Archive for the ‘Medical Billing’ Category

Medicare Access and CHIP Reauthorization Fact Sheet

On April 27, 2016, the Department of Health and Human Services issued a Notice Executive of Proposed Rulemaking to implement key provisions of the Medicare Access and Summary CHIP Reauthorization Act of 2015 (MACRA), bipartisan legislation that replaced the flawed Sustainable Growth Rate formula with a new approach to paying clinicians for the value and quality of care they provide.

Click to view or download the fact sheet here. 

Four Technologies You Should Be Using In Your Practice

Physicians and their practices are becoming pretty comfortable using technology, according to the data from Physicians Practice’s 2016 Technology Survey, which features 1,568 respondents from across the country. Apart from EHRs, which have made significant inroads into independent medical practice, there are a plethora of other technologies that can make a physician’s life just a little bit easier and are increasingly being adopted into their practices.

Not surprising, a clear majority (78 percent) of practices say they use billing and coding software. Far more interesting, from our perspective, is that roughly a third of respondents say they use technology to conduct data analytics (33 percent) and manage their revenue cycle (29.4 percent), and 16 percent use technology to facilitate patient check-in and registration ( a 2 percent increase over 2015). While small, this number is significant given the fact that every dollar counts in medical practices, especially so for the smaller groups. In fact, when asked “What is your most pressing information technology problem?” after citing EHR-related problems, 8 percent of survey respondents said, “Costs to purchase and implement other technologies.”

In this regard, solo physician or two-doc practices are less likely to purchase and use new technologies, according to consultant Laurie Morgan of California-based practice-management firm Capko & Morgan, yet paradoxically, she says they are the ones that stand to gain the most help from technology.

“I think that smaller practices in my experience have been reluctant to look at some of these tools, partly because if they have looked in the past they have found that it just isn’t available for the platforms they are using, or maybe they thought it was it was too expensive,” she says. “But actually they can benefit from it so enormously because they have smaller teams and everyone is trying to do multiple jobs, so this technology can actually help a smaller practice even more, potentially, than a larger one.”

In an industry overwhelmed by government mandates, using front-office technology to help with data reporting just makes sense. And according to experts, the return on investment may be greater than docs think. If you are wondering which technologies would help your practice most, here are four that our experts say you should consider:


The 2016 Physicians Practice Technology Survey indicates that 30 percent of respondents use some type of revenue cycle management (RCM) software in their practices. Tom Furr, chief executive officer at Patient Pay, a payment software company based in Durham, N.C., points out that RCM can mean many things to different people. The term can encompass patient insurance eligibility verification, medical billing, claims processing and follow up, and both payer and patient collections, typically using some type of billing software and a practice management system. Practices can also outsource some or all of those functions to outside vendors. “But at the end of the day…  RCM is there to help you collect your dollars,” Furr says. “The revenue cycle is the ability to capture dollars quickly and efficiently, and that is both insurance payments but also patient payments.” That’s why, he says, new high-deductible health insurance plans are becoming a game changer when it comes to spurring efforts to collect patient payments effectively.

Jeff Wood, vice president of product management for Navicure, a Duluth, Ga.-based RCM software company, agrees. Because uptake of new high-deductible plans has been relative slow, practices are just now feeling the pinch when it comes to collecting growing patient financial responsibilities, he says. Wood uses the metaphor of the frog sitting in a pot of slowly heating water, noting that “… the [amount of patient financial responsibility] has increased every year and then all of a sudden the water is boiling, and [practices] say, ‘Wait a minute! I really have to do something about the patient [collection] side of things.'”

Aside from tightening up collection policies and procedures, physicians can look to technology to assist them in collecting patient copays and deductibles. There are several tech vendors that can provide electronic payment and collection services to practices and their patients, and in some cases, eliminate the need to send paper billing statements. Another bonus stemming from the use of an online payment solution is patient satisfaction: Both Wood and Furr say that patients are increasingly paying for services online and they want the same convenience from their medical providers.


Thirty-three percent of respondents in the 2016 Physicians Practice Technology Survey use some type of data analytics in their practices. Good data analytic capabilities can be the lifeblood of a practice, Furr says. “It’s just like financial information that you get from your bookkeeper,” he notes. “‘How much cash do we have in the bank? How much do we need to collect?’ All these basic data elements. It’s important in the RCM space to kind of understand who’s paying, who’s not paying, how quickly are you being paid, and what’s the preferred method for being paid.”

In small practices, tracking patient cost-sharing amounts can be absolutely vital, especially given the growing predominance of high-deductible health plans that shift a greater percentage of costs to patients. Matthew Parker a family medicine physician who owns a solo practice in Birmingham, Ala., says oftentimes he is essentially seeing patients for free, as he waits for payer reimbursement. “Practices traditionally have relied on the copays to buy supplies and make payroll occasionally, and things like that,” he says. And that is where the rub is for Parker: “I will say this … about the high deductibles — that has been a real challenge. And there are so many zero dollar copays now. It’s strangling us.”

That’s where data analytics can give a practice much more power over its revenue cycle. Furr says business intelligence (BI) software will provide physicians and administrators with a dashboard of financial metrics that can be customized to meet the needs of the individual practice. “It is a visual representation of a whole bunch of data. It is very easy to understand. You can look at one page and get six, eight, or 10 different data points of interest that the doctor or the head of the practice would like to see.” The utility of a dashboard that displays key practice metrics at a glance is that busy physicians can see where their payments are coming from and how long they take to come in. In Parker’s case, knowing which of his patients will not be required to pay a copay at the office visit could give him the ability to make changes to his payer mix, for example, or adjust the types and numbers of patient visits he schedules in a day.


The 2016 Physicians Practice Technology Survey revealed that 26 percent of respondents use some type of point-of-sale (POS) payment terminal to collect patient copays and deductibles at the time of service. Studies show that the rate of successfully collecting patient coinsurance drops precipitously once patients leave your practice, according to a 2013 study by Greenway Health. Mary Pat Whaley, a Durham, N.C.-based practice management consultant, says not collecting at the time of service can bring a host of problems. “To me, the worst thing [a practice can] say is ‘Oh don’t worry about it, we’ll send you a bill after your insurance pays.’ I think the patient has a right to know what to expect, and if they are not expecting to pay the full freight at the office visit, they may be really shocked,” she says.

The proliferation of high-deductible health insurance plans is putting an even greater burden on practices as they struggle to collect much larger patient balances, and in some cases, explain to new patients what insurance terms (copays, deductibles, co-insurance, etc.) mean and why they have significant payment responsibilities. Patient collectibles used to make up 5 percent to 10 percent of the physician’s fee, says Whaley, with insurance being responsible for the remainder. Now that figure is closer to 30 percent of the bill. That’s why Whaley’s consulting firm, Manage My Practice, recommends using a secure credit card on file (CCF) solution. CCF technology relies on software that interfaces with a cloud-based server to securely retain patient credit card information so that practices never have to physically store credit card numbers onsite, eliminating the risk of theft, fraud, or electronic data breaches. “The benefits are you don’t have to send out statements, you save staff time, you don’t have to chase patients to get them to pay, and payment is given upfront or a commitment to payment,” says Whaley.


A small number of practices (16 percent of respondents in the 2016 Physicians Practice Technology Survey) use some type of patient registration technology in their practices. While that number may seem low, there is great potential to streamline front-office work flow through self-service technology, says Morgan. “The whole benefit of these systems is eliminating extra work that the front-desk person would normally have to do, and also improving the accuracy of the [patient] information,” she says, “… Patients enter the information directly and it goes right into the [EHR/PM] system.” There is a range of registration technology that is available to practices: kiosks, tablets, and even patient portals. Morgan says that slow adoption is likely tied to compatibility issues with existing practice PM and/or EHR systems, but that is slowly changing as tablet/kiosk companies continue to add new partners.

Aside from collecting patient demographic and insurance information, tablets and kiosks can be used for short patient satisfaction surveys and also collecting patient copays at the time of service. Patients often don’t fully understand their insurance benefits, so it is reassuring, says Morgan, for them to look up their financial responsibility on a self-service tool. It divorces the practice from what is essentially a contract between the patient and insurance company.

“Many of these systems allow the patient to set up a payment plan too, so they can take some of the anxiety out of [the doctor’s visit] for the patient,” she says. “Definitely staff are getting better at [collections] because they’ve had to, but if there’s an opportunity to make it easier for everybody, why not take advantage of it.”

Erica Sprey, associate editor at Physicians Practice. She may be reached at [email protected].

CMS Proposes Medicare 2017 Reimbursement

The proposed 2017 Medicare Physician Fee Schedule asserts myriad changes likely to affect physician reimbursement in the coming year. As in previous years, the impact of the 2017 schedule varies based on specialty, with primary care physicians seeing modest gains while certain specialists experience flat or declining payments. Here’s what the proposed fee schedule has in store for physicians in 2017:

Conversion Factor. Adjustments to the fee schedule’s conversion factor next year will be somewhat of a wash. Counterbalancing a mandated 0.5% update to the conversion factor in 2017 are the proposed downward adjustment of 0.07% for imaging and a relative value unit (RVU) adjustment of 0.51% for budget neutrality. As a result, the 2017 Medicare physician fee schedule conversion factor drops ever so slightly, from 35.8043 to 35.7551.

Looking at the combined impacts of other proposed adjustments, Family Medicine would see a 3% gain ­–– the most accorded to any specialty in 2017. The news isn’t so cheery for Interventional Radiology, which would take a 7% hit, the most of any single physician specialty. Pathology and Vascular Surgery also face fee schedule setbacks of a negative 2% each overall.

Telehealth. The Centers for Medicare & Medicaid Services (CMS) intends to expand covered telehealth services in 2017 by proposing to pay for end-stage renal disease (ESRD)-related services, advanced care planning and critical care consultations. The latter group of services— the critical care consultations via telehealth —would be paid through new codes, GTTT1 and GTTT2. The agency also announced plans to create a new place of service (POS) code to clarify reporting of the location of a telehealth service.

Under Scrutiny. Zero-day global services, which are commonly billed alongside an evaluation and management (E/M) service code appended with modifier 25, come onto CMS’ radar screen in 2017. In its research, the agency reports that nearly one in five – 19% – of codes with a 0-day global service were billed more half the time with an E/M code that had been appended with modifier 25. Although many of the 83 codes that CMS has placed under review are for dermatologic services, this list also includes simple pulmonary, otolaryngology, and orthopaedic procedures. Home dialysis is also cited as a target for assessment.

Also under examination are global surgical packages, which the government has committed to review to “improve the accuracy of valuation of surgical services.” Due to be completed by January 1, 2019, this potential revaluation would have an impact on the 4,200 CPT® codes with a 10- or 90-day global period. The government has proposed gathering data about the frequency and input of global surgical codes by establishing eight new G codes in 2017 that are intended to measure pre- and post-operative care, as well as non-face-to-face services. Although usage of the codes on claims will be for informational purposes only, CMS is seeking feedback about the potential burden of this approach to data collection, as well as the impact of an additional proposal to withhold up to 5% of payments from surgeons who choose not to participate in the research.

Care Management. In 2017, CMS proposes to introduce a series of new care management codes for primary care, behavioral health and care coordination services. These additions include code GPPP6 for assessment and care planning of patients with cognitive impairment; GPPP1, GPPP2 and GPPP3 for behavioral health integration services in the Psychiatric Collaborative Care Model used in the primary care setting; and GPPPX for general behavioral health integration provided outside of the Model.

Two more G codes proposed for introduction in 2017 are likely to pique the interest of all physicians: GDDD1, an add-on code for patients using mobility-assistive technology, and GPPP7 for comprehensive assessment of and care planning by a physician or other qualified health care professional for patients requiring chronic care management services. These add-on codes are meant to boost pay when providing these services during a patient’s visit.

To address what it sees as the under-utilization of chronic care management (CCM) code 99490, which can be reported once per month when providing 20 or more minutes of non-face-to-face care to a patient, CMS proposes to ease certain requirements for using the code. These steps include the removal of the current requirement that physicians furnishing CCM after hours must have 24/7 electronic access to the patient’s care plan. Other welcomed changes relax requirements for initiating visits, formatting and sharing care plans and clinical summaries, and obtaining the patient’s consent.

The government also intends to cover the codes, 99487 and 99489, for complex CCM. These two new CCM codes, as well as GPPP1, GPPP2, GPPP3 and GPPPX, will require only general supervision by the physician or advanced practice provider when providing these complex and, often, time-consuming services. The proposal also would lift the burden of direct supervision—replacing it with general supervision—for the use of these codes in rural health clinics (RHCs) and federally qualified health centers (FQHCs).

Prolonged Care. Prolonged care codes 99358 and 99359 for extended non-face-to-face E/M services before or after an in-person office visit have existed for a number of years, but have never been reimbursed. In 2017, CMS will begin paying for the codes when the services are rendered to Medicare patients.

Diabetes Self-Management Training. The government is proposing an expansion of opportunities to be paid for diabetes self-management training (DSMT), G0108 and G0109 – and has introduced the framework for an entirely new initiative – the Medicare Diabetes Prevention Program (MDPP). CMS proposed reimbursement method focuses on paying for patients who experience weight loss.

Imaging. Effective beginning January 1, 2017, federal law reduces payment by 20% for the technical component (TC) (including the TC portion of a global service) for X-rays taken using film. CMS will require a new modifier on claims for the technical component of the X-ray service, including when the service is billed globally.  In subsequent years, computed radiology (CR) takes a hit with a mandated 7% reduction in payments for imaging services that are X-rays (including the X-ray component of a packaged service) taken using CR. The payment hit for CR commences in 2018.

Data Reporting. Accountable care organization (ACO) participants have not been required to submit data for the Physician Quality Reporting System (PQRS). While that sounds favorable to physicians, it can prove disadvantageous if and when the ACO is poorly managed. In response, CMS proposes to allow eligible professionals (EPs) billing under the tax identification number (TIN) of an ACO the option of reporting separately as individual EPs or as group practices for PQRS, beginning in 2016. ACO participants also would have the option of reporting quality data outside of the ACO to meet PQRS requirements in 2017 and 2018. The agency intends to exempt these groups from the group reporting registration process for the current calendar year, since the deadline was June 30, 2016.

Informal Review. In another welcomed move, the informal review for penalties for failure to successfully report to PQRS will be eased for affected physicians. The informal review process for the Value-based Payment Modifier (VBPM) also will be restructured. CMS proposes to revise the informal review policies, creating a protocol for how VBPM quality and cost composites would be affected for the 2017 and 2018 payment years should unexpected issues arise, such as an error by CMS in its calculations or a mistake by a vendor or other third party.

While most of the changes would not become effective until January 1, 2017, CMS is currently seeking comment about its recommendations in advance of issuing its final rule in early November. Read the complete proposed rule in the Federal Register at

On a final note, through a separate rulemaking process, CMS proposed to shorten the reporting period for attesting to meaningful use (MU) in the electronic health record (EHR) Incentive Program. The reporting period would be any continuous 90-day period between January 1, 2016, and December 31, 2016, instead of a full year of use as currently required. The final rule regarding MU reporting is expected to be released in October; this may be the best news of all!

Woodcock & Associates, July 15,2016,


10 Reasons Your Medical Practice May Not Be Converting New Patients

You’ve optimized your medical practice’s website, but your conversion rates haven’t budged. Look for the following causes of poor conversion rates to find the root of the problem.

  1. Poor phone etiquette.

    If you design your website carefully and invest in effective marketing campaigns, your facility will receive plenty of calls. However, if your front desk staff doesn’t practice good phone etiquette, you may lose conversions. Make sure your staff is friendly and polite to everyone who calls your facility.

  2. Prices quoted over the phone.

    Quoting prices over the phone can send potential patients away if your staff isn’t careful. For example, if your staff quotes a price inaccurately or without taking the patient’s insurance coverage into account, the patient may choose a competitor. If you allow your staff to quote prices, be sure that they have the resources they need to provide accurate information. Alternatively, consider instructing your staff to direct inquiring patients to a financial counselor for an in-person discussion.

  3. Ringing phones go unanswered.

    Some potential patients may try to call your medical practice or hospital more than once, but they are likely to give up quickly if their calls go unanswered. Make sure that you have enough people on staff to man the phones and run the front desk at the same time.

  4. Contact forms aren’t readily available on your website.

    Not every potential patient will be comfortable calling your facility directly. Instead, some patients may prefer completing a contact form and communicating with your staff via email. If contact forms are not readily available on your website, you may lose business.

  5. Your website doesn’t utilize video content.

    Research has shown that videos can boost conversion rates by up to 2 percent or more. Thus, including videos on your website is an excellent way to engage potential patients, build a connection with the doctors and encourage web traffic to convert.

  6. Your “before and after” photos aren’t flattering enough.

    If you offer results-based services, such as plastic surgery, you may post “before and after” pictures on your website to impress potential patients. However, if these pictures are not clear or flattering enough, patients may choose a competing facility. Use realistic images and patients; avoid showing glorified results that won’t relate with the common patient.

  7. Your website images aren’t authentic.

    Using generic images on your website is a turn-off for potential patients. Instead, use recent pictures of the actual staff members, doctors and nurses who work in your facility.

  8. You don’t have an answering service.

    Not all patients are able or willing to call your facility during business hours. To avoid losing business, invest in an answering service to take calls after hours.

  9. Your website isn’t optimized for search engines.

    When potential patients in your area search for services online, your website should be as close to the top of the results as possible. In order to improve your website’s position in search engine rankings, you must invest in a solid SEO strategy. The easiest way to do this is to invest in some form of content marketing (ie: blogs, video, etc…).

  10. You aren’t booking patients in a timely manner.

    Patients who call your facility want to be able to book their procedures as soon as possible. If your waiting period is too long, you may lose some business.

If your medical practice is suffering from empty appointment slots, check out some of the areas described above to identify areas where you may be losing potential patients and appointment opportunities.

By Jonathan Catley, Online Sales & Marketing Manager, MD Connect , Dec. 14, 2015

Can Electronic Health Records Prevent Harm to Patients?

Health information technology (HIT) has been shown to improve patient safety, especially with processes and applications that improve clinicians’ decision-making, documentation, and communication.

But research has often looked at these applications in single institutions. A question that remains unanswered is the impact of fully installed electronic health records (EHR) systems used in multiple organizations. Another big question: can EHRs go beyond improving safety-related processes to actually preventing adverse events, such as potentially deadly hospital-acquired infections, from reaching patients?

A new AHRQ-funded study appearing in the February 6 issue of The Journal of Patient Safety gives us some insight into these questions. It found that cardiovascular, surgery, and pneumonia patients whose complete treatment was captured in a fully electronic EHR were between 17 and 30 percent less likely to experience in-hospital adverse events.

The findings suggest that hospitals with EHRs can provide what advocates have long claimed: better coordinated care from admission to discharge that reduces the risk of harm reaching patients.

In the study, a research team led by AHRQ investigators analyzed patient medical record data from the 2012 and 2013 Medicare Patient Safety Monitoring System (MPSMS). The database includes 21 hospital adverse event measures that are considered to be bellwethers of patient safety. Researchers grouped the measures into four categories: hospital-acquired infections, such as central line-associated bloodstream infections; adverse drug events; general events, such as falls and pressure ulcers; and post-procedural events, such as blood clots.

To assess the role of EHRs in preventing adverse events, the researchers measured to what extent care received by patients in the 1,351 hospitals was captured by a fully electronic EHR. Hospital care was categorized as:

  • Fully electronic, in which all physician notes, nursing assessments, problem lists, medication lists, discharge summaries, and provider orders are electronically generated.
  • Partially electronic, in which some, but not all, of those components are electronically generated.
  • Non-electronic, in which none of these components are present.

Among the patients in the study sample, 347,281 exposures to adverse events occurred. Of these exposures, 7,820 adverse events actually took place, resulting in a 2.25 percent occurrence rate of events for which patients were at risk. Occurrence rates were highest among patients hospitalized for pneumonia and lowest among patients requiring surgery.

Thirteen percent, or 5,876 patients, received care that was captured by a fully electronic EHR. While these patients had lower odds of any adverse event, this association varied by medical condition and type of adverse event.

For example, patients hospitalized for pneumonia and exposed to a fully electronic EHR had 35 percent lower odds of adverse drug events, 34 percent lower odds of hospital-acquired infections, and 25 percent lower odds of general events. Among patients hospitalized for cardiovascular surgery, a fully electronic EHR was associated with 31 percent lower odds of post-procedural events and 21 percent fewer general events. Fully electronic EHRs were associated with a 36 percent lower odds of hospital-acquired infections among patients hospitalized for surgery.

The findings build on the results of a 2014 study of Pennsylvania hospitals that used patient safety data drawn from the Pennsylvania Patient Safety Authority, into which hospitals are required to report patient safety events. Hospitals using advanced EHRs had a 27 percent overall decline in these events, the authors found, fueled by a 30 percent drop in events due to medication errors.

Like all good research, the AHRQ study addresses some questions and raises others.

The findings showed a significant relationship between fully electronic EHRs and adverse drug event rates for patients hospitalized with pneumonia, but not for those with cardiovascular disease or needing surgery. This may be due to the fact that certain high-alert medications, such as opioids, which are often associated with adverse drug events, were not included in the MPSMS measures. Also, the study did not address which safety features of EHRs had been optimized or which applications had the greatest impact on reducing adverse events.

As of today, most hospitals and clinicians have embraced specific EHR applications and we continue to see implementation of more quality and safety features. EHRs can play a key role in preventing adverse events, and as this study suggests, adoption of EHRs can better manage the multiple tasks that prevent adverse events before they occur, keeping patients safer as a result.

By Amy Helwig, M.D., M.S., Deputy Director, AHRQ’s Center for Quality Improvement and Patient Safety and
Edwin Lomotan, M.D., Medical Officer and Chief of Clinical Informatics, AHRQ’s Center for Evidence and Practice Improvement, Feb. 16, 2016 Published in HiTech Answers (

LTPAC Medicine’s Shabby Treatment in the 2016 Medicare PFS

This post analyzes how regulatory changes embodied in the 2016 Fee Schedule affect LTPAC Medical Groups. The title is an accurate synopsis. Only those who believe suffering builds character will find comfort in 2016.

Back in April, a Whitehouse press release celebrated the passage of MACRA (The Medicare Access and CHIP Reauthorization Act): “At last, the doctors who care for seniors and many Americans with disabilities will no longer have to worry that about the possibility of an arbitrary cut in their pay.”

The Fee Schedule is the acid test for Physician pay; those values are now available. Nearly every medical professional billing to Medicare Part B was adversely affected. Medscape published a concise analysis of the generalized pain. The Kaiser Foundation opined on the sunsetting of the Primary Care Incentive Payments, a particularly painful cut for LTPAC Medical groups where up to 90%+ of patients receive PCIP eligible Part B services. On average, the demise of PCIP will relate to about 5%, or greater, reduction in a Group’s income. Because that payment was a ‘bonus payment’ it only applied to the Part B reimbursements which are @ 80% of the fee schedule (i.e. 8% added $s).

MACRA: proof that Life imitates Art. Giant Crustacea colonize Earth, humans are invited for lunch! You can pretend to be Dr. Who in this choose your own adventure novel. Or you might be a real Doctor subjected to MACRA – The Medicare Access and CHIP Reauthorization Act of 2015. That law promised an annual +0.5% upward Part B payment adjustment.

The Fee Schedule contained a painful surprise. Other current laws obligate CMS to find an annual Part B savings of 1% though reducing ‘potentially misvalued’ CPT®/HCPCS codes. In the past, savings came from surgery, imaging, testing, and cardiology. In 2016, CMS searched for problematic codes – the cupboard was bare! Their savings only amounted to 0.23%. That meant the remaining 0.77% had to be recovered via an across the board cut in the fee schedule. The combined results yielded an additional 0.3% cut in the fee schedule.

Hold on for more hidden cuts! – We aren’t finished exploring how LTPAC Medicine is subject to ‘Arbitrary Cuts’. Long time readers will recall my posts about possible pay cuts from Value Based Purchasing’s cost measures. This arises from the high costs the CMS attributed to LTPAC Groups due to their Patient Panel.

AMDA, and other commenters, petitioned CMS to adjust their cost benchmarks for the LTPAC Population with its high incidence of prior hospitalizations, cognitive impairment, and traumatic accidents. These efforts have included multiple face-to-face meetings, and timely written comments at each regulatory opportunity.

To summarize the CMS’ non-response “After consideration of the comments received, we will continue to work with stakeholders to further explore options for risk stratified comparisons.” In other words – the CMS chose to ignore their punitive treatment of Physician-led LTPAC medical groups. [Note – through a quirk in the phase-in of VBP risk-sharing, Medical Groups without Physicians will avoid the high cost designation in 2016 because no patients are ‘attributed’ to their TIN/NPI combinations.]

The CMS’ failure to correct its cost allocation/assignment methodologies will assign larger physician-led LTPAC Medical Groups (over 9 staff) to the ‘High Cost’ tier under the VBP stratification methodology. The bottom line – an additional 2% pay reduction to CY 2018 Part B payments.

CJR research generates more ‘proof’ that SNF Admissions are extraordinarily costly. (CJR is Medicare’s new acronym forComprehensive Care for Joint Replacement). All recent efforts to prove the high cost of the Patients attributed to LTPAC Medical Groups used supplemental QRUR report data. Is there an independent source that shows how patients sent to SNF settings are systematically ‘high cost’? This is important because if the patient is ‘high cost’ prior to their 1st encounter with the LTPAC Physician – how can that clinician be assigned responsibility?

For years we’ve worked closely with DHG (Dixon, Hughes, Goodman), the Southeast’s largest CPA groups. In November, Michael Wolford, a Manager in DHG’s healthcare group led a presentation on the final CJR rules. DHG’s webinar, intended largely for Hospital consumption, illustrated how to analyze discharges with DRGs covered by the CJR. They included the following slide – which graphically illustrates that SNFs receive the most costly patients:

hip_frOnly a small percent of all hip replacements are associated with a preceding Hip Fracture – but the costs are 76% higher. Nearly 85% of these very high cost patients are sent to a SNF. Only 36% of the (relatively)) lower cost joint replacement patients without a Hip Fracture are sent to the SNF. Note that neither the joint replacement, nor the underlying hip fracture add ‘acuity’ to the patient’s expected cost. Acuity measurement is intended to correct (normalize) the costs associated with medically complex patients.

VBP Costs are attributed to PCPs based on measuring which Medical Group provided the most care. Assuming the physician who admits the patient provides the ‘plurality’ of all Evaluation & Management encounters, he or she becomes responsible for the entire year’s cost under Value Based Purchasing. When asked to comment on this, CMS responded:

“We noted that high costs within the post-acute and long-term care settings present a unique opportunity for these professionals to improve performance on cost and quality measures.”

This idiocy will only increase the difficulty groups face recruiting new providers to replace those retiring in the coming years.

Summarizing the Pain: the typical LTPAC Medical group should budget for at least 5.3% pay reduction in 2016, everything else remaining equal. These same groups appear predestined to suffer at least a 2% additional Part B fee reduction in CY 2018 based on ‘high cost’ status.

The math:


P.S. groups that failed to satisfactorily report PQRS in 2014 already have an additional 2016 Part B payment reduction of 2%.

The News Isn’t All Bad! There are some new regulations embodied in the updated Fee Schedule that are good – but they fix issues that should never have been problems in the first place.

CMS Approves Advanced Care Planning (ACP): All of us probably remember Sarah Palin’s Death Panels from the 2008 Presidential Campaign. That’s when CMS first proposed adding an ACP benefit to Medicare. This year, a reprise of that same concept generated surprisingly little organized protest – at least not enough to derail the inclusion of CPT codes 99497 and 99498 on the list of Covered Services.

As a symbolic issue, adding these codes is a major step towards a more intentional process for anticipating issues in End of Life Care. Yet, when I analyzed their utility in LTPAC Medicine, the tangible benefits are harder to identify. First, the codes are strictly Time Based (no rounding up the minutes) – 99497 requires a minimum of 30 minutes of service, and 99498 requires an additional 30 minutes. The payments, depending on location, will be approximately $85 and $75 respectively. They do permit Incident to billing according to their CPT® description, but elsewhere CMS states Incident to usage is prohibited in Institutional Settings (e.g. SNF/NF).

An option, always available to physicians providing ‘Counseling and Coordination of Care Services’ is to document that >50% of the encounter was for that purpose. That allows billing under the E&M Code which corresponds (strictly) to the time spent. For example, CPT® 99310 is listed at a 35 minute duration if billing under the Care Coordination option; the corresponding payment is approximately $135. There might be many good reasons to prefer use of ACP over E&M codes billed on the basis of Time, but they aren’t based on economics.

SNF E&M Encounters no longer considered Primary Care for ACO Attribution. This article already covered CMS’s inaction on attributing the SNF’s High Cost Patient population to Primary Care Physicians for VBP. In a similar request, many Hospitalists petitioned to have the SNF (POS 31) excluded as a Primary Care location for Patient Attribution under the ACO (Accountable Care Organization) program.

This Attribution rule caused problems for Hospitalists following patients into the SNF as a Post-Acute Care setting. Hospital Care is exempt from the definition of Primary Care under ACO regulations. When ACO regulations were first drafted, there were provisions inserted to preclude ‘gaming the system’. One concern was that PCPs might join multiple ACOs and improperly associate high cost patients with a particular ACO. The current ACO regulations restrict PCPs to association with a Single ACO – not a problem with Hospital Care since that is not considered Primary Care. Yet, if that hospitalist group followed their patients into the SNF, they ran afoul the rule – one ACO per PCP Practice.

The new rule allows physicians working in SNFs (POS 31) to treat patients in multiple ACOs without affecting the patients’ ACOAttribution. This revision may change care practices in unpredictable ways. In 2015, some ACOs did not enroll LTPAC Medical Groups, or follow their patients into the SNF setting. They knew there was a good statistical probability that the LTPAC group covering that SNF would capture some of the ACOs current population through ‘attribution’ which ‘deattributed’ the patient to the previous PCP & ACO.

A nuance to the rule change – it only applies to the SNF (POS31); NF (POS 32) is still considered a Primary Care location under ACO Attribution rules. This creates a strange dichotomy – patient Attribution under ACOs now does not align with the rules for VBP. Different PCP Medical Groups could be held accountable for the costs of the same patient, one under the ACO model, and a LTC group under the VBP scheme.

Housekeeping: A number of provisions in each year’s Fee Schedule are important but not directly impacting Group Practice management. The highlights for 2016:

TCM – Transitional Care Management Services: TCM is embodied in CPT® 99495-99496. These codes are available for use by an individual’s PCP when they are a patient moving from Institutional Care to a community setting. Some LTPAC Groups report using this code when their patients move from the SNF setting to either NF or ALF status. The code is complicated to use (same as with CCM). The Fee Schedule simplified the rules for Claims Submission – effectively establishing the occurrence (e.g. the date) of the required face-to-face E&M encounter as the ‘billable’ event in the month-long TCM service.

Quality Reporting Changes: This year’s Fee Schedule included multiple changes in Quality Reporting. This included both policy changes, and additions/deletions/updates to individual measures and measures groups. The next post in this Blog will focus on specific PQRS changes that affect LTPAC Medicine. Two high level changes are worth noting.

GPRO (Group Practice Reporting Option: Effective with performance year 2015, groups that elect GPRO will have the option to report by other methods. Previously, the GPRO election was ‘non-reversible’. That meant that once the GPRO election window closed (e.g. July 1, 2015) the group was unable to change their PQRS reporting strategy. Some groups discovered they misunderstood the GPRO requirements and were unable to complete reporting. That ‘trap’ was eliminated retroactively with the final regulation. For performance years 2015 and beyond groups are not bound by the GPRO election (see page 987 of the final rule for a lengthy discussion or wait until CMS literature is updated). For 2016, we believe this change creates an important strategic option for reporting. We’ll be covering that in our target educational offerings for EHR users.

Measuring Quality Performance Scores using ABC™ (Achievable Benchmarks of Care): How well a provider (or group) scores on quality measures is determining an increasing percentage of their reimbursement. The existing methodologies for establishing benchmarks, or performance goals, has deep flaws. These benchmarks were established based on Provider Performance – which yielded results that were widely divergent (e.g. higher performance scores) from the universe of patients’ performance. That arose because smart providers only reported on measures they performed with good results. As quality metric measurement became more pervasive, providers realized they would be compared to these ‘star performers’. The ABC™ program is supposed to derive its benchmarks from Patient level PQRS data, not Provider submitted information. The regulations don’t contain all the information needed to analyze the scope of this change, but the intent is correct – measure your patients’ achievements against other patients with similar conditions.

Rod Baird, founder and president, Geriatric Practice Management (GPM) and gEHRiMed , Jan. 5, 2016

ICD-10 in these First Few Weeks

Now that ICD-10 is here, we can finally set aside the lingering debate about whether the change would occur in our lifetimes—or ever. We can begin to see the pay-off of months and years of training and preparation—and we can look forward to fewer articles about “truly bizarre” ICD-10 codes.

That’s got to be a relief for everyone, especially those who have walked into a lamppost at some point.

In these first few weeks of ICD-10, as we’re seeing mostly business as usual—and as providers have little choice but to take a wait-and-see posture toward the impact on reimbursement for the first rounds of ICD-10 claims—it’s time to make an adjusted set of contingency plans. This isn’t just checking a box—it’s following through on your commitment to a successful ICD-10 transition.

Address training needs strategically

If you haven’t already, formalize your process for gathering ICD-10-related feedback from your team—and for finding ways to share this insight across your organization. This will help everyone who is working together to form new processes around ICD-10. For example, when physicians understand the specific challenges of coders, they will better understand the adjustments they need to make to their documentation process. And when clinical documentation improvement specialists understand the developing trends in denial management, they can pay special attention to documenting medical necessity or take other steps that help prevent similar denials from occurring in the future.

Ask your staff which specific parts of their workflow are taking longer or becoming more cumbersome; where additional (or alternative) resources would be helpful; where they notice opportunities for improvement or the need for additional training.

Once you’ve gathered and analyzed this feedback, act on it by adjusting your training plans and resources accordingly. Don’t stop there—look ahead at the coming months. Examine your Q4 2014 and Q1 2015 claims data and pay special attention to the most common families of codes you’re likely to need through the rest of this year and the first part of 2016.

Depending on where you’re located, for example, you may need to be ready to document and code snow-sports injuries throughout the winter while next summer you’ll need to master mountain-bike-related codes. And wherever you’re located, you’re more likely to need to code flu and flu-related conditions in winter and spring—get a jump on those trainings and reference materials now.

Here are a few other ways to add strategic focus to your ICD-10 training and planning:

  • As remits start to roll in, immediately identify and continue to monitor denial trends by payer. Get staff comfortable with specialized or strategic work-queues so that you’ll be better prepared to segment workload by payer as needed.
  • Apply the lessons learned from commercial payers to government-payer claims. The announcement from CMS regarding “families” of ICD-10 codes has been thoroughly written about elsewhere—but a less-discussed risks is that processes for ICD-10-coded Medicare claims will evolve differently due to CMS’ adjusted rules.

To guard against this, code and develop processes for Medicare claims as though nothing had changed about CMS’ rules for these claims. The goal should be to abide by the full specificity and documentation necessary for ICD-10—if you don’t, there will be a gap in your processes for Medicare claims when CMS’ rules re-adjust a year from now.

  • In anticipation of a potential spike in ICD-10-related denials, focus on reducing preventable, non-ICD-10-related denials. Until meaningful feedback begins to roll in from payers—and perhaps more importantly, if that feedback shows little ICD-10-related impact—the greatest single sources and root-causes of your denials will be the same as they were before ICD-10. If a spike does occur, the effect on your organization will be lower overall if you’ve addressed root-causes of denials and streamlined workflows for preemptively addressing them.

Remember the front office.

The flow of information relevant to ICD-10 begins when the patient makes their appointment. In fact, the specific ability to code initial, subsequent, or sequela encounters accounts for a significant percentage of the overall increase in number of codes, as does laterality—information that can often be gathered effectively during check-in or appointment-setting.

A real-world example: let’s say a physician forgets to document whether it’s an initial, subsequent, or sequela encounter. If your coders can find this information on the appointment record, that might make the difference between the claim going out the door on time or being delayed due to incomplete documentation.

Everything’s fine so far—so keep making it better

While signs in the industry are positive thus far, there’s still a long way to go on ICD-10. The right ongoing training plan and the right insight into your organizational performance will help you build on the momentum of this positive start—and help you move forward strategically so that no matter what, your organization is stronger if and when ICD-10-related disruption occurs.

Crystal Ewing, Product Manager at ZirMed, Oct. 16, 2015

ICD10 Quick Start Guide 2015

This guide outlines 5 steps health care professionals can take to switch to ICD-10. You may have completed some steps already as part of your transition, and you can combine or skip steps if that works best for your practice.

View the ICD10 Quick Start Guide Here. 

Centers for Medicare & Medicaid Services (, October 1, 2015