Accurate documentation of any health condition is important from the point of view of patient care as well as timely and correct reimbursement. Rheumatoid arthritis (RA) coding is thus an important process in the provider’s office, just as medical coding for various other specialties. Physicians have to utilize the correct diagnostic and procedural codes for arthritis and its treatment. The following diagnostic codes are used to report RA –
- ICD-9-CM – 714.0 – Rheumatoid arthritis
- ICD-10-CM – M06.9 Rheumatoid arthritis, unspecified
Arthritis is one of the most common causes of disability in the United States. About 50 million people in the United States are diagnosed with some form of arthritis. Rheumatoid arthritis (RA) is an autoimmune disease that mainly affects the synovial tissues around the joints. More than 1.5 million people suffer from RA in the United States. Out of every 100,000 people, 41 are diagnosed with this condition every year. Reports suggest that by the end of 2030, the number of people with arthritis is expected to rise to 67 million.
Women are about two and a half times more likely to suffer from this syndrome than men. This disease begins between the ages of 30 – 60 in women and somewhat later in life in men. The lifetime risk for developing this condition is 4% in women and 3% in men. However, RA can occur at any age and even small children can get it. More than 3, 00,000 children in the US have the juvenile form of this disease.
Routine Tests and Diagnosis – Why is it Essential?
Rheumatoid arthritis is a systemic disease that can affect all body parts such as the heart, lungs, tissues, muscles, ligaments and cartilage. The signs and symptoms of this disease may vary in severity and may even come and go. It may also differ from one person to another. Some of the main symptoms include chronic pain, joint swelling and stiffness, fatigue, and weight loss. The potential risk factors associated with this syndrome include heredity, sex, age and lifestyle. Moreover, RA increases the risk of developing other conditions such as stroke, osteoporosis, heart and lung problems, and carpel tunnel syndrome.
Early diagnosis and treatment of rheumatoid arthritis can help control the disease symptoms and prevent disability. However, it is difficult to diagnose this condition in its early stages as the initial signs and the symptoms mimic those of many other diseases. There is no single blood test or other tests to verify the diagnosis. As part of the physical exam, rheumatologists will check your joints for swelling, redness, reflexes and muscle strength.
These specialists will perform a comprehensive diagnostic evaluation of the disease symptoms by conducting blood tests and X-rays and clearly documenting them. This helps them to better track the progress of this disease in the joints over time.
Anti-inflammatory Drugs Slow Down Bone Loss in Early RA Patients
A recent study found that aggressive anti-inflammatory treatment could reduce the intensity of bone loss in patients with early rheumatoid arthritis. The study results show that modern aggressive treatment can minimize osteoporosis in patients with RA.
About 92 patients (mean age – 50.9 years) suffering from RA participated in the research. Out of the total participants, two thirds were women and 80% of them had conducted their bone mineral density assessment at 10 years. These patients experienced disease symptoms for a mean of 12. 4 months. The key findings include –
- Researchers found that about 18.5% of patients with this disease used biologic disease-modifying anti-rheumatic drugs during the first 2 years of the study.
- On the other hand, 62.6% patients utilized the same drugs for the next 8 years and at the same time the average bone mineral density loss reduced substantially.
- The average yearly rate of bone loss at 2 years and 10 years reduced from -1.00% to -0.56% for the femoral neck, from -0.96% to -0.41% for total spine, and from -0.42% to 0.00% for the L1-L4 vertebrae.
VFC (Vaccines for Children) program is federally funded and provides vaccines free of cost to children who are enrolled in Medicaid, underinsured, uninsured, or an Alaska or American Indian Native through age 18. Facilitating access to vaccines and vaccine activities is among Medicaid’s top priorities. All ACIP (Advisory Committee on Immunization Practice) recommended vaccines are provided to children under the age of 21 who are eligible for the Early Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. Under the VFC program, the Centers for Disease Control and Prevention purchases vaccines at a discounted rate and distributes them to state health departments and local/territorial public health agencies that in turn distribute them at no cost to public health clinics and private physicians’ offices that are registered as VFC providers. Providers can bill for an administration fee for the cost they incur in administering the vaccine. Medicaid covers the vaccine administration fee for children enrolled in its program, whereas the uninsured and underinsured children enrolled in VFC program, the parents have to pay. This administration fee varies from one state to another.
HPV Vaccine to Ward off Varied Cancer Types
HPV or the human papilloma virus is known to cause several types of cancer such as those of the cervix and throat. HPV infection can be prevented with the administration of HPV vaccine. Medical billing for HPV vaccine should contain the following information:
- Human Papilloma Virus Quadrivalent Vaccine (Gardisil®) CPT code 90649 (Human Papilloma Virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent]). This code is billed with modifier SL for both sexes ages 9 through 26 of age, females who are not pregnant. The vaccine is to be administered as a 3-dose regimen at 0, 2 and 6 month intervals. Providers should keep a vaccination log, and clearly document in the patient’s medical records details such as vaccination dates, sites of vaccination, dosage given and the lot number of the vaccine administered.
The newly licensed Gardasil vaccine provides protection against cervical cancer caused by HPV. However, not all insurance plans cover this vaccine administration. Medicaid covers this vaccine for females 19 – 26 years old. Females in the age group 9 – 18 who are Medicaid eligible or have no insurance can obtain the vaccine from clinics enrolled in the VFC program or at local Health Departments.
- Human Papilloma Virus Bivalent Vaccine (Cervarix®) CPT code 90650 (Human Papilloma virus [HPV vaccine], types 16, 18, bivalent, 3 dose schedule, for intramuscular use)
This is a VFC program benefit available for female recipients 9 – 18 years of age.
Providers have to verify the insurance information of those approaching for vaccine administration.
HPV Vaccines in Children – Safe to be Administered with Other Vaccines
Many parents are concerned about the safety and adverse reaction of HPV vaccination for children and think that it is not needed. Federal health officials have found that only few kids are getting HPV vaccines that protect them from a range of cancers, including cervical cancer and cancers of the throat and mouth.
A new study, published online by the Centers for Disease Control and Prevention notes that a HPV vaccine added to the child’s other immunizations does not affect the safety or efficacy of any of the vaccines involved. The review included 9 studies, 4 of quadrivalent HPV vaccine and 5 of bivalent HPV vaccine. 1 double-blind and 8 open-label, randomized controlled trials of multiple vaccine co-administration published between 2008 and 2012 were reviewed by the team. The studies demonstrated non-inferiority of immune response and an acceptable safety profile when HPV vaccine was co-administered with other vaccines. Co-administered vaccines included: meningococcal conjugate, hepatitis A, hepatitis B, combined hepatitis A and B, tetanus, diphtheria, acellular pertussis, and inactivated poliovirus vaccines.
Each study assessed immune response by measuring seroconversion or seroprotection that is the percentage of participants with antibody concentration or titers above a predetermined threshold.
To determine safety, the study participants were asked to report symptoms 30 minutes after vaccine administration and at various intervals thereafter. The most commonly reported symptoms were adverse events at the injection sites such as pain, swelling, and bruising. The authors concluded that the available data suggests [the] HPV vaccine is safe and effective when administered with other vaccines. The team also noted that the HPV vaccine coverage is below target levels in the United States.
HPV vaccination coverage indicated receipt of any HPV vaccine and does not distinguish between HPV2 and HPV4. Vaccination coverage was assessed for each dose of the HPV vaccination series. According to the CDC, if healthcare providers increase HPV vaccination coverage to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years.
Most pediatricians recommend routine vaccination against HPV for girls, and to a lesser extent, for boys. It is important for healthcare providers to educate patients and parents of children in the target age range for HPV vaccination about HPV-related diseases and be prepared to respond to questions regarding HPV vaccination, including its benefits, limitations, and safety, as discussed earlier. If the patient is tested for HPV DNA and the results are positive, vaccination is still recommended because the chance that the patient has been exposed to all vaccine-preventable HPV genotypes is low.
With the ICD-10 compliance date fast approaching, many providers and medical coders continue to be plagued by doubts and ambiguities related to the new coding system. It is important that they obtain a clear view regarding ICD-10 and the features that distinguish it, as well as the government’s stand regarding its implementation.
Successful ICD-10 implementation demands considerable training and education for clinicians, coders and others within the healthcare fraternity that is associated with the revenue cycle. Flawless transition to the new coding system also requires specific and adequate documentation to ensure accurate medical coding. Many myths are rampant regarding ICD-10, and these must be driven out if you are to effect the transition smoothly. Here are some of the major myths doing the rounds and the actual facts.
- Myth: Medical record content will increase phenomenally.
- Fact: It is true that ICD-10 requires more documentation. However, this will amount only to a few more words for each documented condition. For instance, if the condition is one like asthma with different stages, ICD-10 allows documenting and coding each of these stages.
- Myth: ICD-10 codes are all highly complex and comprise 7 characters each.
- Fact: The most common code length is 4 characters, and there are 3 character codes too. It is a more logical system than ICD-9, because the first character indicates the disease category. This enables anyone to understand which disease family the code falls under. Often, one ICD-10 code can signify what multiple ICD-9 codes do. The new coding system reduces possibilities of error while ensuring accurate reimbursement for healthcare providers.
- Myth: Medicaid plans need not switch over to ICD-10.
- Fact: All HIPAA-covered entities including state Medicaid plans will have to switch over to ICD-10. CMS is offering special assistance to help the states with this huge transition. Payers not covered by HIPAA such as Workers’ Compensation, auto and property insurance are also encouraged to become ICD-10 compliant. The more specific nature of the codes will only be of more significant value to non-covered entities.
- Myth: The October 1, 2015 ICD-10 compliance date is likely to be extended.
- Fact: All HIPAA covered entities must implement the new ICD-10 code set with dates of service, or date of discharge in the case of inpatients, that occur on or after October 1, 2015. HHS has no plans to extend this compliance date.
- Myth: No clinical input is involved in the development of ICD-10.
- Fact: There was a lot of clinical input involved in ICD-10 development and a number of medical specialty societies contributed to its development.
- Myth: ICD-10 is probably out of date since it was developed many years ago.
- Fact: ICD-10 codes have been updated annually since their original development in keeping with the advancements in medicine and technology and the changes in the healthcare environment prior to the implementation of the partial code freeze. As a result of the code freeze, the last regular annual updates were made to both ICD-9 and ICD-10 code sets on October 1, 2011. Limited code updates for new diseases and new technologies were made to both code sets on October 1, 2012; October 1, 2013 and October 1, 2014. On October 1, 2015 only limited code updates for new technologies and new diseases will be made to the ICD-10 code sets. On or after October 1, 2015, no further updates will be made to ICD-9 because it will no longer be used. Regular updates to ICD-10 will resume on October 1, 2016.
- Myth: Super bills based on ICD-10 will not be very useful on account of being too complex/long.
- Fact: ICD-10 based super bills will not necessarily be longer or more complex than ICD-9 based super bills. Both these types of super bills provide all possible code options for many conditions.
- Myth: General Equivalency Mappings (GEMs) were developed to assist in coding medical records.
- Fact: GEMs were not developed to assist in coding medical records. Mapping is not the same as coding. Mapping connects the concepts in two code sets without considering medical record information while medical coding involves assigning the most appropriate codes on the basis of medical record information and relevant coding guidelines and rules. GEMs is used to convert databases such as payment systems, payment and coverage edits, risk adjustment logic, quality measures and a variety of research applications involving trend data from ICD-9-CM to ICD-10-CM-PCS.
- Myth: GEMs have been developed for Medicare use only. So each payer will have to develop their own mappings between the 2 code systems.
- Fact: The GEMs was developed by CMS and CDC for the use of all providers, data users and payers. They are free of charge and available in the public domain.
- Myth: Medically unnecessary diagnostic tests have to be performed to assign an ICD-10 code.
- Fact: ICD-10-CM codes are assigned according to the medical record documentation. In both coding systems, the condition has to be coded to the highest degree of certainty if a diagnosis has not been established. ICD-10 contains many more codes for symptoms and signs than ICD-9. It is designed to better report ambulatory encounters when there may not yet be known definitive diagnoses. ICD-10 system also has non-specific codes to report conditions where more detailed clinical information is not available.
- Myth: ICD-10-PCS will replace Current Procedural Terminology (CPT).
- Fact: ICD-10-PCS will not replace CPT. It will be used only for facility reporting of hospital inpatient procedures.
You can access CMS’ fact sheet on the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) at http://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD-10MythsandFacts.pdf.
Misdiagnosis is proven to be a serious concern for hospitals and may lead to patient harm, incorrect or delayed treatment, wasted resources and malpractice lawsuits. A wrong diagnosis by a healthcare professional can also result in medical coding errors. Inaccurate codes in medical bills can lead to medical office financial problems such as delayed payments, reimbursement denials, costly fines and loss of revenue. Even though, patient misdiagnosis has always existed as a major problem in the medical field, the number of cases reporting misdiagnosis issue has increased significantly.
A recent population-based estimate reveals that around 12 million adults in the US who seek outpatient care are misdiagnosed annually. This figure amounts to at least 1 out of every 20 US adults and the study found that this could potentially lead to severe harm for the patient. The study was partially funded by the Agency for Healthcare Research and Quality (AHRQ) and the results were published online in the April 17, 2014 edition of the journal BMJ Quality and Safety.
In order to determine the frequency of diagnostic errors in US outpatient care every year, researchers combined inferences from three large observational studies involving U.S. adult populations. They used data from three previous studies of errors in general primary care diagnosis, lung cancer diagnosis and colorectal cancer diagnosis.
In all the three studies, a detailed review of all the medical records was done to check whether any diagnostic error had occurred and these errors were confirmed through rigorous chart review. To estimate the annual frequency of misdiagnoses, the proportion of errors found was directly applied to the large population of all outpatient visits and to the total US adult population. Researchers found that about half of the diagnostic errors they found could have severely harmed the patients.
The authors of the study reveal diagnostic errors can harm patients by delaying their treatment. Their findings should encourage new efforts to monitor and curb the numbers of misdiagnoses. For example, a possible delay or incorrect diagnosis could make the disease more complicated to treat or more deadly. The research found that more than 6 million patients a year in the US could come across instances when a misdiagnosis could possibly lead to a deadly delay in the treatment of cancer or other such serious disease.
While combining the estimates (taken from three previous studies), outpatient diagnostic errors was recorded at the rate of 5.08% or approximately 12 million US adults on a yearly basis.
Researchers expect that this study will provide a strong foundation for healthcare organizations, healthcare professionals and policy makers to build up their future efforts to reduce diagnostic errors.
Keeping the patients engaged and loyal has become important to the long-term financial viability of a healthcare practice. The new health plans have increase the patient’s financial responsibility and they need to be well-informed about their healthcare options. They also have higher expectations about the quality of care. Better patient engagement can reduce the costs of healthcare, improve outcomes, and benefit your practice’s revenue cycle.
Strategies to Boost Patient Engagement
There are many ways to engage patients and provide improved service to boost practice revenue:
- Patient Education – This is a vital patient engagement strategy. It is important that they are well-informed about their plan’s preventative opportunities, network choices, coverage, and medical billing strategies. Providing them with access to such information will make healthcare more patient-centered, and thereby, more value-based. Empowering patients and their families will ensure better adherence to treatment plans and prevent readmissions and complications which can end up costing your healthcare practice more money or cause payment delays if the costs are not covered by their plan.
Provide them with information in a clear, accessible format through an online portal or by sending email newsletters to help them understand their health conditions better and ensure that they follow the treatment plan.
- Improved Access to Care – It’s crucial that patients can access the care system quickly and well. Whether an existing patient who needs nursing services or a new patient who needs a physician referral and appointment, effective communication is the key to quicker and seamless access to care. A well-designed appointment system can help deliver timely and convenient access to medical services, and enhance patient satisfaction and physician efficiency.
Phone calls, video chat, and online meetings will be ways patients and providers will engage for virtual doctor appointments. Experimenting with telemedicine options for the elderly is another choice. Patient portals could facilitate email and other electronic format communication in a secure and compliant way, which would benefit both the provider and the patient alike. Using medical mobile applications to deliver information at the right time can also improve patient satisfaction.
- Introduction of Electronic Forms – Wait time complaints because of the need to fill up of pre-appointment forms is a major issue. If the patient can electronically receive and fill out the necessary forms before their appointment, wait times could be eliminated to some extent. Introducing electronic check-in processes allows immediate collection of co-pays and outstanding balances.
- Healthcare Kiosks – Kiosks offer self-service abilities that help to reduce data entry, delays in the waiting room and ensure accuracy of the information. Patients can use them to view their billing statements. They also provide a quick way to inform patients of their balance and co-pay and can even collect the amount due prior to the visit.
Patient engagement can definitely drive down operating costs and promote better revenue cycle management.
In a press release published on October 9, the Secretary of Health and Human Services (HHS) Sylvia Burwell announced next year’s standard Medicare premium and deductibles with no change for Part B and a slight change for Part A. With approximately 49 million Medicare Part B enrollees, premiums and deductibles will remain unchanged at $104.90 and $147 respectively for 2015. At the same time, the premiums of Medicare Part A will fall 4.5 percent ($19) to $407 in 2015. Though the providers can continue to bill for their services with this year’s deductible in 2015 for Medicare Part B, they need to consider this change while billing for services covered under Medicare Part A in 2015.
Medicare Part A
- 99% of Medicare beneficiaries do not pay a Part A premium because they have a minimum of 40 quarters of Medicare-covered employment. Medicare enrollees age 65 and over and certain disabled individuals who have fewer than 30 quarters of coverage pay a monthly premium to qualify for coverage under Part A. Enrollees who have between 30 and 39 quarters of coverage can buy into Part A at a reduced monthly premium rate which is $224 for the year 2015. This is $10 less than the rate in 2014.
- The Medicare Part A deductible that beneficiaries should pay when they are admitted to a hospital will be $1,260 in 2015, a small increase of $44 from $1,216 (this year’s deductible). The beneficiaries’ share of costs for the first 60 days is covered by the Part A deductible; they must pay an additional $315 per day for days 61 – 90 in the year 2015 and $630 per day for hospital stays beyond the 90th day.
- Medicare enrollees admitted into skilled nursing facilities will pay $157.50 as the amount for daily co-insurance for days 21 through 100 in a benefit period in 2015. In 2014, it was $152.00.
- Income-related monthly premium rates (higher Part B monthly premiums paid by beneficiaries with higher incomes – less than 5% of Medicare enrollees) will remain the same as that in 2014.
Medicare Part B
Medicare Part B covers physician’s services, outpatient hospital services, some home health services, durable medical equipment and other items. As per the HHS Office of the Assistant Secretary for Planning and Evaluation, the premiums will be more than $125 lower over the course of a year with unchanged premiums and deductibles compared to the projections for 2015 made in 2009 by the Congressional Budget Office (CBO). Here are some facts to consider.
- If we consider this in the perspective of Medicare beneficiaries, the unchanged premiums and deductibles will leave more of elder persons’ cost of living adjustments from Social Security into their pockets. Majority of people signed up for Medicare Part B automatically and money is taken automatically from their Social Security payments.
- HHS Secretary opined in the press release that the stabilization of Part B premiums is an example for slower health care cost growth promulgated by the Affordable Care Act, to deliver more sustainable and affordable healthcare services. CMS Administrator says that the administration has taken important steps to improve the quality of care while keeping the Medicare premiums and deductibles the same. Both statements ensure greater financial and health security for older people next year.
- A CMS actuarial analysis of the Part B premiums reveals that the most prominent factor that can help to stabilize premiums will be a sharp cut in physician fees. CMS is expecting to reduce physician payments for enrollees over age 65 to $65 per enrollee per month (around 14 percent) and cut the physician fee schedule for disabled enrollees around 16 percent, to about $70 per enrollee per month.
Cutting doctors’ fees arbitrarily is unsustainable and will risk the next generation of new cost-saving and quality-enhancing reforms. Doctors will have to thoroughly examine their billing and coding procedures and manage their revenue cycle effectively to receive maximum reimbursement in this scenario. Professional billing expertise is vital to avoid claim denials in the backdrop of fierce payment cut. Effective policies and their successful implementation are essential to address the risks of payment cuts.
Physician quality reporting system (PQRS) was established in 2007 and is a pay for reporting program that provides a combination of incentive payments and negative payment adjustments to encourage providers to report quality information during patient encounters. All physicians as well as non-physician practitioners that provide covered PFS services for Medicare Part B Fee for Service (FFS) beneficiaries can participate in this program. PQRS benefits and penalty payments are calculated each year on the basis of a specified percent of each Eligible Professional (EP)’s Medicare Part B allowed charges. Here are some important facts.
- Starting in 2015, a downward payment adjustment will apply to eligible professionals who fail to satisfactorily report data on quality measures for covered professional services or fail to satisfactorily participate in a Qualified Clinical Data Registry (QCDR).
- CMS has proposed to add 28 new individual measures and two measures groups to fill existing measure gaps. At the same time they plan to remove 73 measures from the reporting of PQRS. With these proposed modifications, the PQRS individual measure set would become 240 total measures.
- EPs generally have to report only nine measures covering 3 National Quality Strategy domains. CMS is now proposing that EPs who see at least one Medicare patient in a face-to-face encounter should report on at least 2 measures from a newly proposed cross-cutting measures set. This is in addition to any other measures that the EP has to report.
The deadline to submit data for 2014 PQRS is February 27, 2015.
Incentives and Penalties
An incentive equal to 0.5% of the total estimated Part B allowed charges for all covered professional services provided by the eligible professional during the applicable reporting period will be paid to EPs who satisfactorily report in the 2014 PQRS program. Group practices participating in the GPRO (Group Practice Report Option) can also qualify for PQRS incentive payments equal to 0.5% of the practice’s total estimated Medicare Part B PFS allowed charges for all covered professional services provided during a 2014 PQRS reporting period, if they meet the criteria for satisfactory reporting specified by CMS.
Non-participation in the PQRS program will bring the following penalties.
- 2014 – No penalty
- 2015 – -1.5%
- 2016 – -2.0%
- 2017 – -2.0%
Eligible professionals who do not satisfactorily report on quality measures for covered professional services during the 2014 PQRS program year will incur a 2% payment adjustment to their Medicare PFS amount for the services they provide in 2016.
Individual EPs can participate in the 2014 PQRS program via any of the following:
- Medicare Part B Claims
- Direct Electronic Health Records (EHR) using Certified EHR Technology (CEHRT)
- Qualified PQRS Registry
- Qualified clinical data registry(QCDR)
- CEHRT via Data Submission Vendor
The 2015 QCDR measure data is proposed to be made available on Physician Compare collected either at the individual level or aggregated to a higher level of the QCDR’s choice, such as the group practice level.
The new rule released by CMS provides a breather for physicians since it allows flexibility in certified EHR technology for meeting meaningful use in 2014. In addition, this rule finalizes the extension of Stage 2 through 2016 for certain providers. Stage 3 will begin in 2017 according to the new rule. See CMS’ press release on the same.
Eligible providers can now use either the 2011 edition certified EHR technology (CEHRT) or a combination of 2011 and 2014 edition certified EHR technology for the EHR reporting period in 2014. However, in the year 2015, all eligible providers are required to use the 2014 edition of CEHRT. As CMS made clear, this flexibility allowed will ensure that providers can continue to participate in the EHR incentive programs. Moreover, more providers will also be able to meet important meaningful use objectives such as drug allergy and drug interaction checks, provide clinical summaries to patients, reporting on key public health data, electronic prescribing and reporting on quality measures.
This move, no doubt, was welcomed with overwhelming support because at the end of July, only 1900 eligible providers had attested to Stage 2. While this is a welcome step indeed, much more needs to be done to make sure that more providers could satisfy the meaningful use criteria.
Physicians are required to demonstrate their proficiency in electronic health records as a condition of licensure effective January 1, 2015. They will be considered to have demonstrated proficiency provided they meet any one of the following conditions:
- Participated in the Stage 1 of Meaningful Use program as an Eligible Professional
- Completed at least 3hours of accredited CME program on EHR
- Have a relationship with a hospital that has been certified as a Stage 1 Meaningful Use participant. This means that the physician must either be employed by the hospital, or credentialed by the hospital or have a contractual agreement with the hospital.
- Participated or is an authorized user in a state’s official health information exchange.
Now, there is an important fact to consider. The rule is applicable only to providers that “could not fully implement 2014 edition CEHRT for the EHR reporting period in 2014 due to delays in 2014 Edition CEHRT availability”.
- A Medicaid eligible professional who is in the first year of the program in 2014, and has to meet the requirements for adopting, implementing, or upgrading CEHRT, has to use 2014 CEHRT.
- For eligible hospitals, the 2015 Meaningful Use year starts in less than a month and for professionals in four months. So they don’t benefit from this modification.
- Providers who have achieved meaningful use in 2013 but have modified their software so that their present version is no longer certified, and have not moved to 2014 software for some reason or other also do not stand to gain by the present modifications in the rule.
Incident-to billing refers to billing outpatient services that are performed in a physician’s office located in a separate office, institution, or in a patient’s home. These services are often provided by a non-physician practitioner (NPP) such as a nurse practitioner (NP), physician assistant (PA), or other non-physician provider. Incident-to services include administering injections, taking vital signs, changing dressings and removing sutures. When a physician assistant or a NP supervises, the services are billed under the PA’s or NP’s NPI and reimbursed at 85% of the physician fee schedule.
Since this billing process can be rather confusing, it is important to understand clearly how incident-to billing works.
NPPs can provide services without direct physician supervision and can bill directly for the provided services, and as incident-to a physician’s services if they are licensed by their state to assist in providing the services.
Billing under a Physician’s NPI (National Provider Identifier)
NPPs providing services that are incident-to a physician or other practitioner’s service can bill under the physician’s NPI provided the service is:
- An integral, though incidental part of the physician’s professional service.
- Of the kind that is commonly furnished in physician clinics and offices.
- Usually rendered without charge or included in the physician’s bill.
- Provided by the physician or auxiliary personnel under the physician’s direct supervision.
There should have been a direct, professional service provided by the physician to start the course of treatment, of which the service being performed by the non-physician is an incidental part. The physician must see the patient first, to start the plan of care for that patient, after which the NPP follows that plan of care during subsequent visits. An important thing to note is that if a patient mentions a new problem during a follow-up visit for a problem with an established plan of care, that visit cannot be billed as incident-to. Such a visit should be billed as the appropriate new or established service under the NPP’s own provider number. In this case, the physician should have performed the initial service for the diagnosis or condition and remain actively involved during the entire treatment course. The physician must also perform subsequent services to prove his continued active involvement in the patient’s care.
The term direct physician supervision in the office setting signifies, according to CMS, that the physician is present in the office and is immediately available and able to provide assistance and direction throughout the time the service is performed. It doesn’t necessarily mean that the physician must be present in the same room. Any service conducted outside the office setting, such as the patient’s home, institution other than a hospital, or Skilled Nursing Facility, can be classified as incident to a physician’s service only when there is direct personal supervision by the physician.
An NPP or other auxiliary staff member can bill a service under a physician’s NPI only when a physician is in the office and directly available to help, if it is needed. The physician providing the direct supervision or one who is in the office need not be the physician that established the plan of care for the patient.
While many services and supplies are covered incident-to in an office setting when provided by an NP, the physician cannot bill for them when provided in hospital settings. Simply put, if the physician uses the services of his own employees in a hospital setting and merely supervises the services, he is not eligible for Medicare payment. In a hospital setting, the physician is not entitled to practitioner payment if he does not personally perform the service.
General supervision requirements apply with regard to service provided to homebound patients (patients whose ability to leave home is restricted and requires considerable effort) in underserved areas. General supervision requires the physician to be physically present at the patient’s place of residence when the service is performed. The service must be ordered by the physician and performed under his overall supervision and control. The physician retains professional liability for the service.
It is important to follow the guidelines, though complex, of incident-to billing very closely because this is a billing area that is minutely scrutinized by payers who recognize this billing technique.
One of the major advantages of the Affordable Care Act (ACA) is its potential to reduce the total healthcare cost partly by cutting down the number of emergency room (ER) visits by patients with less-than-urgent needs. Earlier, the advocates of Obamacare asserted that the new healthcare law will diminish the emergency room crowding caused due to lack of coverage. The main theory behind this new rule was that individuals without health insurance coverage have no place to turn when they require serious medical attention and as a result will directly head to emergency department. Health insurance coverage will allow people to skip ER facilities and rely on less crowded physician offices.
However, a recent poll conducted by “The American College Emergency Physicians” found more ER visits since January 1, 2014 and about nine in ten physicians expect ER visits to rise in the next 3 years. As an initial part of the survey, more than 1,800 emergency room doctors were interviewed, with nearly 46% of physicians reporting a significant increase in the number of patients in these rooms after the coverage went into effect fully. Moreover, 86% of physicians surveyed said that they believed these numbers will record a further increase over the next three years.
Experts cite different reasons for this spike. A long standing shortage of primary-care physicians leaves very few people to handle this increasing number of newly insured people. As per the Association of American Medical Colleges, in the United States there will be a shortage of 91,500 physicians by 2020 and by 2025 it will be 130,600. Primary care physicians such as general internists, family doctors, and pediatricians (those doctors whom many people would consult first before seeing specialists) are in highest demand.
However, this is just one prominent reason for increased ER patient visits. Researchers suggest that some physicians no longer accept Medicaid and the low income group often can’t spare extra time from their work when primary care offices are open, while ERs are open round-the-clock and by law must at least stabilize patients. Moreover, uninsured patients who don’t have proper access to any physicians are also likely to use ERs, even when it is a highly expensive option. The survey results challenge the incessant affirmations that ObamaCare’s implementation would reduce emergency department visits.
At its core, health insurance is all about financial coverage. With these findings, experts in this field emphasize the importance of building up the primary care facility. The number of patient emergency room visits will continue to increase if other initiatives like retail clinics are not supported. Moreover, some health-policy experts believe that much of the increase can be alleviated by educating patients about their healthcare options. In most cases, people who have just gained health insurance for the first time are simply used to going to the emergency rooms for most of their healthcare needs. Therefore, it is equally important to make patients aware about the need to use emergency departments correctly.