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CMS releases proposed MCR Fee Schedule [read full issue]

CMS releases proposed MCR Fee Schedule

CMS has released the 2010 Medicare Physician Fee Schedule (MPFS) proposed rule. The proposed rule projects a 21.5 percent cut to the MPFS for 2010 which will take effect unless Congress intervenes to implement legislation with additional funding to avert the cut. The proposed rule will be published July 13 in the Federal Register, but is available now at: http://www.federalregister.gov/OFRUpload/OFRData/2009-15835_PI.pdf.

This significant cut will be somewhat mitigated for Emergency Physicians in the slight boost in the practice expense component of the fee schedule calculation that they received. This has contributed to an increase in the fee schedule for the Evaluation and Management (E&M) codes that are the bulk of emergency physicians’ payments...

Scam Alert re MCR & MCD faxes [read full issue]

Scam Alert re MCR & MCD faxes
Scam Alert

The Centers for Medicare & Medicaid Services (CMS) has become aware of a scam where perpetrators are sending faxes to physician offices posing as the Medicare carrier or Medicare Administrative Contractor (MAC). The fax instructs physician staff to respond to a questionnaire to provide an account information update within 48 hours in order to prevent a gap in Medicare payments. The fax may have the CMS logo and/or the contractor logo to enhance the appearance of authenticity.

Medicare FFS providers, including physicians, non-physician practitioners, should be wary of this type of request. If you receive a request for information in the manner described above, please check with your contractor before submitting any information. Medicare providers should only send information to a Medicare contractor using the address found in the download section of the CMS.gov website found at http://www.cms.hhs.gov/MedicareProviderSupEnroll or http://www.cms.hhs.gov/MLNGenInfo/.

Please let us know if you have any questions or concerns.

Best wishes,
Lisa
-------------------------------------------
Government Affairs Department
Medical Group Management Association (MGMA)
Washington DC
(877) 275-6462 EXT 1300
govaff@mgma.com

PracticeMax, Inc. and MedaPhase, Inc. Merger [read full issue]

PracticeMax, Inc. and MedaPhase, Inc. Announce Merger

Swine Flu Watch in TX [read full issue]

Swine Flu in TX

2 Swine Flu cases reported in TX.

Some schools closing.

CDC website info:
http://www.cdc.gov/swineflu/

Texas Department of State Health Services website info with links to all swine flu related articles:
http://www.dshs.state.tx.us/news/releases/swine_flu.shtm

Information for Professionals

•   Texas Guidance for Clinicians: Patients with Influenza-Like Illness:     http://www.dshs.state.tx.us/news/releases/tx_flu-like_guide.shtm

•   Laboratory Testing Protocol for Persons with Influenza-Like Illness or Acute Respiratory Illness:     http://www.dshs.state.tx.us/news/releases/flu_lab_protocol.shtm

•   Personal Protection Equipment Guidelines for First Responders:     http://www.dshs.state.tx.us/news/releases/ppe_flu_responders.shtm

•   Interim Guidance on Infection Control and Antiviral Recommendations for Patients with Confirmed or Suspected Swine Influenza A Virus Infection:     http://www.cdc.gov/flu/swine/recommendations.htm

MedaPhase newsletter Feb 2009 [read full issue]

Change is Coming
W. Rick White, MBA, FACMPE
CEO

WASHINGTON – “President Barack Obama offered a grim portrait of America’s plight in an address to a joint session of Congress on Tuesday night, but promised to lead an economic renewal that would lift the country out of its current crisis without bankrupting its future”. – San Antonio Express-News, February 25, 2009. Immediately following this speech, Louisiana Gov. Bobby Jindal …”derided Pres. Obama’s legislative agenda as big-government ideas that will not succeed in repairing the nation’s economy.” Also yesterday Federal Reserve Chairman Ben Bernanke gave Wall Street a prediction that the recession could end this year.

Who knows what will happen? One thing is certain; change is going to happen. Just this week, Director of Finance and Accounting for MedaPhase, Mr. Forrest Smith, pulled an HFMA article from the internet that said that the American Recovery and Reinvestment Act (ARRA) 0f 2009 signed by Pres. Obama made some retroactive changes to COBRA benefits requiring employers to provide a 65% subsidy for the cost of nine months of continuation coverage for employees between September 1, 2008 and December 31, 2009. Employers are supposed to retrieve this cost through some credits toward FICA tax but no one knows right now how this is going to work. This is an example of the types of changes to which we will have to stay alert and responsive. Probably we will see similar events with regard to payment policy for healthcare services in the Emergency Department and beyond. Please note Ms. Kottman’s article later in this newsletter of some impending legislation regarding balance billing in Louisiana and Texas.

Alert: PERM audit reviews
Lynne Kottman, CCP, CHBME
Legislative Advocate

An article in the March/April Texas Medicaid Bulletin discussed the Medical Records Requests process for PERM audit reviews. Medicaid states that claims are randomly selected for review by Livanta LLC who has the contract as the CMS Documentation Database Contractor. PERM audits are or will be performed, on a rotating basis, in all states.

Balance Billing Update
Lynne Kottman, CCP, CHBME
Legislative Advocate

Balance Billing

After the disastrous finding by the courts in California that effectively ban balance billing without currently providing a mechanism for fair payment, the insurance industry is attempting to use the momentum to move to prohibit balance billing in other states around the nation. There are specific attempts in both the states of Texas and Louisiana to limit Emergency physicians from balance billing managed care patients.

* Louisiana Threat
* Erroneous information provided to Texas Legislators
* TMA Joins Class-action Suit
* United Agrees to Shut Down Ingenix
* What you can do
* Balance Billing Talking Points

Coding Corner: Documentation Dilemma
W. Maria Johnson, CPC, ACS-ED
Director of Auditing, Training & Communication

Documentation Dilemma

Ambiguous procedure notes can often result in improper or missed CPT code assignment. This phenomenon usually happens with highly complex surgical services. Often, the result is a significant loss of Relative Value Units.

Special Edition- TX bill banning balanced billing? [read full issue]

S.B. No 351, A new bill in the TX legislature
Lynne Kottman

Two bills that could impact Emergency Medicine have been introduced in the Texas Legislature.

The first, introduced in the House, House bill 344, addresses relates to eliminating payments from the Medicaid program for adverse events and would parallel the recent changes in Medicare payments.

The second, SB 351 introduced in the Senate by Senator Shapleigh, bans balance billing of enrollees of managed care health benefit plans by “emergency room physicians.” It addresses possible payment methodologies, appeal processes, and provides for administrative penalties. This is the first of what is expected to be a number of bills addressing this issue. The text of the proposed bill follows:

MedaPhase Newsletter 11-2008 [read full issue]

Some Good News
W. Rick White, MBA, FACMPE
Chief Executive Officer

Usually I am accused of relaying “doom and gloom” messages about the business side of physician practices, especially with regard to Emergency Medicine. Later in this newsletter CMS changes are revealed in which it is estimated that there will be a 4% increase in reimbursement from Medicare next year. To the extent that many managed care contracts are indexed to Medicare rates as a percent, this increase may have a magnified positive effect on revenue for physicians. In an era of economic bad news and considering that during this past summer congress was considering a 10.6% decrease in reimbursement, this is especially good news.

Medicare Changes
Lynne Kottman, CCP, CHBME
Legislative Advocate

The 2009 Medicare Physician Fee Schedule was published in the Federal Register on 11/19/08.

ACEP estimates Emergency Physicians’ will receive a 4% average increase. This comes about because provisions in MIPPA that called for a 1.1% raise in 2009 also directed CMS to change how the fee schedule adjustment is made. This budget neutrality adjustment often negates the increases for Emergency Physicians because of the undervalued cost value due to the AMA cost determination for “practice expenses” for emergency physicians. This year the Congressional direction to give greater consideration to the physician work value, combined with the increase in physician work values of the E/M codes from 2007 will result in a gain for most Emergency Medicine codes.

Please see the 2009 schedule below:

Legislative Efforts to Limit/Prohibit 'Balance-Billing' by 'Non-Contracted Physicians a 'Hot Topic'
Robert Kottman, M.D., FACEP
Legislative Advocate

For several years, state legislatures have wrestled with the conflict among insurance companies, enrollees in insurance companies’ health plans and health care providers regarding reimbursements to non-contracted providers. Health company representatives claim that non-contracted providers (especially facility-based physicians such as emergency physicians, anesthesiologists, pathologists, radiologists and neonatologists) submit claims for professional services which are exorbitant and are far above the “usual and customary” payments for these services.

MedaPhase Newsletter - Special Edition - Oct 08 [read full issue]

Our Role and the Economy
W. Rick White, Jr., MBA, FACMPE
Chief Executive Officer

Our Role and the Economy

I read an article today entitled “Now is the Time to be Afraid”. There is no way to determine whether the article’s claims are well founded and no, I have no idea what the markets will do tomorrow. In fact, I am somewhat helpless in that I have no control over it at all.
What I can control is how MedaPhase responds to the current times. On Wednesday morning of last week I called all of our employees together and gave a ‘let’s not panic’ speech. Things have definitely gotten worse since then. According to the article I read, it is time to panic. Well, I still do not believe it. Somehow, sometime this nosedive will level off and begin to rise again before it crashes. The sky is not falling and the world is not going to come to an end anytime soon. This is my belief and I am sticking to it.

Documentation Feedback
Jennifer Hackworth, RHIA
Director of Coding

Documentation Feedback

Understanding that documentation feedback is one of the most important aspects of our services, MedaPhase has implemented a new process for getting our physicians feedback in a timely, consistent manner.

Quarterly audits are being performed for each physician. At the end of every quarter, 10 charts are selected for physician feedback. In most cases, MedaPhase will include charts that have been

History Doesn�t Always Repeat Itself (on Paper)�Trends in Provider Documentation of History Elements
Jennifer Hackworth, RHIA
Director of Coding

History Doesn’t Always Repeat Itself (on Paper)…
Trends in Provider Documentation of History Elements

Across the board, provider documentation reviews show a similar trend: when it comes to deficiencies, most are identified in the History element of E/M documentation. The History element includes the History of Present Illness (HPI), Review of Systems (ROS), and Past, Family and Social History (PFSH). In order to support a high level of service (ED-99285), all three elements of History must be documented comprehensively.

Billing Shared Visits
Jennifer Hackworth, RHIA
Director of Coding

Billing Shared Visits:

At times, the line between physician and non-physician provider services may be fuzzy. Who gets credit for what services? What documentation is required? What kind of reimbursement should be expected?

MedaPhase Newsletter - Sept 08 [read full issue]

Legislative Update for 2009 Texas Legislature
Robert Kottman, M.D., FACEP
Legislative Advocate

The 2009 Texas Legislature will again deal with numerous healthcare issues, many of which were unresolved in the 2007 session. One of the thorniest issues concerns the lack of health plan network adequacy which results in patients receiving services from “out of network” physicians and then receiving “balance-bills” for the portion of the physicians’ charges which are not paid by the health plan. This issue has been particularly troublesome for hospital-based physicians when the hospital is contracted with the health plan but the physicians are not contracted, usually due to unrealistically low reimbursement rates offered by the health plans.

The Creation of Understanding
W. Rick White, Jr., MBA, FACMPE
CEO

On the first day of one of my graduate courses in college (many years ago) we spent the entire class period defining communication. By the end of the class we settled on defining communication as the creation of understanding. With that premise in mind we spent the rest of the semester looking at the barriers to complete understanding between people within their own organizations and outside of their own organizations. Often leadership mistakenly assumes that a one-way expression of facts or thoughts in voice commands, memos or e-mails is communication. However, to create understanding among people within an organization or between people in other groups takes both senders and receivers. The sender encodes a message through the selection of words from a particular language. The receiver decodes the message in order to understand the message the sender is trying to get across. Finally, to make the communication loop complete there should be feedback demonstrating that the receiver “got it”.

Key Employee List
The following are the key employees for MedaPhase, Inc.

If you need to contact one of these employees, please dial (210) 692-0424 and the extension number, or if located out of Bexar County, Texas, please dial (888) 826-9212 and then the extension.

MedaPhase Newsletter - June 2008 [read full issue]

Medicare Physician Fee Schedule for last half of 2008
Robert Kottman, MD, FACEP
Legislative Advocate

There is still time to contact your US Congressmen and US Senators regarding the Medicare Physician Fee Schedule for the last half of 2008 and for the year of 2009, As we all know, if Congress does not act, on July 1, 2008 the Medicare Physician Fee Schedule will decrease by 10.6%. Now is the time to make contact by e-mail, phone or letter or even personal visit to a Representative’s local of Washington, D.C. office to urge you legislators to stop the draconian fee cut.

Will You Be At the Table?
Lynne Kottman, CCP, CHBME
Legislative Advocate

The following article recently came out from Leah S. Cohen, a MGMA Government Affairs Representative:

The Centers for Medicare and Medicaid Services (CMS) May 16 announced that beginning Jan. 1, 2009, it will launch a three-year Acute Care Episode (ACE) demonstration project that will include bundling Medicare payments to hospitals and physicians into a single payment.

The demonstration is limited to applicants from Texas, Oklahoma, New Mexico, and Colorado. CMS will competitively award only one ACE demonstration site per market area (defined as a metropolitan core-based statistical area, or the aggregate of rural areas within a state) during the first year of the demonstration, but plans to expand the program and award multiple providers within a market area in the following two years.

Leadership Opportunities
W. Rick White, Jr., MBA, FACMPE
Chief Executive Officer

Early in my career I worked for a company that displayed great pride in the “esprit de corps” among its leadership. Their common slogan was “We do not have problems at our company; we have only opportunities to demonstrate our leadership ability!” This year MedaPhase’s leadership team has had such opportunities as well. In an effort to create greater efficiencies and control cost, we have restructured jobs, office locations and switched to a new computer system. Although I am pleased with our progress overall, it has not been without some challenges. With every new challenge, however, came a corresponding new learning opportunity. I am extremely grateful for the team of people in our organization that have demonstrated great responsiveness and creativity in developing ways of overcoming obstacles along the way.

Clearing the Air on Fracture Care
Jennifer Hackworth, RHIA
Director of Coding

ED physicians can provide a tremendous amount of care when a patient presents with a fracture or dislocation. In those cases, there are several potential codes that may be utilized, depending on the type of fracture/dislocation and the care that is given. Documentation of that care is vital to ensure minimal liability risk and proper reimbursement. In most cases, there will be one of three scenarios:

MedaPhase Newsletter 2008 03 [read full issue]

New Trailblazer EM tool
Robert Kottman, MD
Medical Director
Legislative Advocate

New TrailBlazer (Texas, Oklahoma, New Mexico and Colorado Medicare Administrative Contractor) Evaluation and Management “Coding and Documentation Reference Guide” (Audit Tool) is official and on the TrailBlazer website as of Feb. 27, 2008.

http://www.trailblazerhealth.com/partb/downloads/empocketref.pdf

New Twist on Balance Billing
Lynne Kottman, CCP, CHBME
Chief Compliance Officer
Legislative Advocate

While some of the largest states Florida, Texas, and California are in different levels of state regulation over balance billing, the state of New York is now weighing in with the attorney general Andrew Cuomo’s investigation and potential suit against UnitedHealth Group. United is one of the largest medical insurers and the largest in New York. Cuomo is also currently investigating Aetna, Cigna and Empire BlueCross/BlueShield.

MedaPhase Metamorphoses
W. Rick White, Jr., MBA, FACMPE
Chief Executive Officer

The old adage that there is nothing constant but change is certainly true of MedaPhase, Inc. today. On January 1^st of this year we began using a new billing software called AdvancedMD. Gradually phasing out the use of our other two systems we are currently working from three separate software databases simultaneously. Follow-up of accounts receivable for dates of service prior to January 1 is being done in the former systems in order to ensure continuity of collection processes on each individual account level. Accurate reporting requires the combining of two separate databases and then reconciling these totals to the actual bank deposits. At the end of another three to four months the few active accounts on each system will be loaded into AdvancedMD for further action. The inactive accounts will be archived or sent to an outside collection agency as appropriate. This is only one stage of our metamorphoses.

MedaPhase Newsletter 2007 12 [read full issue]

CPT Code Changes for 2008
Robert Kottman, MD, FACEP

Relatively few of the CPT Code changes for 2008 will have an impact on emergency medicine:

Hydration, Injection and Infusion Codes
Behavioral intervention
New thoracentesis codes
New chest tube insertion code
Other new codes
Observation Services

PQRI 2008 Update
Lynne Kottman, CCP, CHBME

Guidance for the 2008 Physician Quality Reporting Initiative (PQRI) was released with the 2008 Medicare Physician Fee Schedule Final Rule in November. The reporting period for the 2008 program will be January 1 - December 31, 2008.

The rules for the 2008 program are virtually unchanged for Emergency Department Providers. The reporting requirements remain at least 80% of at least 3 of the quality measures to qualify for the 1.5% bonus on allowable Medicare charges.

New Beginnings�New Opportunities
W. Rick White, MBA, FACMPE
Chief Executive Officer

Beginning January 1, 2008, MedaPhase will start to use a new computer system for its billing information system. After months of reviewing proposals and viewing demonstrations AdvancedMD was the unanimous selection by MedaPhase directors, managers and supervisors. Anyone interested in knowing more about the system itself and the company can review several of its features on the internet at www.advancedmd.com.

Documentation of Treatment of Phimosis to Facilitate Correct Coding
Robert Kottman, MD, FACEP
Maria Johnson, CPC, ACS-EM

Phimosis is a pathological condition in which the foreskin of an uncircumcised male cannot be retracted over the head of the penis (glans) back onto the shaft of the penis. This condition is due to adhesions between the foreskin and the glans of the penis.

The proper ICD-9 code for this condition is 605- Redundant prepuce and foreskin.

Physician Shortage Area Bonus to Sunset

The Physicians Shortage Area bonus program established in the Medicare Modernization Act of 2003 was established for the time frame January of 2005 through December of 2007. CMS has announced that this program, which pays a 5% bonus on provider Medicare payments to providers in designated physician shortage areas, will be allowed to sunset and will no longer be paid after December of 2007.

Legislative Update Newsflash [read full issue]

The Medicare �Fix� may be Out
MedaPhase Legislative Advocates
Robert Kottman, M.D., FACEP & Lynne Kottman, CCP, CHBME

Chances for a Congressional “fix” to the impending 10.1% pay cut in the Medicare Physician Fee Schedule for 2008, which we reported earlier this week, are now looking dim partially due to a threatened veto. The Senate Finance Committee had been working on a bill that would have eliminated the 10.1% Medicare pay cut for all physicians by obtaining the funds necessary to “pay for” the fee freeze through reductions in Federal payments to Medicare Advantage health plans. Medicare Advantage plans are private Medicare plans run by commercial insurance companies, which receive Federal funds to subsidize their operations. These Federal funds to the Medicare Advantage plans are felt by many to be too large- thus making a reduction in this funding the mechanism which would permit a “freeze” on Medicare Physician Fees for 2008 and avoiding the 10.1% pay cut.

Legislative Newsflash [read full issue]

Legislative Advocacy Report
MedaPhase Legislative Advocates
Robert Kottman, M.D., FACEP & Lynne Kottman, CCP, CHBME

Dr. Robert Kottman and Mrs. Kottman report the following from their meeting with Congressional Staff members on Monday, November 26:

Items of discussion –

Medicare Fee Schedule

Renewal of the SCHIPS program

ACEP access to Emergency Medical Services bill

MedaPhase Newsletter September 2007 [read full issue]

Addressing the Upcoming Medicare Reduction

As it currently stands, without Congressional intervention, Medicare payments to Emergency Physicians will be reduced by 12% in 2008. While the House had originally addressed this issue with a potential fix in their SCHIP bill, the Medicare section was removed in the reconciliation bill with the Senate.

Please contact your House members and urge them to:

co-sponsor and promote the passage of H.R. 882/S.10 to provide additional funding for emergency department physician services
support congressional hearings to address the problems in our nation's emergency departments
support a bill that provides redress to the proposed 12% payment reduction for Emergency Medicine physicians and for a small increase in Medicare payments
continue to support this bill when it is reconciled with the Senate’s initiatives after the August recess
support an overturning of any Presidential veto of the reconciliation bill for H.P.3162

To contact your House representative, just click on this link http://www.house.gov/writerep/ and fill out the information. The link will take you to the Write your Representative page on the United States House of Representatives website.

Below you will find a sample letter to a House Member, created by Dr. Robert Kottman, our Legislative Advocate. If you do not have time to write your own letter, you could use this as a template for addressing this issue as well as the ACEP sponsored “Access to Emergency Medical Services Act of 2007”
(http://www.acep.org/webportal/Advocacy/fed/accessems/default.htm).

Does Your Documentation Support the Use of IV Infusion/Hydration Codes?
Jennifer Gannon, RHIA, ACS-EM
Coding Manager

In 2006, CPT made numerous changes to the IV infusion code section. This section was revised and expanded to allow reporting of hydration and therapeutic, prophylactic or diagnostic intravenous infusions and injections. CPT directs “if a significant separately identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported using modifier 25 in addition to 90760-90779.” However, there are several elements of documentation that should be included in the record in order for the professional service to be reported.

�On-Call� Payments To Specialists At Risk

Many hospitals around the country are encountering problems with specialist on-call coverage for their emergency departments. The reasons are varied and largely involve problems with obtaining specialty care for un-funded patients. Many hospitals are attempting to address this problem by paying physicians to take emergency department call. Due to the Stark prohibition on self-referral, some hospital-physician “on call” arrangements may be problematic. One hospital asked the Office of Inspector General ("OIG") for an opinion on their program and while that advisory opinion was favorable to that hospital’s program, it may call into question the legality of other less rigorous plans.

New TrailBlazer E&M Audit Tool - October 2007
Robert Kottman, M.D., FACEP
Legislative Advocate

For the past 3 years, Trailblazer has been developing a new “E&M Documentation Guide” to be used by coders when assigning evaluation and management codes for physician services. The new TrailBlazer E&M Documentation Guide (Audit Tool) should appear on the TrailBlazer website by Oct. 15, 2007 and will replace the audit tool which currently appears on the site.

MedaPhase Newsletter August 2007 [read full issue]

Medicaid: New Compliance Enforcement
Lynne Kottman, CCP, CHBME
Corporate Compliance Officer
Legislative Advocate

In response to an OMB report that identified Medicaid and SCHIP as programs susceptible to payment errors, Congress has authorized and funded a number of programs designed to identify and eliminate overpayments. Some of the programs include: Payment Accuracy Measurement (PAM), Medicare-Medicaid Data Match (Medi-Medi), Payment Error Rate Measurement (PERM), and the Medicaid Integrity Program (MIP) and 5 year Comprehensive Medicaid Integrity Plan (CMIP).

The country may soon be overrun with Federal and State Medicaid Auditors and Contractors. It will be imperative that providers and their billing agents stay on top of audit and record requests to avoid potential recoupments (or worse).

Called to a Code Blue
Jennifer Gannon, RHIA, ACS-EM
Coding Manager

Do you know what kind of documentation your coders are looking for when you get called to a Code Blue? There are several elements that should be documented in order for the ED physician’s inpatient encounter to be coded and billed appropriately. The progress note should contain a date/time; documentation of the encounter, including written procedure notes; a diagnosis; and a signature of the physician.

Meds & Dxs which frequently reflect Critical Care Services
Robert Kottman, M.D.

Critical Care is defined as care provided to patients with Critical illness or injury that acutely impairs one or more vital organ systems or where there is a high risk of life threatening deterioration. A patient that is potentially unstable could fall under the definition of Critical Care.

Critical Care codes are time driven and require at least 30 minutes of patient care, excluding time spent performing separately billable procedures.

Some of the drugs and diagnosis that often, but not always, could indicate Critical Care are listed below.

New Texas Provider Billing Disclosure Law

The Texas Legislature passed into law SB 1731 authored by Senator Robert Duncan. (R-Lubbock) In addition to disclosure requirements for all Texas physicians, there are a number of issues included in this bill which directly impact Hospital based physicians.

Newsflash - re: MCR, SCHIP, Champ Act, & CHIP [read full issue]

Medicare Fee Fix in Future?

H.R. 3162 - the "Children's Health and Medicare Protection Act of 2007”

H.R. 3162 would replace the scheduled 9.9 percent cut to the Medicare Physician Fee Schedule for 2008 with a 0.5 percent positive update for both 2008 and 2009.

Please contact your House members ...

SCHIP Reauthorization

We received this important information from one of our physicians.

Please read and consider contacting your Senators to support this effort.

Senators to Vote to Reauthorize SCHIP!

The U.S. Senate is scheduled to vote on legislation that would reauthorize the State Children’s Health Insurance Program (SCHIP) before the end of July. The reauthorization of this successful child health program will help countless pediatric patients in South Texas.

Champ Act

The following information was provided by the TMA:

The Children's Health and Medicare Protection (CHAMP) Act <http://waysandmeans.house.gov/media/pdf/110/CHAMP/summary.pdf> should be up for debate on the floor of the U.S. House of Representatives this week. TMA and the AMA both support the CHAMP Act as the best chance to avoid a 10-percent cut in physicians' Medicare payments next year.

Here are the good things we see in the CHAMP Act so far:

CHIP Rate Hike Coming

The Texas Health and Human Services Commission proposed a 15-percent increase for evaluation and management codes for treating adult Medicaid patients.

Newsflash- BlueCross RICO Settlement Claims Coming [read full issue]

Blue Cross RICO Settlement Claims Coming

We received the following information today from the TMA that applies to providers in all states.

Blue Cross and Blue Shield (BCBS) Settlement Update

The BCBS settlement claim forms are being mailed to physicians on July 27.

Newsflash- Act Now limited time to delete NPI data [read full issue]

Act Now! Time for Deleting NPI Data Running Out

The Deadline to delete sensitive information from your NPI data is July 16. Some information that may be included in the database is your social security or tax ID number which is used as your provider number by some carriers. All NPI data in the data base as of July 17 will be made available to the public on August 1, 2007.

If you are reviewing your information, please make note of your taxonomy code (which for TX EM physicians is 207PE0004X) and make any necessary changes. The dropdown menu first lists – Allopathic. After making that selection, an additional dropdown menu allows you to select Emergency Medicine – Emergency Medical Services.

Please find below the message from the TMA outlining this problem and how to proceed in making any necessary changes.

Newsflash - re AMA's PPI Survey [read full issue]

AMA Physician Practice Information Survey

Important Physician Survey Released

Since Medicare reimbursement is a cornerstone of most Emergency Department practices, we want to encourage you to complete the new AMA Physician Practice Information (PPI) Survey if given the opportunity to do so.

In the coming weeks you may receive a Physician Practice Information (PPI) Survey.

News of Note - TX Margin Tax [read full issue]

Texas Margin Tax
Forrest Smith, MBA, CHFP, FHFMA
Director of Finance and Accounting

[Acknowledgment: Much of what I write here is compiled from notes I took at a recent South Texas Chapter, Healthcare Financial Management Association (HFMA) meeting June 1, 2007. At that meeting Paige Gerich, CPA with the CPA firm of BKD LLP in Houston, Texas made an excellent presentation entitled “Texas Margin Tax, a Prescription for Complexity.” Ms. Gerich can be reached by phone at 713-499-4636 or email pgerich@bkd.com].

House Bill 3 passed by the Texas Legislature in 2006 imposed a margin tax health care providers. This tax replaces the Franchise Tax from which healthcare providers were exempt. An important provision of the law is that most healthcare providers will file a return even if no tax is due. Doctor, do not miss the filing deadline or you could pay a “failure to file penalties” even if you owe no tax. I am going to limit my discussion in this paper to physician organizations though this new tax affects all healthcare organizations. This includes but is not limited to not-for-profit healthcare organizations especially if they have a for-profit entity or partner.

News of Note [read full issue]

PQRI: CMS eliminates 2 ED measures
Lynne Kottman, CCP, CHBME
Corportate Compliance Officer, Legislative Advocate

CMS has released final specs on PQRI that contain some changes. Consideration of the administration of t-PA for CVA/Stroke and Dysphagia screening for CVA/Stroke or Intracranial Hemorrhage no longer apply to Emergency Medicine. It appears that these measures have had the Emergency Medicine E/M codes removed from the list of possible 'encounter codes'. 99281-99285, 99291, and 99292 are no longer listed as allowable denominator codes.

Texas Medicaid: Potential Fee Increases

Our Medical Director, Dr. Robert Kottman, who serves on the Texas Medicaid Physician Payment Advisory Committee, provided the following update from the TMA on the PPAC Recommendations for the use of the funds designated by the Legislature to settle the FREW lawsuit.

Subject: PPAC Recommendations

Today, the Medicaid Physician Payment Advisory Committee held its second meeting to fine tune the proposal it adopted in May. Below is a summary of the PPAC recommendations.

MedaPhase Newsletter - May 2007 [read full issue]

Congratulations
W. Rick White, Jr., MBA, FACMPE
Chief Executive Officer

MedaPhase would like to congratulate our Medical Director, Robert Kottman, M.D., FACEP, who has been awarded the Texas College of Emergency Physicians James E. Hayes, MD, FACEP - Award for Outstanding Contribution to the Field of Emergency Medicine. The award was presented by John Myers, MD, FACEP, outgoing President of TCEP.

Testing Opportunity for the PQRI
Lynne Kottman, CCP, CHBME
Corportate Compliance Officer, Legislative Advocate

MedaPhase will be taking advantage of the new opportunity provided by CMS to test our billing systems, and verify our readiness for PQRI quality data code reporting. CMS has designated "G8300" as a test code for PQRI reporting prior to July 1, 2007, the start date for PQRI reporting. G8300 was formerly used in the 2006 PVRP program and will be retired on July 1, 2007; meaning it will be rejected on any claims submitted for dates of service on and after July 1, 2007.

Blue Cross Agrees to Settlement in �RICO� Case
On April 27, the state's largest health care payment plan settled a class action lawsuit filed under the Racketeer Influenced and Corrupt Organizations Act (RICO). The suit was filed by a number of state medical associations across the country including the Texas Medical Association. More than 90 percent of Blue Cross and Blue Shield health plans and the Blue Cross and Blue Shield Association have agreed to implement terms of the settlement. The settlement terms include changes to key business practice and a restructuring of the administration and payments for medical care for their enrollees.

Potential for Increased Texas Medicaid Payments
Part of the proposed settlement of the Frew lawsuit against the state of Texas is an increase in Medicaid payments to providers. The final settlement will be determined by Health and Human Services Commission and must be approved by the trial judge. HHSC will be using the recommendations of the Medicaid Physician Payment Advisory Committee (PPAC) as a basis for their final determination. Dr. Robert Kottman, MedaPhase’s Medical Director serves on the PPAC and has provided us the following information on the proposed agreement:

PQRI Update
Lynne Kottman, CCP, CHBME
Corportate Compliance Officer, Legislative Advocate

Information about PQRI has been changing on almost a daily basis as the implementation date approaches. PQRI is the current provider reporting program outlined in the Tax Relief and Healthcare Act of 2006 and includes a potential for bonus payments up to 1.5% of all the reporting provider’s allowable Medicare Charges from July to December of 2007.

MedaPhase Newsletter - March 2007 [read full issue]

Emergency Physician Documentation & Billing for Interpretations of EKGs & X-rays
Robert Kottman, MD, FACEP
Medical Director

An underlying principle of emergency medicine is that emergency physicians should bill for the services that they provide. When the services provided are interpretative rather than procedural, this principle remains unchanged. There has long been a reticence on the part of some emergency physicians to bill for the interpretation of EKGs and X-rays, despite the obvious fact that the emergency physician is providing the interpretive service in “real time” - by which is meant “contemporaneously with the patient’s presence in the emergency department” and “the interpretation that directly contributed to the diagnosis and treatment of the patient.”

It is common practice for the cardiologist and radiologist, respectively, to perform a “quality assurance” re-interpretation of an EKG or X-ray that has already been interpreted in “real time” by the emergency physician. This re-interpretation is often performed hours to days after the patient has left the emergency department. Clearly, these are not “contemporaneous” interpretations.

Medicare has long held that, if more than one diagnostic interpretive service is billed to Medicare (by two or more providers) then the Medicare carrier is to determine which interpretation “contributed to the diagnosis and treatment of the patient” and which “was actually quality control”.

NPI Contingency Plan Needed
Lynne Kottman, CCP, CHBME
Legislative Advocate

On May 23^rd, the NPI (National Provider Identifier) will be the required identifier on all claims. While most providers have gotten the message and obtained an NPI, many health plans are not prepared to process claims using this identifier. In addition to this issue, some software vendors have not completed reprogramming for the NPI and many have not completed successful testing.

Organizational Mission and Core Values
W. Rick White, Jr., MBA, FACMPE
Chief Executive Officer

(Parts 2 and 3 of a 3 part series)

In the last edition of the MedaPhase Newsletter, my article focused on Organizational Vision, a concept that separates successful organizations that have achieved an outward identity of quality and service. Originally my plan was to write three separate articles on Vision, Mission and Core Values. However, this article will cover the concepts of organizational Mission and Core Values as inseparable. The dependency of one to another will be emphasized.

Medicare Payment Schedule - Gaines & Losses
Much has been about the changes in the Medicare fee schedule. The majority of visits for Emergancy Departments are the 5 E&M codes, all but one of which had a gain in 2007.

Physician Quality Reporting Initiative Webpage Now Available
Lynne Kottman, CCP, CHBME
Legislative Advocate

The Centers for Medicare & Medicaid Services (CMS) has announced that the 2007 Physician Quality Reporting Initiative (PQRI) webpage is now available.

According to a CMS press release, "Eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services."

News of Note - re PVRP change to PQRI [read full issue]

2007 Physician Quality Reporting Initiative (PQRI)
Lynne Kottman, CCP, CHMBE
Legislative Advocate

PQRI = New program
PVRP = Old program (which is going away)

Summary from conference call with Sue Nezda, MD, FACEP from CMS

Unchanged from past information:

CMS will pay 1.5% of all Medicare charges including co-pays, not just the charges for items being measured - (she specified that they consider charges to be the Medicare payable amounts.)
Providers will need to report on at least 80% of at least 3 quality measures

Updated information:

News of Note [read full issue]

Explaining Medicare's Upcoming Pay for Performance
Lynne Kottman, CCP, CHMBE
Legislative Advocate

We have seen a lot of P4P (or PVRP) discussion in journals, and on the internet lately and the question comes up: What do these measures mean to me?

Congress decided that they wanted to follow the business concept of paying more for better performance. In the medical arena, they began looking to hospitals through the Medicare Modernization Act of 2003 to begin reporting on performance measures. In the Emergency Department, one of the standards measured was Aspirin given to patients presenting with Acute MI. In addition to tying the results to payments to hospitals, CMS plans to publish the results (in June) of these performance measures on their website at:

www.hospitalcompare.hhs.gov.

MedaPhase Newsletter [read full issue]

Vision
W. Rick White, Jr., MBA, FACMPE
Chief Executive Officer

(1^st of a 3 part series on Vision, Mission and Core Values)

Most doctors’ eyes will likely glaze over when forced into a committee meeting to discuss the vision, mission and core values of an organization. Physicians intuitively know their own individual vision and mission when they don their scrubs and show up for work. They do whatever needs to be done within the scope of their skills and training at the appropriate time. Group practices or hospitals on the other hand need a concerted effort to develop a consensus toward a shared vision of the goals, mission and standards of the entity as a whole.

News of Note: CERT and Medicare
Lynne Kottman, CCP, CHBME
Director of Compliance

CERT Changes

What is CERT? The Comprehensive Error Rate Testing Program (CERT) is the Centers for Medicare and Medicaid (CMS) contract process to monitor the accuracy of claims filed and payments made by the Medicare contractors.

What are the changes? The CERT program has recently changed their time frames for responses to notification.

Medicare Provider Enrollment – Issues potentially impact all providers. This could mean YOU!

What are the issues? NPI implementation, New Provider Enrollment, and Revalidation

Skin and/or Mucous Membranes Repair or Removal
Robert Kottman, M.D.
Medical Director

Significant revenue is lost annually by emergency physicians due to lack of appropriate documentation of skin and/or mucous membrane repairs or debridement/removal of nails (whether toenails or fingernails). The following codes and Texas Medicare reimbursements (applicable to the ‘Rest of Texas’ GPCI—which includes Bexar County) may be helpful in encouraging proper documentation of work done in treatment of emergency department patients with skin, mucous membrane or nail/nailbed injuries.

Coding Corner: Documentation Pearls
Susan Reese, CPC, CCS-P, CCP, ACS-EM
Director of Coding

Physician Documentation Tips & Diagnosis Tips

Addressing Returned Mail
Jason Lott, MBA-HCM
Director of Operations

What percentage of patient mail sent out is returned to your office or billing company due to a bad address? Who is tracking and responding to this increasing and potentially adverse issue that can affect sustained cash flows? With the continuously increasing self pay volumes along with rising insurance based deductibles, copays and expansion of health savings / reimbursement accounts, there are more patients falling into practice billing cycles. To this extent, there is typically a direct proportional increase in non-billable addresses or return mail that must be addressed.

MedaPhase Newsletter October 2006 [read full issue]

New Orleans Post Katrina - Is the Safety Net Still Intact?
Lynne Kottman, CCP, CHBME

Everyone can remember the riveting scenes of the New Orleans area after the devastation of Katrina and the ensuing floods. Several area Emergency Departments remained opened throughout and now, one year later, the question becomes "How is the emergency medical 'safety net' holding up?"

The Balance-Billing Controversy - Part 1: History
Robert Kottman, MD, FACEP
Medical Director & Legislative Advocate

All around the country, states are addressing an issue that some state legislators view as non-contracted (with health insurance companies) hospital-based physicians “defrauding consumers” by billing them “exorbitant fees” when the health insurers have already paid these physicians very generous “usual and customary” reimbursements - as defined by the insurers. This problem is often characterized as improper “balance-billing”.

Get Reimbursed: Properly Documenting Hypertension
Nancy Maguire ACS, CRT, APC, AFC, CPC, CPC-H
Associate Director of Coding & Compliance

Hypertension is classified as primary or secondary in the diagnosis-coding manual. Hypertension not otherwise specified is assigned to ICD-9-CM code 401.9. If documentation states hypertension without any greater detail, the code assignment is generic (401.9) and does not convey severity. A mild, nonmalignant form of hypertension is termed benign hypertension (401.1). Malignant hypertension (also documented as accelerated hypertension) is another code choice but only if you document by the specific terms malignant or accelerated. If you specify this type, the code changes to 401.0.

Coding Corner: Understanding the Emergency Medicine Caveat

CPT has included a very special exception for key documentation elements that can be found in the definition of E&M code 99285 (Emergency Department Services). This special exception is not included in any other E&M definition.

The fact that this special exemption exists is often overlooked by emergency medicine physicians. The Emergency Caveat is also frequently misunderstood and misused.

News of Note: Payment for X-Ray Interpretations

When the OIG Fiscal 2007 Work Plan was released recently, it contained the following item of concern to Emergency Physicians (underline added):

Inappropriate Payments for Diagnostic X-rays in Hospital Emergency Departments

We will determine the extent of inappropriate payments for diagnostic x-rays performed in hospital emergency departments. In 2004, more than 2.5 million diagnostic x-rays were performed in Medicare-certified hospitals with emergency departments. Interpretations by emergency room physicians of diagnostic x-rays should not be billed separately. We will assess the extent to which Medicare is inappropriately paying for diagnostic x-rays interpreted by emergency room physicians. (OEI; 00-00-00000; expected issue date: FY 2008; new start)

Good News Update

MedaPhase Newsletter September 2006 [read full issue]

The Uninsured, the Underinsured and the Almost Insured
W. Rick White, Jr., MBA, FACMPE
Chief Executive Officer

A recent article in an area business journal quoted a Census Bureau report announcing that another 1.3 million Americans have been added to the uninsured roles, totaling 46.6 million nationally. Almost all of the increase in the uninsured came from working adults. Although last year’s annual average increase in premiums was 9.2%, the increase followed four consecutive years of double digit increases. One writer pointed out that it is the low-wage workers who are being hurt the most. Small business owners are responding to these premium increases by dropping their insurance coverage altogether.

Observation Services in the ED
Robert Kottman, M.D., FACEP
Medical Director & Legislative Advocate

Observation services are being increasingly provided by emergency physicians, whether within the ED proper or at a different site within the hospital. Observation services may be provided in any bed in any part of the hospital, including the ED. Observation is not a location, but a status.

If an ED bed is to be utilized for provision of observation services, the physician providing observation services must:

Taking a Patient History
Nancy Maguire ACS, CRT, APC, AFC, CPC, CPC-H
Associate Director of Coding & Compliance

The three key elements in selecting the appropriate level of E&M code are history, physical examination, and medical decision-making. Medical decision-making (MDM) drives the history and physical exam. These elements must meet or exceed the minimum requirements specified by CPT. When determining the level of history for an E&M code, the documented elements in the History of Present Illness (HPI), Review of Systems (ROS), and/or the Past, Family, Social History (PFSH) determine the level of history performed.

Featured Consultant: Irma Nin, M.D.

Evidence Based Clinical Orders

Emergency Departments are increasingly being forced by their administration to focus on improving “Through-Put” times. One of the areas that can positively impact this goal is the streamlining of the ordering process. Dr. Irma Nin, M.D., an emergency physician from Venice, Florida has developed, both from experience and published literature, an Evidence Based cost effective system for the ordering process.

Coding Corner: Documentation of Laceration Repairs

Single Layer Closures: With a single layer closure, please document carefully for the work being done and state the length of the wound in cms.

Intermediate Upgrade: If the wound is heavily contaminated requiring extensive cleaning or removal of foreign matter it can be coded and billed as an Intermediate Laceration repair instead of a simple repair.

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