AMERICANAMERICAN OSTEOPATHIC OSTEOPATHIC ASSOCIATIONASSOCIATION

5010 Data Standard, ICD-10-CM/PSC, Osteopathic

Manipulative Treatment and Medicare

December 3, 2011

DIVISION OF

SOCIOECONOMIC AFFAIRS

Socioeconomic Affairs StaffSocioeconomic Affairs Staff

• Yolanda Doss, MJ, RHIA,

Director, Division of Socioeconomic Affairs

• Sandra Peter, MHA

Assistant Director, Clinical Practice Outreach

• Michele Campbell, CPC,

Coding & Reimbursement Specialist

• Kavin Williams, CPC, CCP

Health Reimbursement Policy Specialist

Yolanda Doss, MJ, Yolanda Doss, MJ, RHIARHIA

Responsibilities include:– Helping to secure reimbursement for

osteopathic services– Securing the acceptance of osteopathic

credentials– Addressing Medicare issues– HIPAA compliance– Fraud and Abuse

Sandra Peters, MHASandra Peters, MHAResponsibilities include:

– Develop educational material on physician advocacy, manage care, quality and performance measures impacting osteopathic medicine

– Design and manage a set of member services to enhance their manage care interactions and to promote their opportunities to participate in manage care

– Provide update to the AOA leadership on health care trends particularly in the areas of pay for performance and physician profiling

Kavin T. Williams, Kavin T. Williams, CPC, CCPCPC, CCP

Responsibilities include:– Assists AOA members with reimbursement

and health payment policies.– Oversees and assists AOA members with

coding and payment disputes with carriers.– Oversees the AOA Coding and

Reimbursement Advisory Panel.– Represents the AOA at national

reimbursement policy meetings.

Are you ready for ICD 10 and the Are you ready for ICD 10 and the HIPAA 5010 Data Standard? HIPAA 5010 Data Standard?

• Objectives– To educate physicians on the ICD 10 and

HIPAA 5010 implementation compliance dates

– To educate physicians on the  impact the new coding sets will have on the current reimbursement and coding structure

 

The Transition to HIPAA 5010The Transition to HIPAA 5010

• Have you heard of the HIPAA 5010 Data Standard?

• Have you begun testing?

• Will you be ready for January 1, 2012?

Background of HIPAA 5010 Background of HIPAA 5010 Data StandardData Standard

• The current version of the standards (4010/4010A1) are identified as lacking certain functionality for health care needs

• Version 5010 will accommodate the ICD 10 codes

Mark Your CalendarsMark Your Calendars

• Important dates for 5010 Implementation– January 1, 2011-begin external testing of the

5010 version for electronic claims– December 31, 2011-to be at level II

compliance external testing of the 5010 for electronic claims must be completed

– January 1, 2012 – All electronic claims must use Version 5010. Version 4010 claims will no longer be accepted

Getting StartedGetting Started

• Now is the time….• Testing should be conducted both internally and

externally with current business partners • Internal testing of version 5010 should have

been completed by December 31, 2010• External should be completed by December 31,

2011

Getting StartedGetting Started

• Testing early will allow you to identify any potential issues, and address them in advance

• As HIPAA covered entity, CMS has to ensure that its business processes, systems , policies and those of ist contractors, providers, health plans, etc. are compliant with HIPAA

Pitfalls Pitfalls

• Lack of testing with your vendors, clearing houses, insurers to ensure that you can accept and send transactions is probably the top barrier to success

• Cost

• Timing (deadlines)

SummarizeSummarize

• Implementation date to be compliant for the 5010 HIPAA Data transaction is January 1, 2012

• If you have not begun testing the time is NOW!!

• Contact your vendors to inquire/schedule your internal and external testing

Vendor Model Letter Vendor Model Letter • Dear Vendor (Clearinghouse, EMR system, Medicare, private payers):

•  

• My (name of practice)________________ uses your ___________________ product/services, version ___________. As ICD-10-CM implementation approaches, we would like some information and clarification about your plans to upgrade your systems.

•  

• Specifically, we would like to know your plans for updating software to comply with HIPAA transactions.  Can you provide a timetable for the following.

•  

• When will you be installing upgrades and will there be a charge for this data?

•  

• Will my practice need additional hardware or support services to install the upgrade(s)?

•  

• Thank you in advance for complying with and your prompt attention to this request. 

•  

• Sincerely,

•  

ICD-10-CM/PCSICD-10-CM/PCS

HistoryHistory

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is the United States' clinical modification to the World Health Organization’s (WHO) International Classification of Diseases, Tenth Revision (ICD-10). ICD-10 was adopted by the World Health Assembly in 1990. Following the publication of ICD-10, a number of countries performed an analysis to determine if the WHO classification would meet their needs given the changes to the roles of ICD since the ninth revision.

HistoryHistory

The United States remains the only industrialized nation that has not yet implemented ICD-10 (or a clinical modification) for morbidity, meaning diseases or causes of illness typically coded in a healthcare facility. Since 1999, however, the US has used ICD-10 for mortality reporting – the coding of death certificates (typically done by a vital statistics office, not the healthcare facility). Implementing ICD-10-CM will maintain data comparability internationally and between mortality and morbidity data in the U.S.

DevelopmentDevelopment

In 1994 under the leadership of the National Center for Health Statistics (NCHS), the United States began their process of determining whether an ICD-10 modification should be developed. NCHS awarded a contract to the Center for Health Policy Studies to decide if a clinical modification was necessary. A Technical Advisory Panel (TAP) was formed and their recommendation was to create a clinical modification. In 1997, the entire draft of the Tabular List of ICD-10-CM and the preliminary crosswalk between ICD-9-CM and ICD-10-CM were made available on the NCHS website for public comments. The public comment period ran from December 1997 through February 1998. Since that time revisions were based on further study and the comments submitted. Draft versions of ICD-10-CM were made available in 2002, 2007, 2009, 2010, and 2011. Limited code updates will continue to occur to this draft prior to implementation of ICD-10-CM.

DevelopmentDevelopment

While ICD-10 provides many more categories for diseases and other health-related conditions than previous revisions, the clinical modifications thus far to ICD-10 offer a higher level of specificity by including separate codes for laterality and additional character and extensions for expanded detail. In addition, other changes included combining etiology and manifestations, poisoning and external cause, or diagnosis and symptoms into a single code. ICD-10-CM also provides code titles and language that complement accepted clinical practice. ICD-10-CM codes have the potential to reveal more about quality of care, so that data can be used in a more meaningful way to better understand complications, better design clinically robust algorithms and better track the outcomes of care. ICD-10-CM incorporates greater specificity and clinical detail to provide information for clinical decision making and outcome research.

ICD 10 ICD 10

• Implementation date is October 1, 2013

• Benefits of ICD 10

• Have you started preparation for ICD 10?

• How do I get started?

• How do I find the necessary resource information?

Benefits of ICD 10Benefits of ICD 10

• The Benefits of ICD-10-CM• ICD-10-CM incorporates much greater clinical detail and specificity

than ICD-9-CM. Terminology and disease classification have been updated to be consistent with current clinical practice. The modern classification system will provide much better data needed for:

• Measuring the quality, safety, and efficacy of care; • Reducing the need for attachments to explain the patient’s

condition; • Designing payment systems and processing claims for

reimbursement; • Conducting research, epidemiological studies, and clinical trials;

Benefits of ICD 10Benefits of ICD 10• Setting health policy; • Operational and strategic planning; • Designing health care delivery systems; • Monitoring resource utilization; • Improving clinical, financial, and administrative performance; • Preventing and detecting health care fraud and abuse; and • Tracking public health and risks.• Non-specific codes still exist for use when the medical record

documentation does not support a more specific code

ICD 9 vs ICD 10ICD 9 vs ICD 10

• Here are some SIMILARITIES AND DIFFERENCES BETWEEN THE TWO CODING SYSTEMS:

• ICD-10-CM uses 3–7 alpha and numeric digits and full code titles, but the format is very much the same as ICD-9-CM (e.g., ICD-10-CM has the same hierarchical structure as ICD-9-CM).

• The 7th character in ICD-10-CM is used in several chapters (e.g., the Obstetrics, Injury, Musculoskeletal, and External Cause chapters). It has a different meaning depending on the section where it is being used (e.g., in the Injury and External Cause sections, the 7th character classifies an initial encounter, subsequent encounter, or sequelae (late effect)).

Similarities & Differences Similarities & Differences cont’dcont’d

• Primarily, changes in ICD-10-CM are in its organization and structure, code composition and level of detail

ICD-9-CMICD-9-CM

• 3–5 digits;

• First digit is alpha (E or V) or numeric (alpha characters are not case sensitive);

• Digits 2–5 are numeric; and • Decimal is used after third character. • Examples: • 496 – Chronic airway obstruction, not elsewhere classified (NEC);

511.9 – Unspecified pleural effusion; and

V02.61 – Hepatitis B carrier.

ICD-10-CMICD-10-CM

• 3–7 digits;

• Digit 1 is alpha; Digit 2 is numeric; • Digits 3–7 are alpha or numeric (alpha characters are not case

sensitive); and • Decimal is used after third character. • Examples:

A78 – Q fever;

A69.21 – Meningitis due to Lyme disease; and

S52.131A – Displaced fracture of neck of right radius, initial encounter for closed fracture.

What will change?What will change?

• Coding– Code set will increase from 17,000 to 140,000

therefore the code books and styles will completely change ( both ICD 10-Cm and ICD 10-PCS)

– Clinical knowledge-Coders may need to be reeducated on anatomy and physiology

– All staff who handle coding, from the front office staff to the practice manager

Additional ChangesAdditional Changes

• Laterality ( left, right, bilateral)

• For example:– C50.511- Malignant neoplasm of lower-outer

quadrant of right female breast– H16.013- Central corneal ulcer, bilateral– L89.012- Pressure ulcer of right elbow, stage

II

Changes Cont’dChanges Cont’d

• Combination codes for certain conditions and common associated symptoms and manifestations– Example:

• K57.21-Diverticulitis of large intestine with perforation and abscess with bleeding

• E11.341- Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema

Changes Cont’dChanges Cont’d• Combination codes for poisonings and

their associated external cause– Example

• T42.3x25-Poisoning by barbiturates, intentional self-harm, sequela. (The ‘x’ character is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g, character 5 and/or 6) when a code that is less than 6 characters in length requires a seventh character

Changes Cont’dChanges Cont’d

• Example– T45.1x5A-Adverse effect of calcium-channel

blockers, initial encounter– T15.02XD-Foreign body in cornea, left eye,

subsequent encounter

Inclusion of clinical concepts that do not exist currently in ICD-9-CM (e.g., underdosing, blood type, blood type, blood alcohol level)

Changes cont’dChanges cont’d

Example

T45.526D-Underdosing of antithrombotic drugs, subsequent encounter

Z67.40-Blood alcohol level of 120-199 mg/100mL

Expansion of codes

Example-E10.610-Type 1 diabetes mellitus with diabetic neuropathic arthropathy

Other changes in ICD 10Other changes in ICD 10

• Injuries are grouped by anatomical site as opposed to type of injury

• Category restructuring and code reorganization have occurred in a number of ICD-10-CM chapters resulting in the classification of certain diseases and disorders that are different from ICD -9-CM

Other changes cont’dOther changes cont’d• Certain diseases have been reclassified to different

chapters or sections in order to reflect current medical knowledge

• New code definitions• Example-Acute Myocardial Infarction is now 4 weeks

rather than 8 weeks• ICD-9-CM V codes (factors influencing health status and

contact with health services) and E codes( External Causes of Injury and Poisoning) are incorporated in the main classification as opposed to being separated into supplementary classifications as they do currently in ICD-9-CM

Documentation Is the Center Documentation Is the Center Piece for Successful Reporting Piece for Successful Reporting

of ICD-10 Diagnosis Codesof ICD-10 Diagnosis Codes

Why get started nowWhy get started now

• Due to the potential significant financial and clinical impact ICD-10 and the changes required for transition to the information systems that are being mandated, physicians should be taking steps now to understand how to successfully prepare for ICD-10

ICD-10 ICD-10

• Coding and billing systems will need to be updated to support the new code set

• Currently the code set has 3-5 digits and ICD-10 will increase to 5-7 digits

• Documentation will be impacted severely which will cause a domino effect from productivity to increased claims delays

Steps to take to get startedSteps to take to get started

2. Understand the potential impact this will have on physicians practice

– Financial: How much will this transition cost a practice (training, software, etc)

– Productivity: How significant will this be for a practices bottom line and for how long?

– Education-what is needed and for whom is it needed (coders, billers, front office staff, lab personnel, etc)

QuizQuiz• True or false? V and E codes are supplemental classifications in ICD-10-CM.• True or false? In ICD-10-CM, injuries are grouped by anatomical site rather than

injury category. • What is the maximum number of characters in ICD-10-CM?• How many chapters does ICD-10-CM contain?• True or false? The first modification to ICD-10 was published in 2001• True or false? The final rule, published in the Federal Register naming ICD-10-

CM as a new medical code set standard to replace the ICD-9-CM diagnosis codes, sets October 1, 2013 as the implementation for ICD-10.

• True or false? ICD-10-CM uses extensions in some sections to identify an initial encounter, subsequent encounter or sequelae.

• Which letter of the alphabet is not utilized in ICD-10-CM?• The first character of an ICD-10-CM code is always an alphabetic letter.

Osteopathic Manipulative Treatment Osteopathic Manipulative Treatment (OMT)(OMT)

• Reporting of OMT Services

• E/M

• Modifier-25

• Documentation

• Compensatory Changes

• OMT Survey

Osteopathic Manipulative Osteopathic Manipulative Treatment (OMT)Treatment (OMT)

1-2 Body Regions Involved1-2 Body Regions Involved

VignetteVignetteA 25 yr. old female presents with right lower neck pain of two weeks duration. Somatic dysfunction of cervical and thoracic regions are identified on exam.

Description of Pre-Service WorkDescription of Pre-Service Work

The physician determines which osteopathic techniques (eg, HVLA, Muscle energy, Counterstrain, articulatory, etc) would be most appropriate for this patient, in what order the affected body regions need to be treated and whether those body regions should be treated with specific segmental or general technique approaches. The physician explains the intended procedure to the patient, answers any preliminary questions, and obtains verbal consent for the OMT. The patient is placed in the appropriate potion on the treatment table for the initial technique and region(s) to be treated.

Description of Intra-Service WorkDescription of Intra-Service Work

Patient is initially in the supine position on the treatment table. Motion restrictions of C6 and C7 are isolated through palpation and treated using muscle energy technique. Dysfunctions of T1 and T2 are treated using passive thrust (HVLA) technique. Patient position is changed as necessary for treatment of the individual somatic dysfunctions. Patient feedback and palpatory changes guide further technique application as appropriate.

Description of Post-Service Description of Post-Service Work Work

Post-care instructions related to the procedure are given, including side effects, treatment reactions, self-care, and follow-up. The procedure is documented in the medical record

Osteopathic manipulative treatment Osteopathic manipulative treatment (OMT) (OMT)

9-10 body regions involved9-10 body regions involved

VignetteVignette A 40 year old male presents with sub-occipital headache, and pain in the neck, upper and lower back, left shoulder and chest, and right ankle. He was involved in a rear-end MVA two weeks ago. X-rays in the ED were negative. He has been taking prescribed analgesic and muscle relaxant medications with minimal improvement. On examination, somatic dysfunction is identified at the occipitoatlantal, left glenohumeral and right tibiotalar joints, as well as the cervical, thoracic, costal, lumbar, sacral and pelvic

regions.

Description of Pre-Service WorkDescription of Pre-Service Work

The physician determines which osteopathic techniques (eg, HVLA, Muscle energy, Counterstrain, articulatory, etc) would be most appropriate for this patient, in what order the affected body regions need to be treated and whether those body regions should be treated with specific segmental or general technique approaches. The physician explains the intended procedure to the patient, answers any preliminary questions, and obtains verbal consent for the OMT. The patient is placed in the appropriate position on the treatment table for the initial technique and region(s) to be treated.

Description of Intra-Service WorkDescription of Intra-Service Work

Patient is initially in the supine position on the treatment table. Motion restrictions of identified joints are isolated through palpation and treated using a variety of techniques as follows: occipitoatlantal joint and sacrum are treated using muscle energy and counterstain techniques; right glenohumeral joint and pelvis are treated with articulatory technique; lumbar, thoracic, cervical and right ankle are treated with passive thrust (HVLA) technique; costal dysfunctions are treated using muscle energy technique. Patient position is changed as necessary for treatment of the individual somatic dysfunctions. Patient feedback and palpatory changes guide selection of further technique

application as appropriate.

Description of Post-Service WorkDescription of Post-Service Work

Post-care instructions related to the procedure are given, including side effects, treatment reactions, self-care, and follow-up. The procedure is documented in the medical record

OMT RVUsOMT RVUs

2011

• 98925 = 0.45• 98926 = 0.65• 98927 = 0.87• 98928 = 1.03• 98929 = 1.19

Conversion Factor = $33.9764

2012

• 98925 = 0.46• 98926 = 0.71• 98927 = 0.96• 98928 = 1.21• 98929 = 1.46

Conversion Factor = $24.6712

MedicareMedicare

The Objective is to Provide The Objective is to Provide InformationInformation

on the Following Topics:on the Following Topics:• Medicare 2012 Updates• Evaluation & Management • Medicare Audits• Recovery Audit Contractors (RAC)• “Incident To” Services

Medicare 2012 UpdatesMedicare 2012 Updates

• Physician Fee Schedule is facing a 27.4 percent reduction

• Physician Quality Reporting Initiative (PQRI) Bonus Payment 2%

• E-Prescribing Bonus Payment 2%

• OMT Survey

Physician DocumentationPhysician Documentation

• This is critical to your reimbursement• If it was not documented it did not happen• Clear and Legible, words to document by• Chief complaint (this is the driver to most

insurance auditors)• Familiarize yourself with your documentation

style- is it 1995 guidelines that you follow or 1997?

Documentation Guidelines Documentation Guidelines

• The medical record should be complete and legible.

• The documentation of each patient encounter should include:– reason for the encounter and relevant

history, physical examination findings and prior diagnostic test results;

– assessment, clinical impression or diagnosis;

– plan for care

Documentation Guidelines Documentation Guidelines [Cont.][Cont.]

• The patient’s progress, response to and changes in treatment, and revisions of diagnosis should be documented.

• The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

• Hospital visits should be included in the patient’s chart

Evaluation & Management Evaluation & Management (E/M) Coding(E/M) Coding

• Coding for office visits

• Modifier usage when billing an E/M with a procedure (OMT)

• Time Based Coding

Chief Complaint (CC)Chief Complaint (CC)

• The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factors that is the reason for the encounter, usually stated in the “patient’s own” words.

• Documentation Guidelines states that the medical record should clearly reflect the chief complaint

Medical NecessityMedical Necessity• This area is not black/white• There are numerous definitions of medical

necessity• Linking the appropriate diagnosis to the

appropriate procedure to support the necessity of the procedure performed is critical.

• Medicare defines medical necessity as services or items reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member.

Coding For TimeCoding For Time

• When is it appropriate to code for time?

• What is the auditor looking for when they review a chart that was billed as time being the controlling factor?

Tips For Verbiage When Tips For Verbiage When Billing For TimeBilling For Time

Example of correct documentation of time:• In your note it should read “ I spent 45 minutes

with the patient and over 50% of that time was spent discussing …

Example of incorrect documentation of time:• “I spent 45 minutes with the patient, discussed

surgical options versus medical management.

What Is An Audit?What Is An Audit?

• An effective tool used by Medicare and other payors to recover monies lost to fraud and erroneous billings.

Why Audits Are Why Audits Are Initiated?Initiated?

• Suspicion (Billing Pattern)• Outlier Physicians• The Senior Patrol• Whistleblowers• Procedure Codes

Who Are The Auditors?Who Are The Auditors?• The Office of the Inspector General (OIG)• Medicare• The Department of Justice (DOJ)• The Federal Bureau of Investigation (FBI)• Carriers

Types of AuditsTypes of Audits

• Prepayment Audits• Post-Payment Audits• Statistical Sampling Method

What Auditors Look For?What Auditors Look For?• Billing for services or supplies that were not

provided.• Billing for non-allowable or non-covered

services.• Altering claim forms to receive a higher

payment amount.• Unbundling claims.

How To Respond To A How To Respond To A Request For Request For

DocumentationDocumentation

• Reply to the audit notice in a timely fashion.• Gather and submit Only the requested

documentation.• Be cooperative.• You may want to conduct an internal audit.

How to Respond to the How to Respond to the Audit FindingsAudit Findings

• If the findings are not favorable:• Attempt to discuss the findings with the

reviewer. • If necessary request redetermination.• If necessary request a level one appeal.

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Medicare Medicare Recovery AuditRecovery Audit

Contractors (RACs) Contractors (RACs)

72

RAC LegislationRAC Legislation

• The RAC program was created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 which pays incentive fees to third-party auditors that identify and correct improper payments paid to healthcare providers in fee-for-service Medicare.

• The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 also requires permanent and nationwide RAC program by no later than 2010

The RAC Demonstration The RAC Demonstration ProjectProject

• The RAC demonstration project took place of New York, Florida, and California.

• By 2010 the RAC covered all 50 states.

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RAC Program MissionRAC Program Mission

• To detect and correct past improper payments,

• To implement actions that will prevent future improper payments.

• Providers can avoid submitting claims that don’t comply with Medicare rules

• CMS can lower its error rate• Taxpayers & future Medicare

beneficiaries are protected

The New RAC’s Are:The New RAC’s Are:• Diversified Collection Services, Inc. of Livermore, California,

in Region A, initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York.

• CGI Technologies and Solutions, Inc. of Fairfax, Virginia, in Region B, initially working in Michigan, Indiana and Minnesota.

• Connolly Consulting Associates, Inc. of Wilton, Connecticut, in Region C, initially working in South Carolina, Florida, Colorado and New Mexico.

• HealthDataInsights, Inc. of Las Vegas, Nevada, in Region D, initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.

Additional states will be added to each RAC region in 2009

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Minimize Provider Minimize Provider BurdenBurden

• Limit the RAC “look back period” to three years– Maximum look back date is October 1,

2007 • RACs will accept imaged medical records on

CD/DVD

• Limit the number of medical record requests

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Medical Record Limit Medical Record Limit ExampleExample

• Outpatient Hospital – 360,000 Medicare paid services in 2007 – Divided by 12 = average 30,000

Medicare paid services per month – x .01 = 300– Limit = 200 records/45 days (hit the max)

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Summary of Medical Summary of Medical Record Limits (for FY Record Limits (for FY

2009)2009)

• Inpatient Hospital, IRF, SNF, Hospice

– 10% of the average monthly Medicare claims (max 200) per 45 days per NPI

• Other Part A Billers (HH)– 1% of the average monthly Medicare

episodes of care (max 200) per 45 days per NPI

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Summary of Medical Record Summary of Medical Record Limits (for FY 2009) Limits (for FY 2009)

ContinuedContinued

• Physicians (including podiatrists, chiropractors) • Sole Practitioner: 10 medical records per 45 days per NPI• Partnership 2-5 individuals: 20 medical records per 45 days

per NPI• Group 6-15 individuals: 30 medical records per 45 days per

NPI• Large Group 16+ individuals: 50 medical records per 45 days

per NPI

– Other Part B Billers (DME, Lab, Outpatient hospitals) • 1% of the average monthly Medicare services (max 200) per

NPI per 45 days

RAC Validation Contractor RAC Validation Contractor (RVC)(RVC)

• CMS has contracted with Provider Resources, Inc. of Erie, PA, to work as the Recovery Audit Contractor (RAC) Validation Contractor.

• The RAC Validation Contractor (RVC) will work with CMS and the RAC to approve new issues the RACs want to pursue for improper payments, as well as perform accuracy reviews on a sample of randomly selected claims on which the RACs have already collected overpayment.

• The RVC is another tool CMS will use to provide additional oversight and ensure that the RACs are making accurate claim determinations in the permanent program.

For Additional Information For Additional Information on RACon RAC

• http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6125.pdf

• http://www.cms.hhs.gov/RAC/Downloads/RAC%20Evaluation%20Report.pdf

• http://www.cms.hhs.gov/rac/

Medicare “Incident to” Medicare “Incident to” Physician ServicesPhysician Services

The OIG reviews Medicare services that are “incident to” physicians services to determine the qualifications and appropriateness of the staff who performed them.

Physician DefinedPhysician Defined The “physician” refers to physician or other practitioner (listed below), who are authorized to receive payment for services “incident to” his or her own services.

• physician assistants• nurse practitioners• clinical nurse specialist• nurse midwife, and• clinical psychologist

Professional ServiceProfessional Service

• A direct, personal, professional service which is rendered by the physician

• To meet the “incident to” guidelines, the physician must initiate the course of treatment, and

• Conduct subsequent physician services to show ongoing involvement

Coverage RequirementsCoverage RequirementsTo be covered, service and supplies must

be:

• An integral, though incidental, part of the physician’s or on-physician practitioner’s professional services

• Commonly furnished in a physician’s office or clinic

• Furnished by the practitioner or auxiliary personnel under the physician’s direct supervision

Supervision Supervision RequirementsRequirements

Direct physician supervision of auxiliary personnel is required.

Auxiliary personnel:

• any individual (employee, leased employee, or independent contractor) who is acting under the supervision of a physician

• Auxiliary personnel include nurses, medical assistants, technicians, etc.

Direct Supervision in the Direct Supervision in the OfficeOffice

• Physician must be present in the office suite

• Physician must be immediately available to assist if needed

• Does not require that the physician be in the same room

Direct Supervision in the Direct Supervision in the Office ContinuedOffice Continued

Scenarios that do not meet the direct supervision requirement:

• Availability of a physician by telephone

• Physician presence somewhere in an institution

DocumentationDocumentation To support the use of the incident to provision, the documentation should clearly indicate: • Who performed the “Incident to” service• The physician’s presence in the office suite during the service/procedure

Division WebsiteDivision Website

• Go to www.do-online.org and sign onto DO-Online. – First time users will need their AOA

member number to sign up.• On DO-Online, click on Practice

Management for the division website.• There is also a Division email address:

practicemanagement@osteopathic.org.

What the DO-Online Practice What the DO-Online Practice Management Website has for Management Website has for

YouYou• Billing and Coding• E/M documentation• ICD-9-CM code

updates• OMT information• Legal• Litigation fund• Updates on class action

suits

• CMS/Medicare– Links to local carrier

information

– Information on each CPT code

– Enrollment information

– CMS Medlearn

– CCI link– Fee schedules, new and

prior

What the DO-Online What the DO-Online Practice Management Practice Management Website has for YouWebsite has for You

• Preventive health services

• Demonstration projects

• CERT- fraud and abuse information

• HIPPA

• Managed care

• Osteopathic Advocacy Resources

Division CME SeminarsDivision CME Seminars

• Conducted in conjunction with state associations and specialty colleges.

• Seminars available include Medicare Compliance, HIPAA Privacy Compliance, and Documentation Guidelines and Coding Reimbursement.

• Call Yolanda Doss, MJ, RHIA at 800-621-1773 ext. 8187 or ydoss@osteopathic.org for info.

Contact InformationContact Information

• Yolanda Doss 1-312-202-8187ydoss@osteopathic.org

• Sandra Peters 1-312-202-8088speters@osteopathic.org

• Kavin T. Williams, -312-202-8194kwilliams@osteopathic.org