management into primary care, following the model of behavioral health integration efforts by UCSF Health and other health systems, could yield substantial benefits, but it requires significant investments of money and time, as well as culture shifts, in order to alter provider approaches to chronic pain.  Opioid Utilization Opioid prescribing patterns are being increasingly scrutinized in the setting of the US opioid epidemic, and specialized pain centers have an opportunity to shape application of the newly released CDC opioid guidelines.9  Pain centers can lead their institutions toward adopting responsible forward-thinking opioid prescribing policies and press other departments to think critically about chronic pain management. More broadly, pain centers can serve as advocates for individuals struggling with opioid addiction and explore novel strategies to decrease opioid usage.  Research More research into alternative approaches to manage and treat chronic pain and the impact of treatment on healthcare utilization is needed to guide future interventions. During the transition from FFS to ACO models, there will likely be the need to develop improved short-term FFS payment models for comprehensive pain management. No single strategy has been shown to effectively and reproducibly treat chronic pain, making ongoing research of paramount importance. It is important to acknowledge the obstacles preventing change in chronic pain management. The proposed changes are focused at the system level, requiring changes in culture, infrastructure, and care patterns.  As many health systems across the country take on financial risk for the total cost of care for specific populations, it may be time to take a closer look at chronic pain. With chronic pain increasingly recognized as a disease, we hope that it will be addressed with preventive measures that focus on nonmedication and noninterventional approaches to pain management, including rehabilitation, pain psychology, and several modalities of complementary and integrative medicine. It may be the perfect time to make systematic changes to how we deliver care to patients with chronic pain. Systems that take the lead in such changes will improve care for people with chronic pain, help better control the opioid crisis, and control costs in the setting of alternative payment mechanisms. Well-designed interventions to help provide coordinated effective care for patients with chronic pain could truly improve the value of care delivered at the population level. Read more and download the PDF here
29.01.2018
Empirical Risk
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Join Us for a Day of Risk Adjustment!  Review the different risk adjustment models and their impact on medical practice management.  Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims? Take a deep dive into HCC Coding and clinical documentation. Review real examples to see what validates, what doesn’t, and why. Tips for engaging physicians. Learn how to leverage frontline staff to be successful in the world of risk adjustment and value based payments.   Each Attendee Will Receive:     ($130+ value) Color Presentation Clinical Documentation and Coding Guide HCC Quick Coder Laminated Coding and Documentation Tools Who Should Attend:  Medical Coders and Billers Providers, Managers and Frontline Staff CDI Specialists Executive Leaders ACO, MSO and IPA Teams Rural Health Centers Health Alliance Members Medicare, Medicaid and Commercial Plans   Upcoming Dates and Locations:       Wed May 9th, 2018        9:30 AM – 3:30 PM        Cypress Creek Executive Center        1451 W. Cypress Creek Road, Fort Lauderdale, FL, 33309            Register Now - Very Limited Seating Available              Wed October 24th , 2018         10:00 AM – 4:00 PM         Hilton Garden Inn Tampa / Riverview         4328 Garden Vista Dr., Riverview, FL 33578             Register Now - Early Bird Pricing $199               Thursday, November 8th 2018         9:30 AM – 3:30 PM        Cypress Creek Executive Center        1451 W. Cypress Creek Road, Fort Lauderdale, FL, 33309                    Register Now - Early Bird Pricing $199                        View additional details and download the complete agenda here                         
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