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”. Medicare pays hospitals for all “quality control” functions separately under Medicare Part A - therefore, all interpretive services which are not “contemporaneous with the patient’s presence in the emergency department” and which do not “directly contribute to the diagnosis and treatment of the patient” do not qualify for Medicare reimbursement. 

While it is clear that, from an ethical and moral standpoint, the emergency physician’s “real time” interpretation has much more value than the “delayed re-interpretation” of a diagnostic study - and is the interpretation deserving of reimbursement - many factors may conspire to prevent emergency physicians from billing for interpretive studies. Cardiologists and radiologists usually have contracts with the hospital administration which provide for them to perform interpretive services for hospital patients for EKGs and X-rays, respectively, and that provide for compensation for these services - whether by permitting direct billing of third party and private payers by these specialists or by permitting the hospital to bill for these services and then providing reimbursement to these specialties for their services.  

These contracts are often cited as authority for cardiologists and radiologists to be the sole “billing entities” for these interpretive services. These arguments conveniently neglect the fact that these interpretations may not be contemporaneous with the patient’s presence in the ED and thus have only limited “quality assurance” value. Nevertheless, the ultimate element which determines whether or not the emergency physicians bill for their interpretations of EKGs and X-rays is usually the “political clout” of the emergency physicians versus that of the cardiologists and radiologists. If the cardiologists and/or radiologists are “heavier hitters” than the emergency physicians - and have the ability to influence whether or not the emergency physician group retains its staffing contract at the next renewal date - then the hospital administration may prohibit the emergency physicians from billing for their interpretive services, even though such billing is clearly justified. 

If your physician group has emerged victorious from this “interpretive services turf battle”, then it is important that each physician fully understand the requirements for documentation of these services. First, the interpretation must be exactly that, and not merely a ‘review” of a study previously interpreted by another medical professional. For any interpretive study, the interpretation must be “separately identifiable” within the medical record. This does not mean that a “separate piece of paper” is required, merely that the interpretation should be readily identifiable in a distinct portion of the emergency department medical record. The interpretation must thus be a “written” report, which must be “signed”. If the page of the medical record containing the report is signed, then this signature suffices (the signature is not required in the space immediately below the report). In the Medicare Carrier Manual of May 1997, it is stated, “an interpretation and report should address the findings, relevant clinical issues, and comparative data when available.” 

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.

During the testing phase, a number of issues that could delay claims payments have been identified. As a result, on February 15th the National Committee on Vital and Health Statistics (NCVHS) sent a letter to HHS Secretary Mike Leavitt, urging the Secretary to adopt a contingency plan, "similar to the one utilized for the transaction and code set standards in 2003," because there is a lack of confidence that everyone will be ready to "go live" with the NPI on May 23rd as planned.

The contingency plan envisioned by NCVHS would "...protect otherwise compliant covered entities from enforcement action if they develop and implement contingency plans, such as continuing to accept legacy identifiers, to assure continuity of operations." NCVHS made several recommendations to the Secretary:

Recommendation #1: NCVHS recommends that HHS/CMS take the lead to provide this education, while also enlisting the participation of organizations that represent the healthcare industry. Several of these organizations expressed a willingness to provide assistance in the effort.

Recommendation #2: NCVHS strongly recommends that HHS decide what NPPES information will be made available to the industry, issue a data dissemination notice, and make the data available at the earliest date possible. We believe this is essential to the success of NPI implementation.

Recommendation #3: NCVHS recommends that covered entities be required to accomplish these tasks by the May 23, 2007 compliance date.

Recommendation #4: NCVHS recommends that HHS publish contingency guidance similar to the one utilized for the transaction and code set standards in 2003. Such guidance would protect otherwise compliant covered entities from enforcement action if they develop and implement contingency plans, such as continuing to accept legacy identifiers, to assure continuity of operations. We suggest it would be prudent to institute a six-month contingency using the following conditions:

• If HHS issues the data dissemination notice and makes NPPES data available to the industry prior to or on May 23, 2007, the contingency period would end six months later, on November 23, 2007.
• If HHS issues the data dissemination notice and makes NPPES data available after May 23, 2007, the contingency period would end six months after the date the data are available.

(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.

The stated Mission of MedaPhase is:

The key action verb is this simple statement is “provide”.  The products being provided are to be total business services and solutions.  The key word here is “solutions”.  Probably the most common focus of employees in organizations is that of task orientation, rather than service or solution orientation.  To emphasize this point, employees are measured more on measurable tasks that create a trail of accountability. I have heard that the employees at Nordstrom’s each have a budget of $2,000.00 that they can use at their discretion when faced with the challenge of finding a solution to a customer’s dilemma.   This is a company demonstrating that it is committed to backing, through funding, the concept that an employee’s job is to provide solutions for clients and customers.  It has become a concerted effort this year for MedaPhase to communication, enhance and provide the resources to rededicate ourselves to our Mission.  To that extent a retreat was recently held on a Saturday for all of the leadership team at MedaPhase.  Although speakers from each department were heard covering various aspects of the business processes, a consistent theme throughout the day was to ask ourselves the question, “Is what we do in our daily tasks actually providing solutions for the physicians and hospitals that we serve”? 

The stated Core Values of MedaPhase are:
 “…to provide a solid foundation for the development of a dynamic healthcare delivery system based on principles of honesty, integrity, creativity and dedication to its clients, partners and employees.  The philosophy of providing high quality business and management support is implemented by identifying the true needs and wants of healthcare professionals and then designing the system that best meets those needs and wants.”  

After reading the Mission Statement, then reading the Core Values of MedaPhase, it is readily apparent why the two are, indeed, inseparable.  Another viewpoint is that the Mission Statement tells what you do; whereas the Core Values tell who you are.  The clear purpose of MedaPhase is to provide superior business solutions for clients within the healthcare industry.  One way to do this is to monitor and ensure that the necessary business functions are being done efficiently and timely.  In addition, there must be an underlying current or organizational climate that our core values prompt us to certain actions.  Compliance and privacy issues are better fulfilled when the leadership of an organization supports behavior that is dedicated to providing solutions based on the core values of the organization.

MedaPhase is working diligently to install new processes that will not only create more efficiency, but will drive toward providing solutions for physicians.  A search for a new computer system is underway.  The coding division has been restructured to better focus on ongoing coding on a timely basis and putting auditing and monitoring in a separate area dedicated to coding and compliance.  Scanning capabilities are being expanded in order to have more flexibility and timeliness of obtaining and processing records.  Document management systems are being reviewed that will drive MedaPhase toward a paperless system.  Internal Compliance audits and training is being done on a regular basis.  Legislative advocacy under the leadership of Robert Kottman, MD, is under full swing with the legislative session and interpretations from Medicare and Medicaid programs. 

The organizational climate at MedaPhase is improving to the extent that creativity is being enhanced and rewarded.  An orientation toward client service, communication and satisfaction rather than just doing day-to-day tasks is being adopted by key leadership. 

All of that being said, we are all aware of the great challenges surrounding the healthcare industry today.  Declining reimbursements, overbearing managed care companies making record profits while declining claims for bona-fide services, federal and state intervention, potentially devastating legislation with regard to balance billing and mal-practice liabilities all paint a gloomy picture.  MedaPhase is dedicated as a whole, i.e. all staff members, to helping to provide the best possible solutions to these seemingly insurmountable issues.  Through maintaining a constant dedication to our Mission by exemplifying our core values, MedaPhase will consistently address these issues on a positive and proactive basis. Our main desire is to partner with our clients and align our mutually beneficial goals.   

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."

Under PQRI, eligible professional services are those paid based on the Medicare Physician Fee Schedule. To the extent the eligible professional is providing a service which gets paid under the Medicare Fee Schedule, those services are eligible for the PQRI bonus payment.

The new law defines an "eligible professional" as the following:

1. Medicare physician
• Doctor of Medicine
• Doctor of Osteopathy
• Doctor of Podiatric Medicine
• Doctor of Optometry
• Doctor of Oral Surgery
• Doctor of Dental Medicine
• Chiropractor
2. Practitioners
• Physician Assistant
• Nurse Practitioner
• Clinical Nurse Specialist
• Certified Registered Nurse Anesthetist
• Certified Nurse Midwife
• Clinical Social Worker
• Clinical Psychologist
• Registered Dietician
• Nutrition Professional
3. Therapists
• Physical Therapist
• Occupational Therapist
• Qualified Speech-Language Therapist

To review the quality measures, go to: http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage

(it may be necessary to cut and paste these addresses)