IL Chapter ACC Everything You Want to Know That You Did Not Learn - - PowerPoint PPT Presentation

IL Chapter ACC

Everything You Want to Know That You Did Not Learn in Fellowship

• October 3, 2013

June 30th = Fellow July 1 = Attending MD July 2 = Begin submitting charges July 30 = Revenue received from appropriate billing and coding =

What is Coding Anyway

• Everything you do in any setting has a code
• Everything you do needs a reason = ICD9

diagnosis codes

• ICD 10 – this requires wine aka whine
• Where you do it = site of service
• Inpatients, hospital outpatient, observation,

clinic, IDTF

How Does This Work… Best

• 1. MD understands the complexity of coding
• 2. Understands the documentation requirements
• 3. Understands the revenue stream
• 4. Hire a really good coder that you work in

CONJUNCTION with

PFS = Physician Fee Schedule

• Developed in 1992
• Based on relative resources needed to

accomplish a task

• Includes:

– MD services – Lab tests – Imaging Services – MD administrated drugs

CPT: Codes

• Current procedural terminology
• Began in 1992 as Physician Fee Schedule
• There are 3 categories of CPT codes
• You will use Category 1 codes primarily
• Must use that code that most closely reflects

the actual procedure or service provided

The Coding Cycle

CPT Editorial Panel Adopts Coding Proposals Specialty Society Advisors Review New and Revised CPT Codes Centers for Medicare and Medicaid Services RVS Update Committee RVU’s Assigned (or not) Medicare Payment Schedule

Code Proposals Start Here

Show Me the $$$

• Every Category 1 CPT code has RVU’s assigned to

them

• RVU = Relative Value Unit
• RBRVS = Resource Based Relative Value Scale
• Base figure – Level 3 visit with an initial value of 1.0
• There is a professional component, a technical

component or a combination (global)

Resource Based Relative Value Scale

Payment =

RVU = Relative Value Unit GPCI = Geographic Practice Cost Indices {(RVU work x GPCI work) + (RVU practice expense x GPCI practice expense) + (RVU malpractice x GPCI malpractice)} conversion factor x BN

X

Medicare Formula

In English - What Does That Mean

{ (RVU work x BN x GPCI work)+ (RVU practice expense x GPCI pe) + (RVU malpractice x GPC MP) } X Conversion Factor (BN) =

$199.99

• (1.30 x 1.030) +

(4.22 x 1.051) + (.05 x 2.77)

X

$34.023

=

$199.99 for 5.57 RVU

Imaging vs. E&M

• Imaging

– 2/3 Technical payment – 1/3 Professional payment (supervision, interpretation)

• E&M – consults, follow-up

– Professional

Conversion Factor…

• Annual update to payment

– Inflation issues (Medicare Economic Index - MEI)

PLUS

– An update adjustment factor (better known as sustainable growth rate – SGR)

EQUALS

CONVERSION FACTOR

Sustainable Growth Rate (SGR)

SGR formula based on:

• Projected growth in gross domestic product (GDP)

per capita;

• Number of beneficiaries in fee-for-service

Medicare;

• Percentage change in fees for physicians’ services;

and

• Costs to the Medicare program due to changes in

law or regulation.

The Conversion Factor

• A multiplier that converts the geographically

adjusted inputs into the Medicare allowable rate

• Determined on an annual basis
• Only Congress can authorize changes to the

conversion factor

The Conversion Factor

2001 Medicare Conversion Factor: $38.2581 2002 Medicare Conversion Factor: $36.1992 2003 Medicare Conversion Factor: $36.7856 2004 Medicare Conversion Factor: $37.3374 2005 Medicare Conversion Factor: $37.8975 2006 Medicare Conversion Factor: $37.8975 2007 Medicare Conversion Factor: $35.9848 REVISED 2007 Medicare CF: $37.8975 2008 6 month “reprieve” $38.0870 2009 Medicare Conversion Factor: $36.0666 2010 Medicare CF Jan - May: $36.0791 2010 Medicare CF June – Dec: $36.8729 2011 Medicare Conversion Factor: $33.9764 2012 Medicare Conversion Factor: $34.0376 2013 Medicare Conversion Factor: $34.0230

STAY AWAKE, WE ARE ALMOST DONE!!

Hospital Reimbursement

The Buckets: –Government payers: Medicare, Medicaid and Tri- Care and selectively Federal BCBS

• IPPS: Inpatient Prospective Payment System- Procedure
• r Admission is assigned a code associated with a

national payment adjusted for select factors. The system is code driven (Diagnosis, CPT, HCPCS, DRG)

• This payer class represents the majority of patients’

insurance.

Hospital Reimbursement…

–Private Payors: Combination of payment methodologies: Some FFS, per diem, percent of charges, prospective and capitated arrangements.

• Select provisions include carve outs i.e. for high

cost procedures such as stents.

• Each contract is negotiated by hospital

–Self-pay and charity care

• Under scrutiny for NFP status

Inpatient = DRG’s

• Each DRG has a pre-determined

national payment rate, relative weight (resource consumption) and GMLOS.

• Example: DRG 233 Coronary Bypass with

cardiac Catheterization with MCC

–RW: 7.2081, 12.1 GMLOS, $37,223.42

DRG

• Originally had 467 “groups”
• The 467th group was "Ungroupable".
• You can thank Yale for the system ☺
• The system is also referred to as "the DRGs", and its intent was to identify

the "products" that a hospital provides.

• It was designed to convince Congress to use it for reimbursement, to

replace "cost based" reimbursement that had been used up to that point.

• DRGs are assigned by a "grouper" program based on ICD diagnoses,

procedures, age, sex, discharge status, and the presence of complications

• r comorbidities.
• DRGs have been used in the US since 1982 to determine how much

Medicare pays the hospital for each "product", since patients within each category are clinically similar and are expected to use the same level of hospital resources.

• DRGs may be further grouped into Major Diagnostic Categories (MDCs)

HOPPS

• Hospital out-patient services
• Has its own fee schedule
• Uses APC (ambulatory payment codes)
• Clinically similar services using similar resources
• Use cost to charge ratios
• Facility resources critical

– Equipment, supplies, staff – Uses two year old claims data – National payments are adjusted for geographical cost differences

• For example, Cardiac Cath $2,729.01, RW 37.1534,
• APC 0080 known as CPT Code 93458

– If hospitals did not meet quality requirements they will receive a 2% reduction

HOPPS: Reporting of Quality

• Currently 23 measures

– Median time to Fibrinolysis – Median time to tx for acute coronary intervention – ASA on arrival – Median time to EKG – For 2013: Cardiac imaging for preoperative risk assessment; Troponin results for AMI within 60 min

Inpatient DRG vs. Outpatient APC

Description DRG/APC DRG APC ICD implant 227/108 $42,843 $31,600 Pacemaker 244/655 $12,477 $10,492 Cath and Stent (DE)

247/104

$11,958 $5,794 PV with stent 253/83 $14,970 $4,023 Cath/stent (BMS)

249/104 Dx Cath 287/80

$10,786 $6,480 $5,794 $2,729

PFS vs. HOPPS

National Rates

In PFS radio pharmeuticals are reimbursed

MPFS - Technical OPPS CPT Description 2012 2013 % Diff 2012 2013 % Diff Nuclear 93015 Stress 51.40 $ 43.89 $

• 14.6%

175.97 $ 176.82 $ 0.5% 78452 Cardiac Nuclear 426.83 $ 425.97 $

• 0.2%

676.73 $ 679.68 $ 0.4% Total 478.23 $ 469.86 $

• 1.8%

852.70 $ 856.50 $ 0.4%

Echo…

MPFS - Technical OPPS CPT Description 2012 2013 % Diff 2012 2013 % Diff Echo 93306 Echo Complete 148.40 $ 127.59 $

• 14.0%

383.93 $ 390.49 $ 1.7% Stress Echo 93320 Doppler 35.40 $ 26.88 $

• 24.1%
• $
• $

0.0% 93325 Color Flow 24.51 $ 16.33 $

• 33.4%
• $
• $

0.0% 93351 Stress Echo 155.21 $ 151.40 $

• 2.5%

566.99 $ 558.66 $

• 1.5%

Total 215.12 $ 194.61 $

• 9.5%

566.99 $ 558.66 $

• 1.5%

National Rates

The Hospital: Value Agenda

• In-patient quality

– Hospital compare

• Hospital inpt. quality

(IQR): 57 measures + cost of MI

• Core Measures

– CHF and AMI – Value-Based Purchasing – Re-admission reduction – Hospital acquired condition reduction

• Meaningful Use
• NCDR
• ICD
• Cath/PCI
• ACTION
• IMPACT
• CARE
• Pinnacle
• ACC/STS TVT
• STS

Physician Office: Value Agenda

• eRx
• PQRS
• Physician Value-Based Purchasing
• QRUR reports
• Meaningful Use
• Compliance
• Private payor report cards
• Public Reporting

Trends

• Environmental

– Consolidation – hospitals, physicians, payers – Cost curve is bending – cost sharing, new payment models, transparency – Patient participation – hi deductible plans, HIE’s

• Regulatory/legal

– Bundling of codes – reduction in RVU’s NOT work – MedPac recommendations/discussions – IOAE – OPPS proposed fees schedule – PFS proposed fee schedule – Cost re-basing

• ACO’s, readmission reduction, bundled care initiatives, value based purchasing

– hospital AND physicians

Regulatory…

• Pre-authorization, pre-certification, pre-approval

– Private payor response – Procedural – EP and PCI procedures – Testing – nuclear, CT, MRI, and now – echo and SE

• RAC audits

– Concentration on cardiology specific areas

• Nuclear medical necessity
• ICD implants
• Outpt status vs. inpt status
• Short length of stays
• Pre-payment audits

Industry Consolidation

• Integrations in all sectors, in any and all

combinations

• Merritt Hawkins study projects 75% of all

physicians will be employed by 2014

• 63% of searches in 2012 featured hospital

employment

Clinical – Cardiology Specific

• Evidenced-based care
• Appropriate use criteria

– AUC – driven in procedural and testing – Will be publically reported in 2015

• Reduction in variability of care

– ONE standard

• Patient attribution for cardiology in ACO’s

– 20% of our patients we DIRECT the care