Protecting and Maximizing your Revenue Cycle in 2014

2014 Coding and Fee Schedule Updates, Revenue Cycle Management Strategies and ICD-10

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HIS is a Physician management organization that specializes in managing the revenue cycle for Orthopaedic practices.

HIS has over 20 years of experience partnering with Orthopaedic practices.

We have earned the trust of our clients and we are viewed as experts and leaders in the Orthopaedic community. 

HIS is an organization that partners with Orthopaedic practices to maximize reimbursements, increase workflow efficiency, ensure compliance and improve overall profitability

2014 Coding and Fee Schedule Update

Stay up to date and compliant to protect your Revenue Cycle in 2014

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2014 Coding and Fee Schedule Updates

Revisions to CPT tumor codes

Coding Changes Shoulder and Elbow

New Category III codes

CMS Final Rule changes 2014

NCCI Policy Changes 2014

E&M Audits

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Revision to Subcutaneous Soft Tissue Tumors

All sub-sections of 20000’s have revisions to these CPT® codes

Clarifies that these tumors are in the soft tissue below the skin.

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2014 CPT Revision

Example of “malignant neoplasm” has been removed from all codes for radical resection of a tumor and replaced with sarcoma.

24077- Radical resection of tumor (eg, malignant neoplasm sarcoma), soft tissue of forearm and/or wrist area; less than 3 cm

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2014 CPT Changes

23333- Removal of foreign body, shoulder; deep

23334- Removal of prosthesis, included debridement and synovectomy when performed; humeral or glenoid component

23335- humeral and glenoid components

Removal should only be billed if not being replaced

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Shoulder Prosthesis

Deleted 23331, 23332- old codes needed update

Technique changed- removal more difficult

Replaced with 23333- Removal of foreign body deep (below fascia

and/or intramuscular 23334- Removal of prosthesis, humeral or

glenoid component- debridement and synovectomy included

23335- Removal of prosthesis, humeral and glenoid components (total shoulder)

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Elbow Prosthesis Removal

RUC requested 24160 code description be revised.

24160 and 24164 describe prosthesis vs. implant

Current method of elbow arthroplasty includes the use of cement which makes removal more difficult

Special machines are needed for removal

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2014 Category III Additions

0334T- Sacroiliac joint stabilization for arthrodesis, percutaneous or minimally invasive(indirect visualization), includes obtaining and applying autograft or allograft when performed, includes image guidance (CT or fluoro) when performed Several parentheticals that note to use this

code for percutaneous arthrodesis

0335T-Extra-osseous subtalar joint implant for talotarsal stabilization

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CMS Physician Fee for Service Final Rule 2014

Misvalued Codes: Consistent with amendments made by the Affordable Care Act, CMS has been engaged in a vigorous effort over the past several years to identify and review potentially misvalued codes, and make adjustments where appropriate. We are continuing to make strides as the values for around 200 codes were finalized and approximately 200 additional codes had their work relative value units changed on an interim basis for 2014. Included in these are services for hip and knee replacements, mental health services and GI endoscopy services.  These rates are open for public comment until January 27, 2014.

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-11-27-2.html?DLPage=1&DLSort=0&DLSortDir=descending

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Hip and Knee Arthroplasty

27130, 27447- CMS High Expenditure

27446- Harvard-valued service annual approved charges exceed $10 million

Methods have changed causing this to be possibly misvalued

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Intra-operative Minutes

2005 Current

27130 135 100

27446 105 90

27447 124 100

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2014 Final Rule

Code Description 2013 2014

27130 Total Hip $1,662.85 $1,581.00

27447 Total Knee $1,774.92 $1,579.89

76942Ultrasound Guidance $220.46 $78.71

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2014 NCCI Policy Manual

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/

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2014 Chapter 4 Page IV- 6

4. With the exception of the knee joint, arthroscopic debridement should not be reported separately with a surgical arthroscopy procedure when performed on the same joint at the same patient encounter. For knee joint arthroscopic debridement see the following paragraph.

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2014 Chapter 4 Page IV-7

6. Arthroscopic synovectomy of the knee may be reported with CPT codes 29875 (limited synovectomy, “separate procedure”) or 29876 (major synovectomy of two or three compartments). A synovectomy to “clean up” a joint on which another more extensive procedure is performed is not separately reportable. CPT code 29875 should never be reported with another arthroscopic knee procedure on the ipsilateral knee. CPT code 29876 may be reported for a medically reasonable and necessary synovectomy with another arthroscopic knee procedure on the ipsilateral knee if the synovectomy is performed in two compartments on which another arthroscopic procedure is not performed. For example, CPT code 29876 should never be reported for a major synovectomy with CPT code 29880 (knee arthroscopy, medial AND lateral meniscectomy) on the ipsilateral knee since knee arthroscopic procedures other than synovectomy are performed in two of the three knee compartments

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2014 Chapter 4Page IV- 10

14. If a single cast, strapping, or splint treats multiple closed fractures without manipulation, only one closed fracture treatment without manipulation CPT code may be reported. Additionally, if a single cast, strapping, or splint treats multiple fractures without manipulation in addition to one or more fracture(s) with manipulation, a closed fracture without manipulation CPT code should not be reported separately. These policies also apply to the closed treatment of multiple fractures not requiring application of a cast, strapping, or splint.

If a cast, strapping, or splint applied after an open or percutaneous treatment of a fracture also treats a closed fracture without manipulation, a closed fracture without manipulation CPT code should not be reported separately.

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CMS Allows ’97 Extended HPI with ’95 GuidelinesSeptember 27th, 2013

Effective Sept. 10, the Centers for Medicare & Medicaid Services (CMS) has revised its Evaluation and Management (E/M) Documentation Guidelines (DG), to allow physicians to use the 1997 DG for an extended history of present illness (HPI) with the other elements of the 1995 DG to document an E/M service. As a result, “the status of three or more chronic conditions” qualifies as an Extended HPI for either set of DGs.

The revised guideline is presented as a Question and Answer on the CMS website:

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Who’s Looking

OIG

CMS-CERT, RAC

Cigna

Humana

Workers Compensation

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NGS Prepay Audits

Current procedural terminology (CPT) codes 99205 and 99215 are in the top 15 codes identified for improper payment rates.

If one of your claims is selected for review, you will receive an Additional Documentation Request (ADR) letter. You will have 30 days from the date of the ADR to submit the requested documentation

www.ngsmedicare.com Part B New Article October 1, 2013

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New Patient Visits 2011 Orthopaedics

1 2 3 4 50

200000

400000

600000

800000

1000000

1200000

1400000

1600000

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Established Patient Visits 2011 Orthopaedics

1 2 3 4 50

1000000

2000000

3000000

4000000

5000000

6000000

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Purpose of Auditing

Bills are accurately coded and accurately reflect the services provided (as documented in the medical records);

Documentation is being completed correctly;

Services or items provided are reasonable and necessary; and

Any incentives for unnecessary services exist.

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What to Audit

How many records reviewed per provider?

Medicare or All patients

Prospective not Retrospective

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Reporting Results

Document findings and keep as permanent recordsMedical RecordsSummary Information shared with Provider(s)Spreadsheet

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After the Audit

Create protocol

Determine training means

Mandate Training

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Provider Training

In Person (one-on-one)

Webinar/Module

Newsletter/Worksheet

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Audit Summary

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Questions

4 Critical Functions of Your Revenue Cycle that

Cannot be Ignored

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Customer Service & Satisfaction

Customer servicePatient focused effort

Managing Patient expectations and complaints

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Front End Strategy

Time of Service Collections

Pre-Cert and Authorizations

Pre-Verification

Scheduling

Patient phone call management Inbound and outbound

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Optimal Coding

ICD-9 (10) and CPT selection

Documentation

Appeals

Measuring

Audits

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Education & Training

Certified Coders

One on One Relationship with physician

Open communication

Physician training

ICD-10

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Charge Capture & Reconciliation

System of accountability Every service rendered accounted for and billed

Reconciliation  Frequent reconciliation with multiple check points

through out your revenue cycle Missing Encounter report Including DME

Inventory management Ensure everything is billed and accounted for Cost of goods analysis

Strategic Audits

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Developing a complete Accounts Receivable Strategy

Thorough understanding of your payors Know Your Contracts

Credentialing and revalidation Certification and Pre-Authorization Requirements Timelines relative to submission and appeals Contract rates and payment adherence

Reimbursement Tracking Fee schedule changes Are your rates competitive with the prevalence

of transparency in cost

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Developing a complete Accounts Receivable Strategy

Managing Insurance DenialsConsistent methods, efficient

protocols and resolutionDenial Trending

What are you doing with that information ?

Identify systemic issuesRectify and route to appropriate

personnel

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Establish your A/R Assembly Line

Detailed Management of the A/R

CPI (Critical Performance Indicators)

Reporting and Trending By Payor By Physician By Service Type

Pay attention to the details in the Reports Understanding the details behind the reports will mean

increased collections and lowered D/O Payor claim habits

Set up protocols Control over processes and measure to the details 

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Collecting from the Patient

Patient Balances Toughest position in your Rev Cycle

Right people in the right job

Follow a practice policy Do you see patients w/ outstanding balances ?

Speed and efficient techniques

Staff training and motivation

Do not ignore small balances

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Create a Successful &Repeatable Process

Measure

Manage

Modify

And Repeat

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Questions

ICD-10 ReadinessActionable steps to get your practice ready for the October

2014 transition

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ICD-10 Facts to Consider

There are two code sets for ICD-10 ICD-10-CM- Fee for service code set ICD-10-PCS- Facility code sets

Transaction code sets were officially approved in HIPAA Act of 1996CPT,ICD-9, HCPCS

Workers Compensation, auto, and personal liability insurance are exempt from HIPAA

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How To Prepare

Impact Analysis

Education

Costs

Preparedness

Revenue

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Impact Analysis

Choose representative from each area of the practice Analysis is performed Readiness survey is given

ICD-10-CM Committee should analyze all of the needs Identify and mitigate risks

Create the Analysis based on results Classify issues by impact

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Impact Definition

Very High Affects fundamental functions

High Objectives will be accomplished

Moderate Can cause some negative affects

Low Can cause minor affects

Impact Analysis

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Impact Analysis

Create document to report each business area that will need to be adjusted by:PolicyProcessSystem

This will allow for better assignment of work based on impact

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Who needs education Everyone

Administrative Front Office Clinical Coders Other Back Office Staff Physicians and NPP

Recommendations for Coder Training range from 16-40 hours with a refresher in Anatomy and Physiology

Education

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Impact Definition

Very HighCoding Staff

Training

High Physician Training

ModerateClinical Staff

Training

Low All Others

Impact Analysis - Education

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What is this missing?PRESENT HISTORY:  Ms. returns to see me now one year from her operation at her midfoot. She

has been doing reasonably well in the sense that she does feel that she does have improvement of her pain relief as she had been prior to her surgical reconstruction.  I wanted to make this clear today with her and I asked her if she is better off than she was prior to surgery and she says yes.

PHYSICAL EXAMINATION:  Examination shows that her surgical wounds look good.  Her foot alignment is neutral.    She still does have complete restoration of her medial column or arch.  Her tenderness is present dorsally about the first metatarsophalangeal joint.  She has equal tenderness present plantarward, which is at the site of the FHL tendon. Now this is at the level of the proximal phalanx.  She however does have good push-off power against resistance.  She has no evidence of hallux flexus deformity and no evidence of a claw toe deformity present there.

 IMPRESSION: 

Healed first metatarsocuneiform joint arthrodesis with osteotomy, modified McBride bunionectomy, Akin osteotomy, second metatarsocuneiform joint arthrodesis, ostectomy medial cuneiform and navicular for bossing with removal of loose body and anterior tibial tendon repair.

Two hallux rigidus, osteoarthritis, first metatarsophalangeal joint with flexor hallucis longus tenosynovitis plantar grade toe.

Residual inflammation midfoot

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Site and Laterality

Most codes related to musculoskeletal conditions have site and laterality designations.

Site represents Bone Joint Muscle Multiple sites code

If there is no multiple site code, multiple codes should be used

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Acute Vs. Chronic or Recurrent

Many musculoskeletal conditions result of previous injury or trauma to a site, or are recurrent conditions.

Chapter 13 has Chronic or recurrent bone, joint, or muscle conditions Conditions that are the result of healed injury

If it is difficult to determine acute or chronic, query the provider

Acute injury coding is in Chapter 19

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Fractures

Displaced or non-displaced

Fracture type (2,3,or 4 part)

What kind (greenstick, communited, transverse)

Routine healing, delayed healing, malunion, nonunion

Open or closed Open breaks down further (Type I,

II,IIIA,IIIB,IIIC) Salter-Harris Fractures

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824.1 Fracture of ankle; medial malleolus, open

S82.56XC Nondisplaced fracture of medial malleolus of unspecified tibia, initial encounter for open fracture type IIIA, IIIB, or IIIC

S82.56XB Nondisplaced fracture of medial malleolus of unspecified tibia, initial encounter for open fracture type I or II

S82.53XC Displaced fracture of medial malleolus of unspecified tibia, initial encounter for open fracture type IIIA, IIIB, or IIIC

S82.53XB Displaced fracture of medial malleolus of unspecified tibia, initial encounter for open fracture type I or II

Sneak Peak at ICD-10-CM

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Fracture Comparison

POSTOPERATIVE Left open femoral shaft fracture

INDICATIONS FOR PROCEDURE:

The patient is a 27-year-old female involved in a high-speed motor vehicle accident, sustained a grade 2 open left distal femoral shaft fracture with comminution. Femoral neck was visualized and seen to be okay.

X-ray showed excellent reduction.

ICD-9 821.11

ICD-10 S72.355B

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Preparedness

No grace period

Coding based on date of service

Premature coding

Testing

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Impact Definition

Very HighPractice

Management System

High System Testing

Moderate Pre-Coding

Low EHR

Impact Analysis - Preparedness

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Costs

Training

Practice Management Upgrades

Temporary staffing or over time

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Impact Definition

Very High Training

High Software Programs

Moderate Staffing

LowEncounters/Superbills

Impact Analysis- Costs

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Office Superbill/Encounter

Paper Superbill/Encounter may be impossibleProviders document in writing to be

codedElectronic EncounterEMR capabilities

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Revenue

Reduced revenue:4th Quarter of 2014 & 1st Quarter

2015

Loss in Productivity

Delays in reimbursement

Increase in claims denials

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Impact Definition

Very High

Insurance Carrier /Delays in Claims

Processing

High Staffing

ModerateSlow down in office

flow

Low Holiday Season

Impact Analysis- Revenue

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Questions

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For follow up questions feel free to contact us:

Andy Salmen, Business Development HIS P: (847) 720-7007 E: asalmen@healthinfoservice.comwww.HealthInfoService.com

350 S. Northwest Highway, Suite 200Park Ridge, Illinois 60068

(855) RING-HIS