Arm Your Team for Victory

What will define those who claim victory and those who are defeated in the battle towards value based care? Will it be those organizations with the most money, power and seats at the table? Or will it be those who are nimble, flexible and open to change?

I believe it will be both. As victory will not be defined by the owners and head coaches but instead by how the players execute on the field. It will be the game time decisions that matter most.

A quarterback who can read the defense and adjust accordingly will provide far greater value to the offense than the most athletic quarterback who misses the blitz every time.

Perhaps Napoleon said it best, “Battles are won by the power of the mind.” For in a game of inches, the winners and losers will be defined by those who can execute in the moments that matter most.

Prepare your team for victory with information at the point of care!

ERM Consulting has developed the industries best tools for players on the frontline.

Order yours today!

Coding and Documentation Guide for Providers and Coders

This 42 page guide includes proper ICD-10 coding and clinical documentation for the most common diagnoses included in the risk models. A complete list of CMS-HCCs with RAF and demographics included. Order 1 for your entire team! Orders of 100 or more can be white labeled with your logo at no charge. Please email logo to kgifford@ermconsultinginc.com after purchase.

CMS-HCC Quick Coder

This 36 page guide contains a list of the most common HCC codes in the Medicare (CMS-HCC) model. Common codes are included from both the medical and prescription models. Orders of 100 or more can be white labeled with your logo at no charge. Please email logo to kgifford@ermconsultinginc.com after purchase.

Ohio Doctors Would Report Opioid Diagnosis Codes Under Deal

Ohio doctors have reached tentative agreement with the Kasich administration on a proposed rule requiring them to report the specific diagnosis of every patient who receives a prescription painkiller.

Ohio doctors would report the specific diagnosis of every patient who receives a prescription painkiller under a tentative agreement reached Friday with the Kasich administration.

The 11th-hour compromise between the Republican governor's office, the state Medical Board and associations representing doctors and hospitals followed months of wrangling over new opioid prescribing rules proposed in April in a state that leads the nation in opioid addiction and death.

A record 3,050 Ohioans died from drug overdoses in 2015, a figure expected to jump sharply once 2016 figures are tallied.

The compromise on prescription reporting was reached in time for a legislative rule-making panel's scheduled vote Monday.

The disputed rule required prescribers to enter what's known as an ICD-10 code into Ohio's online reporting database for every controlled substance prescription. The administration argued the reporting mandate was critical to fighting Ohio's top status for opioid abuse and death.

Under the compromise, hospitals and doctors' offices would report codes for opioids right away, but they would have an additional nine months to begin reporting all other controlled substances.

Medical Board Director A.J. Groeber said collecting ICD-10 codes — in other words, knowing what conditions doctors are treating using potentially addictive opioids — is "the linchpin" both to effective regulation and education.

"It's not just about going after the bad actors," Groeber said. "We want to be able to do that, but we also want to educate the vast majority of our well-intentioned licensees to make sure that they know that they can treat patients effectively with fewer pills and fewer days' supply."

Ohio State Medical Association spokesman Reggie Fields said doctors didn't object to the goal, but to the method for accomplishing it, which they saw as unworkable.

"The bottom-line goal here is to try to improve the opioid prescribing that's taking place across the state of Ohio, and we are in complete agreement with that," Fields said. "The only issue we had here was the vehicle that had been proposed to get there was just unfeasible to be able to accomplish, because of the administrative and financial burden."

Ohio Hospital Association spokesman John Palmer said that was because the list of ICD-10 codes is massive and many doctors' offices and hospitals are not yet set up to incorporate the relatively new code system into their reporting.

"There are thousands upon thousands of codes, from things like knee replacements to hip replacements to a splinter or an Orca whale bite or a tiger bite," he said. "So it's just a whole slew of different diagnoses codes."

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Only 6% of PCP's Able to Identify 11 Risk Factors for Pre-Diabetes

Most primary care doctors can't identify all 11 risk factors for prediabetes, a small new survey finds.

Researchers from Johns Hopkins University said their findings should prompt doctors to learn more about this condition that affects an estimated 86 million adults in the United States and could eventually lead to type 2 diabetes.

"We think the findings are a wake-up call for all primary care providers to better recognize the risk factors for prediabetes, which is a major public health issue," said study first author Dr. Eva Tseng in a university news release. She's an assistant professor at Hopkins' School of Medicine.

It's estimated that 90 percent of those with prediabetes are unaware that they have the condition, according to the U.S. Centers for Disease Control and Prevention.

The American Diabetes Association (ADA) explains that changes in diet, exercise and certain medications can help prevent people with prediabetes from going on to develop type 2 diabetes.

To investigate why so many people with prediabetes go undiagnosed, the researchers asked primary care doctors attending a medical retreat to complete a survey testing their knowledge of key risk factors for the condition.

The ADA has guidelines that list a total of 11 specific risk factors that determine if a patient should be screened for prediabetes. They include physical inactivity, a first-degree relative with diabetes, high blood pressure, and a history of heart disease.

A total of 140 doctors took the survey. Nearly one-third of those surveyed weren't even familiar with the ADA's prediabetes guidelines. Only 6 percent were able to identify all 11 risk factors. On average, the doctors could correctly identify just eight of the warning signs.

The doctors also had to identify the healthy range for glucose tests results used to diagnose prediabetes as well as recommendations about weight loss and physical activity for people with the condition.

Only 17 percent identified the correct values for fasting glucose and another key measure of glucose, known as HbA1c, which are used to diagnose prediabetes, the study authors said.

Only 11 percent of the doctors said they would refer a patient to a behavioral weight loss program, even though that's what the ADA recommends. But 96 percent did choose to provide counseling on diet and physical activity.

Most of the doctors said they wouldn't prescribe metformin for prediabetes. But in 2017, the ADA recommended that metformin be considered for patients with prediabetes who haven't reduced their risk for diabetes through lifestyle changes alone.

"Primary care providers play a vital role in screening and identifying patients at risk for developing diabetes. This study highlights the importance of increasing provider knowledge and availability of resources to help patients reduce their risk of diabetes," said study senior author Dr. Nisa Maruthur, an assistant professor of medicine at Hopkins' School of Medicine.

The results were published recently in the Journal of General Internal Medicine.

More information
The U.S. Centers for Disease Control and Prevention provides more information on prediabetes.

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Physicians participating in Advanced APMs in 2017 will receive a 5% Incentive Payment in 2019

Under CMS’s new Quality Payment Program, which will adjust Medicare Part B payments starting in 2019 based on data from this year, physicians and other eligible clinicians must qualify for one of two payment “tracks”, either the Merit-Based Incentive System (MIPS) or the Advanced Alternative Payment Model (Advanced APM) track.   A physician who qualifies under the MIPS in 2017 can earn up to a 4% payment adjustment to Medicare Part B payments in 2019.  Physicians who qualify under the Advanced APM track can earn up to a 5% payment adjustment in 2019.  

Since the Quality Payment Program went into effect on January 1, 2017, it has been unclear whether physicians participating in an Advanced APM in 2017 would be able to meet CMS’ quality and reporting requirements and earn a 5% payment adjustment to their Medicare Part B claims in 2019.

CMS recently provided clarity on this issue by predicting that almost 100% of physicians and other eligible clinicians participating in Advanced APMs in 2017 will qualify for a 5% payment adjustment to their Medicare Part B claims in 2019.  CMS based this prediction on an analysis of Advanced APM claims data submitted from January through August 2016 (before the Quality Payment Program went into effect).

CMS also stated that physicians who participate in an Advanced APM need to meet only one of two criteria to earn the 5% payment adjustment in 2019:  (1) receive 25% of the physician’s Medicare Part B payments through the Advanced APM; or (2) see 20% of the physician’s Medicare patients through the Advanced APM.  [A list of Advanced APMs in which a physician may participate in 2017 can be found at the following link: CMS List of Advanced APMs]

Participating in an Advanced APM can have several benefits (including being exempt from reporting quality data under the MIPS payment track), but also involves taking on some risk.  If you are considering participation in an Advanced APM, please contact an experienced attorney to discuss.

CMS is expected to issue formal determinations regarding the qualification of particular physicians for the Advanced APM track later this year.

POSTED IN BILLING & REIMBURSEMENT, MEDICARE, PHYSICIAN COMPENSATION, REIMBURSEMENT

OPPS, ASC, PFS: Proposed 2018 Policy and Payment Rate Changes

Hospital Outpatient, ASC: CMS Proposes 2018 Policy and Rate Changes

Physician Fee Schedule: CMS Proposes 2018 Payment and Policy Updates

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Hospital Outpatient, ASC: CMS Proposes 2018 Policy and Rate Changes

Proposed rule and Request for Information promote improvements to quality, accessibility, and affordability of care

On July 13, CMS issued a proposed rule that updates payment rates and policy changes in the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. The proposed rule is one of several for 2018 that reflect a broader strategy to relieve regulatory burdens for providers; support the patient-doctor relationship in healthcare; and promote transparency, flexibility and innovation in the delivery of care. 

The OPPS and ASC payment system are updated annually to include changes to payment policies, payment rates, and quality provisions for those Medicare patients who receive care at hospital outpatient departments or receive care at surgical centers. Among the provisions in this rule, CMS is proposing to change the payment rate for certain Medicare Part B drugs purchased by hospitals through the 340B program. The proposed rule also includes a provision that would alleviate some of the burdens rural hospitals experience in recruiting physicians by placing a two-year moratorium on the direct supervision requirement currently in place at rural hospitals and critical access hospitals. In addition, CMS is releasing within the proposed rule a Request for Information to welcome continued feedback on flexibilities and efficiencies in the Medicare program.

For More Information:

• Proposed Rule
• Fact Sheet

See the full text of this excerpted Press Release (issued July 13).

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Physician Fee Schedule: CMS Proposes 2018 Payment and Policy Updates

Proposed rule & Request for Information provide flexibility, support strong patient-doctor relationships

On July 13, CMS issued a proposed rule that would update Medicare payment and policies for doctors and other clinicians who treat Medicare patients in CY 2018. The proposed rule is one of several Medicare payment rules for CY 2018 that reflect a broader strategy to relieve regulatory burdens for providers; support the patient-doctor relationship in healthcare; and promote transparency, flexibility, and innovation in the delivery of care. 

The Physician Fee Schedule is updated annually to include changes to payment policies, payment rates, and quality provisions for services furnished to Medicare beneficiaries. This proposed rule would provide greater potential for payment system modernization and seeks public comment on reducing administrative burdens for providing patient care, including visits, care management, and telehealth services. The rule takes steps to better align incentives and provide clinicians with a smoother transition to the new Merit-based Incentive Payment System under the Quality Payment Program. The rule encourages fairer competition between hospitals and physician practices by promoting greater payment alignment, and it would improve the payment for office-based behavioral health services that are often the therapy and counseling services used to treat opioid addiction and other substance use disorders. In addition, the proposed rule makes additional proposals to implement the Center for Medicare and Medicaid Innovation’s Medicare Diabetes Prevention Program expanded model starting in 2018.

For More Information:

• Proposed Rule
• Fact Sheet

See the full text of this excerpted Press Release (issued July 13).

Urban Coding Legends: Morbid Obesity

Should you code morbid obesity when a patient has a BMI of 36?

This is one of my favorite questions to ask physicians, coders and healthcare executives when I am teaching. Why? Because it is guaranteed to elicit the following three responses:

A.      Yes, absolutely! As long as the patient has 3 or more chronic conditions….

B.      No, I never use that code. I don’t want to upset anyone with open notes and patient portals…

C.      No, morbid obesity should only be coded with a BMI of 40.0 or more…

One-third of the audience will select “A” as the correct answer, one-third will select “B” and one-third will choose “C”. This scenario will play out the same way in Miami, Philadelphia, Austin, Chicago, Little Rock or any other city in America. Why? Because it is an urban coding legend…

Urban Coding Legend #1:

Morbid obesity should always be coded when a patient has a BMI greater than 35.0 and 3 or more chronic conditions.  True or False? The answer is false. Obesity is defined and classified by both the United States Preventive Task Force and The National Institutes of Health and National Heart, Lung, and Blood Institute using the following classification: Obesity is divided into three classes. The third class, extreme obesity, also called severe obesity, is synonymous with the term “morbid obesity” and is diagnosed based on a BMI of 40.0 or greater. According to the NHLBI: A person with a BMI (body mass index) value of 40 or greater would be considered morbidly obese. An adult who has a BMI of 30 or higher is considered merely "obese.". Grade 3 overweight (commonly called severe or morbid obesity) is a BMI greater than or equal to 40 kg/m2. The Origins This “urban coding legend” originated from the corridors of “risk adjustment optimization” teams, searching for “low hanging fruit” and the clinical evidence to “support” it. The following events, recommendations and guidelines set the stage and a story was born… 1.       USPTF Updates Recommendations In 2012, the U.S. Preventive Services Task Force (USPSTF) issued updated recommendations regarding the screening and management of obesity for adults. 2.       The American Academy of Family Physicians The AAFP publishes clinical evidence to support the USPTF Recommendations: From the AAFP: In patients with a BMI of 25 kg/m2 or greater, further evaluation of risk factors is required. Blood pressure and lipid levels should be measured, and fasting glucose tested. Bariatric surgery may be considered in adults who have not achieved weight loss with dietary or other treatments and who have a BMI of 40 kg/m2 or greater, or for those who have a BMI of 35 kg/m2 or greater with significant obesity-related comorbidities (e.g., severe hypertension, type 2 diabetes, obstructive sleep apnea).  Bariatric surgery may also benefit patients with obesity-related comorbidities who have a BMI of 35 kg/m2 or lower, but it is not routinely recommended for these patients 3.      Medicare Payment Guidelines: In response to the updated USPTF Guidelines and AAFP clinical evidence supporting the benefit of gastric bypass surgery as a treatment for obesity Medicare updated their payment policies for this procedure: 150.6 - Claims Guidance for Payment (Rev. 2841, Issued: 12-23-13, Effective: 09-24-13, Implementation: 12-17-13) Covered Bariatric Surgery Procedures for Treatment of Co-Morbid Conditions Related to Morbid Obesity Medicare contractors acting within their respective jurisdictions may determine coverage of stand-alone LSG for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries only when all of the following conditions are satisfied: ·         The beneficiary has a body-mass index (BMI) ≥ 35 kg/m2; ·         The beneficiary has at least one co-morbidity related to obesity; and ·         The beneficiary has been previously unsuccessful with medical treatment for obesity. 4.       Revised HCC Model On April 1, 2013 CMS released the Announcement of Calendar Year (CY) 2014 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter. In the Final Call Letter, CMS confirmed that they would be implementing the updated, clinically revised CMS-HCC risk adjustment model proposed in the Advance Notice for CY2014. The new model expanded the current number of Condition Categories from 70 to 79. Under the revised model, the “Metabolic” category was expanded from one (HCC 21) to three (HCC 21, HCC 22, HCC 23). Given the prevalence of obesity, the new HCC 22 “morbid obesity” was quickly identified as a “low hanging fruit” for optimization teams. By coding morbid obesity with a BMI of 35.0 vs. 40.0 the prevalence rates, A.K.A. payments, to the plans would greatly increase. The previous three events were loosely woven together to form support for the practice and an urban coding legend rose like a phoenix from the ashes. HCC 22 includes the following ICD-10 Codes:  Do you see a BMI under 40 in the above chart? Remember clinical, coding and payment guidelines can not be substituted to fit the situation as needed. ERM Consulting Inc. Kameron Gifford, CPC