Wednesday, September 18, 2013

AMA: 25% of 2014 CPT Code Changes to Impact Gastroenterology

The American Medical Association has released the 2014 Current Procedural Terminology code set, which includes 335 changes to better reflect medical advances.

About 25 percent of all CPT code changes this year stem from the two-year effort to revise gastroenterology codes. The new codes capture the significant advances in endoscopic technology, devices and techniques. Changes to lower gastrointestinal services will be released with the 2015 CPT code set.

The new code set applies to all claims filed on or after Jan. 1, 2014. 

The AMA developed a transition grid to help providers smoothly transition to the revised GI codes.

Hospital settles allegations of false claims

Hutchinson Regional Medical Center
WICHITA, Kansas (AP) – Hutchinson Regional Medical Center has reached a settlement over allegations the hospital submitted false claims to Medicare.
U.S. Attorney Barry Grissom said in a news release Tuesday that the hospital has agreed to pay $853,651. It has also entered into a “corporate integrity agreement” with the Department of Health and Human Services’ fiscal watchdog.
The hospital used a wound therapy that involved putting the patient in a chamber of oxygen with increased pressure. The government contends the procedure was not medically necessary or was undocumented. It also alleged the claims resulted from a kickback deal with at least one doctor and the company supplying the chambers.
The hospital does not admit any wrongdoing in the settlement. Its spokeswoman said one of its executives would comment later Wednesday.

Survey: Mass. primary care docs in short supply

BOSTON (AP) — The state is experiencing a critical shortage of primary care physicians and stark geographical differences in the recruitment and retention of doctors, a new report says.
On a more positive note, the annual Physician Workforce Study, set for release by theMassachusetts Medical Society on Wednesday, also found a growing number of doctors willing to embrace cost-saving techniques such as accountable-care organizations and global payments.
Also, more than three-quarters of the physicians surveyed were happy in their careers, though less than half expressed full satisfaction with Massachusetts as a place to practice medicine, the survey found.
"The supply of physicians in the state remains under stress, notably with primary care, and recruitment and retention continue to be difficult, especially for less populated areas of the state," MMS president Dr. Ronald Dunlap said in a statement accompanying the 2013 survey of more than 8,000 doctors.
He said those factors "affect patient access to care."
The report found critical or severe shortages in family medicine and internal medicine, the two primary care specialties, for an eighth consecutive year. Primary care doctors are viewed as critical to the health care system for their role in preventative care and referrals to other medical specialties.
The findings reflect a report from the doctors' group in July that showed about half of the state's primary care practices were closed to new patients and there were lengthy wait times to see primary care physicians.
Regional disparities in the hiring and retention of doctors continued to be a pressing issue, according to the study.
For example, 78 percent of respondents in Berkshire County and 75 percent in the Springfield area cited an inadequate pool from which to recruit physicians, and about 50 percent in both regions said it was difficult to retain staff.
In the Worcester region, 57 percent reported a less than adequate pool of physicians, 43 percent said it was difficult to retain staff and 30 percent experienced significant difficulties in filling vacancies.
As a result, health care organizations in those markets often were forced to adjust staffing or alter services, the report found.
By contrast, only 18 percent of respondents in greater Boston said they had trouble filling vacancies and less than 33 percent had to adjust staffing or services.
Nearly half the doctors surveyed cited familiarity with the state's 2012 health care cost containment law, which seeks to save the state up to $200 billion in health care costs over the next 15 years, in part through accountable-care organizations, which take a more coordinated approach to medicine.
Seventy-one percent of physicians said they were familiar with ACOs, and 42 percent said they were already part of one.
Nearly 60 percent of doctors said they were familiar with global payments, fixed fees paid to groups of providers in lieu of the more common fee-for-service approach that critics say encourages expensive or unnecessary tests. Fifty-four percent said they were likely to participate in a voluntary global payment system, a 5 percent increase over last year.

OCR, ONC Release Model Notices for HIPAA Compliance


Two HHS agencies have released model notices that health care providers can use to comply with new HIPAA privacy and security rules that take effect in less than a week, Health Data Managementreports (Goedert, Health Data Management, 9/16).


The final HIPAA omnibus rule -- which includes four final rules that implement tougher privacy and security provisions -- was called for under the 2009 federal economic stimulus package's HITECH Act and the Genetic Information Nondiscrimination Act. The rules:
  • Clarify when breaches must be reported to HHS' Office for Civil Rights;
  • Establish new standards for the use of patient-identifiable information for fundraising and marketing;
  • Expand liability to "business associates" of hospitals and other "HIPAA-covered entities," such as data miners and health IT service providers; and
  • Raise the maximum penalty for noncompliance to $1.5 million per violation.
The new federal privacy and security regulations will take effect Sept. 23 (iHealthBeat, 9/10).

Details of Models

The examples were developed by HHS' Office for Civil Rights and the Office of the National Coordinator for Health IT.
OCR and ONC released the model notices in three formats:
  • A booklet;
  • A layered notice with a summary of the information on the first page and full content on additional pages; and
  • A notice with the design elements of a booklet, but formatted for full-page presentation.
Covered entities also can download a text-only version (Miliard, Healthcare IT News, 9/17).

High-Value Health Care — A Sustainable Proposition

Gregory D. Curfman, M.D., Stephen Morrissey, Ph.D., and Jeffrey M. Drazen, M.D.
September 17, 2013DOI: 10.1056/NEJMe1310884
Health care in the United States is at a crossroads. With health care costs representing an unsustainable 17.6% of our gross domestic product, creation of a new, higher-value health care system has never been a greater priority. Although the rate of increase in health care spending has moderated during the economic recession, some experts predict that it will rebound as the economy recovers.
Thus, the need for higher value in health care is urgent. The goal of high-value health care is to produce the best health outcomes at the lowest cost, and this goal has recently created a new alliance. Health care professionals are increasingly given incentives to deliver high-value care by virtue of such payment-reform measures as pay-for-performance policies, bundled-payment strategies, global budgets, and financial risk sharing within accountable care organizations. Likewise, business leaders are strongly encouraged to maintain healthy work forces while trying to rein in rising health care premiums, which reduce opportunities for reinvestment in their businesses and offset wage increases for their employees.
The health care community and the business community today share a fundamental interest in finding ways to achieve higher value in health care. The ultimate objective for both communities is to keep people healthy, prevent the chronic illnesses that consume a large fraction of our health care dollars, use medical interventions appropriately and only when needed, and create an economically sustainable approach to the delivery of health care. While we want to foster innovation and novel therapies against disease, we also recognize that, whenever possible, prevention of disease before it is established is the better solution.
It is in this context that we announce the launch of a novel collaborative publishing initiative between the New England Journal of Medicine and the Harvard Business Review. The focus of our pilot project is on how to achieve a high-value health care system, and we will publish articles on that topic from numerous experts across the health care and business communities. Beginning this week, on Tuesday, September 17, we will be posting new articles at the Insight Center for Leading Health Care Innovation, which will reside on the Harvard Business Review website (, where during the pilot phase all articles will be freely available to all readers. New articles will be posted daily through November 15. All the articles will be archived at the Harvard Business Reviewwebsite, and the articles solicited by the editors of the Journal will also be archived at
The articles will cover three broad areas of this complex, multifaceted topic. One group of articles will address foundational principles in the formulation of a high-value health care system, a second will address the management of innovation in the organization and delivery of health care, and a third will focus on the solutions developed by physician leaders and practitioners on the front lines. Authors in all three areas will illuminate a range of relevant topics, such as organizational leadership, health information technology, leadership in accountable care organizations, redefining primary care, economic projections of health care spending, employer-sponsored health insurance, employee wellness programs, physician payment reform, the pricing of health care interventions, the use of checklists in health care, same-day appointments, and how best to design a bundled payment.
These topics reflect critical — and rapidly changing — points of intersection between the health care and business communities. Take employer-sponsored health insurance, for example: according to a recent Kaiser Family Foundation survey, 93% of businesses with more than 50 workers now offer coverage. But since 1999, premiums have risen 196%, while wages have risen only 50%. Both employers and employees are being squeezed, and they will soon have to face the Affordable Care Act mandate that such businesses offer a minimum level of coverage, as well as the new “Cadillac tax” on high-cost plans. Articles posted at the Insight Center will explore the impact of these provisions on the future of employer-based insurance.
On Tuesday, September 24, we will host an interactive webcast with Michael Porter and Thomas Lee, focused on high-value health care, at the Harvard Business Review site. The webcast will also be archived there.
The collaborative publishing project between the Journal and the Harvard Business Review comes at a turning point in American health care. Never before have the interests of the health care community and the business community been better aligned. As Journal editors, we have already benefited from the collaboration through new colleagues, innovative ideas, and fresh perspectives. As the 2-month pilot project unfolds, we hope you will reap the same benefits. We look forward to receiving your comments about the project, and we hope to continue the collaboration in the future as key stakeholders in health care seek a high-performing health care system that can meet the country's current and future needs.

Be Careful When Using Condition Code 42 When Transferring a Patient Back to Home Health

Please share with Directors of DIM and Discharge Planning

MCare Solutions reviews large volumes of billed Medicare discharges for proper payment under the Transfer Payment Rule.  Generally speaking, the majority of these discharges are roughly split between home health and skilled nursing.  Lately we have noticed the frequent use of discharge status code 06 (transfer to home health) along with condition code 42 (CC42). (This combination of codes would be used when an acute care episode occurred in the middle of a home health episode and the patient was being transferred back to home health.)  Using CC42 indicates to CMS that the reason for the acute stay and the reason for receiving home health services are not related and that the acute provider should receive a full DRG payment.  Since there are no bill edits for this combination of codes, it is extremely important that the use of these codes be correct. 
What is the rule or guideline that the provider would use to properly determine whether acute and home health services are related?
MCare turned to our healthcare attorney at Arnall, Golden, Gregory to research the issue for us.  Their findings provide a concise course of action that our clients can follow to ensure that they are complying with CMS requirements in this matter.  MCare would like to share these findings with you.
When there has been a “Hospital Interlude”, must the hospital always consider the subsequent home health care “related” to the hospitalization? 
No!  In fact, because patients who are admitted to hospitals during home health episodes may have multiple, distinct medical conditions, Hospital Interludes might actually be more likely to result in the appropriate use of condition code 42 than situations involving patients admitted to hospitals directly from home.  Condition code 42 asks whether the hospital’s continuing care plan at the time of discharge calls for the provision of services unrelated to the condition responsible for the patient’s admission to the hospital.  Patients who are admitted while in the middle of a home health care episode may require additional treatment after their hospital stay for the same medical issue that was being treated by home health care prior to their hospital admission, and this medical issue could be distinct from the condition responsible for the patient’s hospitalization.
For instance, if someone receiving home health care for mobility issues due to a hip fracture is admitted to an acute care facility for the treatment of pneumonia, and then is subsequently discharged to home health for mobility issues related to the hip fracture, then condition code 42 would be appropriate, as the pneumonia stay should not be subject to the post-acute transfer policy.   

If not, what criteria should be applied in determining whether condition code 42 is appropriate? 
Hospitals are responsible for deciding whether the home health care the patient is to receive as part of the hospital’s discharge plan is related to the condition responsible for the inpatient hospital admission.  In making that determination, the services called for in the hospital’s continuing care plan should be compared with the patient’s primary diagnosis – not the secondary diagnoses listed on the hospital bill.  If any of the services called for in the hospital’s discharge plan are related to the condition indicated by the hospital’s primary diagnosis, then condition code 42 should not be used. 
Hospitals are not expected to compare home health bills to hospital bills in order to determine relatedness between the two providers’ treatment.  However, whenever hospitals use condition code 42, they are expected to have documentation in the patient's record supporting their decision to use the condition code.

The Post-acute Transfer Policy Focuses on Hospitals’ Principal Diagnosis
Given that the post-acute care transfer policy is either applicable or inapplicable based on the hospital’s principal diagnosis code, the question of relatedness between the home health treatment and the prior hospital stay would also seem to be limited to the condition indicated on the principal diagnosis for the patient.  This is consistent with CMS’ use of the phrase “purpose of the inpatient hospital admission” when describing condition code 42 (since hospitals are instructed by coding rules to code as principal the condition that required the hospital admission), as well the fact that CMS’ overall discussion in the preamble to the post-acute transfer rule focuses on a hospital’s “principal” diagnosis.

CMS did not intend for the post-acute transfer policy to apply whenever any of the services provided during a home health episode are related to any of the services provided during the prior hospital stay.  Rather, CMS’ focus when it created the post-acute transfer policy was on the principal diagnosis and whether continued treatment related to that diagnosis is required upon discharge.


Condition code 42 can be used for Hospital Interludes.  CMS anticipates that Hospitals will look to the patient’s record (particularly the continuing care plan) to determine whether the hospital’s discharge plan called for services separate and distinct from the condition responsible for the patient’s hospitalization.  If the record demonstrates that the patient was discharged to home health for reasons unrelated to the condition responsible for her hospitalization, then condition code 42 is appropriate.

For a copy of the complete opinion, including cited references and examples of CC42 use, please click here.