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The end to ICD-10 code flexibility: How are you handling it? Print E-mail
Written by The Health Law Offices of Anthony C. Vitale   
Tuesday, 11 October 2016 18:09

It may be hard to believe, but ICD-10 recently celebrated its first birthday.

The change from ICD-9 to ICD-10 meant the addition of thousands of more very specific, and in some cases, very unusual diagnostic codes. Examples include: being pecked by a chicken, bitten by a cow and struck by a macaw. You can read more about that in this Medical Economics article.
The switch to ICD-10 also meant that the Centers for Medicare and Medicaid Services (CMS) was expecting a lot of confusion. That's why providers were given a year grace period to get it right.
However, effective Oct. 1, that grace period came to an end. That means CMS no longer is accepting unspecified codes on Medicare fee-for-service claims. CMS review contractors will use coding specificity as the reason for an audit for a denial of a reviewed claim. And, the agency says it will "notify providers of coding issues they identify during review and of steps needed to correct those issues."

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Last Updated on Tuesday, 11 October 2016 18:15
Medicare is telling the world about your practice Print E-mail
Written by Accountable Care Options, LLC   
Thursday, 15 September 2016 07:49

Do you know what’s being said?

Medicare is publishing on the web an enormous amount of data on every practice that bills for its services. The information at could either be very exciting or very scary. 
Medicare is telling the world how many Medicare beneficiaries each practice has, their demographics, the actual risk for the patient population and how sickly the patients are. The agency drills down to average spending and average amount billed per patient per year, the total amount of money the practice received for providing Medicare services, and so on. Practices can essentially Google themselves and their medical neighbors.

Data are now available for 2013, 2014, and 2015, so it’s possible to see short-term trends and identify characteristics of the patient population and the practice.

Big-data companies are diving into the numbers and creating snapshots that show the number of patients, total billing, etc. Others are rating practices based on their ability to perform in certain types of contractual arrangements.

A practice can learn a lot about itself and improve its finances by analyzing the numbers, usually with the help of one of the number crunchers. A large practice that’s highly efficient with certain disease types definitely has stronger negotiating power when it comes to contractual arrangements.

A practice that’s developing a strategy for a risky business venture can look at the data for a demographic, medical condition and geographic area and use the analysis to help determine whether it should go forward.

For example, a practice may be considering a cardiac program but finds in the data that it has very few cardiac patients. But it has a large amount of COPD patients, so maybe the investment should go toward serving that patient population, especially in light of pay-for-performance interventions.

However, the greatest value for a practice is knowing what it looks like in Medicare's eyes. Sometimes that matches the practice’s self-perception and sometimes it doesn't. It’s all a matter of perspective. 

A practitioner may think, "I am very efficient. I have very sick patients and I know they cost a lot, but I do well with them." But Medicare data may present the practice as having a relatively healthy population with certain disease states that are manageable and high cost. Then, it’s time to rethink the practice and its operations.

Similarly, a practice can look at risk scores. For example, if two practices provide skilled nursing at the same hospitals but their risk scores are considerably different, in-depth analysis is needed. What’s the case mix?  How many patients are end-stage renal versus disabled versus regular Medicare age? Depending on arrangements such as an advanced-payment or any new Medicare model, the practice will see a difference in its baseline funding. 

Ultimately, a practice will gain insights about itself. If the practice and its neighbor have the same number of patients and similar risk scores but costs are significantly different, it’s time to investigate why. What is the other practice doing that's more or less different? Where does the practice stand in the market as to efficiency? The answers could change the entire practice.

Last Updated on Thursday, 15 September 2016 07:55
CMS Proposes Expansion of Telehealth Services Eligible for Medicare Reimbursement Print E-mail
Written by Dale C. Van Demark & Marshall E. Jackson, Jr. |   
Saturday, 06 August 2016 08:59

The Centers for Medicare and Medicaid Services (CMS) released its CY2017 Physician Fee Schedule Proposed Rule on July 17 - after receiving requests from various stakeholders to add telehealth services as Medicare-covered services effective for CY 2017, CMS responded by proposing to expand the list of telehealth services eligible for Medicare reimbursement. Additionally, CMS proposed modifications to current policies on Place of Service (POS) coding. Comments on the proposed rule are due on September 6, 2016.

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CMS May Delay MACRA Start Date Print E-mail
Written by Rajiv Leventhal | Healthcare Informatics   
Thursday, 14 July 2016 00:00

During a July 13 U.S. Senate Committee on Finance hearing on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andy Slavitt left open the possibility that the new sweeping changes set to overhaul physician payment could be pushed back from the intended start date of Jan. 1, 2017.

The Congressional hearing, led by Committee Chairman Orrin Hatch (R-UT) and Ranking Member Ron Wyden (D-OR), set out to give Slavitt a chance to describe MACRA's implementation efforts and give members of Congress a chance to address issues and concerns towards the CMS head. Hatch opened his statement by noting that physicians are greatly concerned about the timeline of MACRA, which as currently scheduled, calls for implementation to begin in 2017 with bonuses being paid out to eligible Medicare doctors in 2019. Indeed, as comments from healthcare stakeholders poured in since the release of the proposed MACRA rule in April, various physician groups have called for a host of greater flexibilities, many which center around pushing the start date back at least six months.

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Last Updated on Saturday, 16 July 2016 10:19
The Strategic Implications of MACRA Print E-mail
Written by   
Saturday, 09 July 2016 16:18

On April 27, the Centers for Medicare and Medicaid Services (CMS) unveiled the much-anticipated (and, for some, feared) proposal to implement the physician payment reforms required under the Medicare Access to Care and CHIP Reauthorization Act of 2015 (MACRA).  These reforms, once implemented, will profoundly change how and how much Medicare pays physicians for services furnished to program beneficiaries by substantially linking such payments to performance and incentivizing physicians to participate in alternative payment models. Moreover, while not expressly intended by Congress or CMS, these changes also are likely to cause a dramatic increase in physician-physician consolidation and physician-hospital consolidation and alignment.
Under the Merit-Based Incentive Payment System (MIPS) established in MACRA, and now described in detail by CMS in draft regulations, Medicare payments to physicians will be adjusted based on each physician's performance in four performance categories...

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Last Updated on Tuesday, 26 July 2016 17:12
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