medicare & hippa update€¦ · • the 2015 cpt coding manual contains myriad new codes,...

Medicare & HIPPA Update 3/22/15

David K. Talley, O.D., F.A.A.O. 1

Medicare & HIPPA Update

•  Review the 2015 OIG Work

Plan and Compliance

Programs.

To Do List

•  Review New Codes and Revised

CPT Codes.

•  Review Medicare Deductible,

Premiums and Fee Schedule.

•  Join Listserv.

Practice Survival Series

•  Review Permitted Uses and Disclosures of

PHI in clinical practice.

•  Understand Notices of Private Privacy

Practices.

•  Review the Breach Notification Rule.

Course Description

•  This course updates the Optometrist and ancillary personnel on: Medicare Deductibles, Premiums, Physician Reimbursement, Diagnostic and Treatment Codes, OIG Work Plan, Recovery Audit Contractors, Compliance Programs, Physician Compare, Physician Quality Reporting System, Medicare Physician Fee Schedule Final Rule and HIPPA Audits.


3/22/15 David K. Talley, O.D., F.A.A.O. 2

David K. Talley, O.D., F.A.A.O. Managing Partner E-mail: [email protected] Office: 901-357-0371 Cell: 901-481-0449

Course Instructor Medicare & HIPPA Update


Credentials

•  Dr. Talley is a board certified (ABO) Optometric Physician at a large optometric group practice in Memphis, Tennessee.

•  He has given over 1000 presentations in the areas of primary eye care, ocular disease and practice managment.



Advocacy •  Dr. Talley also volunteers a great deal

of his time for Optometry. He served as the President (Two Terms) and Director (Third Party Center, TPC) for the Tennessee Association of Optometric Physicians (TAOP), Former Chair of the Tennessee Board of Optometry (TNBO) and the TPC Coordinator of Tennessee for the American Optometric Association (AOA) TPC.



Commercial Disclosure •  The content of this course was

prepared independently by Dr. Talley without input from members of the ophthalmic industry.

•  Dr. Talley has no direct financial or proprietary interest in any companies, products or services mentioned in this presentation.

ID 38397-PM 1 Hour





Lesson 1

•  Medicare Deductibles, Premiums

•  Physician Reimbursement

•  Diagnostic and Treatment Codes

•  OIG Work Plan •  Recovery Audit

Contractors

Medicare Update

MEDICARE UPDATE


Medicare Deductible

•  The Medicare Part B deductible remained $147 in 2015.

•  Future increase determined by the annual percentage increase in Part B expenditure.

•  Additional details can be found at: http://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-costs.html

Medicare Update


Medicare Premiums

•  The 2015 Part B premium remained $104.90 a month for most Medicare beneficiaries.


Medicare Update


Medicare Premiums

•  Medicare beneficiaries with taxable income ≥ $85,000 for an individual or $170,000 for a couple will pay Medicare Part B premiums between $104.90 and $335.70 monthly.


Medicare Update


Factor or Fiction?

•  Medicare's Total Expenditure (MTE) for services is equal to the total of Relative Values (RV) for all services provided to Medicare patients during the year x Conversion Factor (CF).

•  IF the RV value rises for some services, the CF must decrease in order to keep the MTE the same.

Medicare Update


2015 Relative Values?

•  Relative Value Unit (RVU) changes took place Jan. 1, so the fee schedule for the first quarter of 2015 is not just a continuation of 2014.

•  Additionally CMS corrected an error in the malpractice RVUs, which results in about a 1% to 2% reimbursement reduction for optometry/ophthalmology.

Medicare Update




2015 Conversion Factor?

•  The conversion factor changed slightly from $35.8228 to $35.8013.

•  If Congress does not intervene prior to April 1, the SGR drops the conversion factor to $28.2239, effective for services performed April 1 to Dec. 31, 2015

Medicare Update


Legislative Update

•  Efforts to eliminate the flawed Sustainable Growth Rate (SGR) formula continue.

•  The SGR Repeal and Medicare Provider Payment Modernization Act (H.R. 4015/S.2000) bill failed to pass in 2014 so the process restarts in 2015.

Medicare Update


Legislative Update

•  H.R. 4015/S.2000 would have repealed the SGR, and would also instituted a 0.5% update to Medicare physician payments for five years, and preserve fee-for-service payments.

•  The act would also create a new, non-budget-neutral, Merit-based Incentive Payment System.

Medicare Update


Physician Reimbursement

•  Expect to have more than one Medicare Physician Fee Schedule (MPFS) in 2015.

•  Overall a net reduction of 2% to 5% for Optometry/Ophthalmology in 2015, not counting a possible SGR cut.

Medicare Update



The big losers are mostly retina: • Intravitreal injection (67028) is reduced by about 3% • PPV (67036) is reduced 9% • PPV with removal of ILM (67042) is reduced 26% • PPV with endolaser PRP (67040) is reduced 29% • SCODI retina (92134) is reduced 2%.

Medicare Update



•  Cataract surgery will drop by about 4%.

•  The comprehensive eye exam for established patients (92014) also took a small hit, about 1%, but the blow is softened as this code is billed frequently.

Medicare Update





•  Also included in the final rule is a plan to transition away from global surgery packages.

•  Minor surgery 10-day global periods expire in 2017; 90-day global periods expire in 2018.

•  Medically reasonable and necessary visits, both pre-op and post-op, would be billed separately.

Medicare Update


Diagnostic Code Changes

•  CMS did not publish new ICD-9 codes in anticipation of ICD-10 implementation on Oct. 1, 2015.

•  There are also no changes to ICD-10 in 2015.

Medicare Update


New ICD-10 Codes

•  Increases levels of specificity. •  155,000 codes versus 17,000 in ICD-9. •  Requires change from standard

electronic claim to version 5010. •  Anticipate significant cost to implement. •  Implementation date is 10/1/2015.

Medicare Update


Why ICD-10 Codes?

•  ICD-9-CM is 30 years old; produces limited data about medical conditions; uses outdated terms; is inconsistent with current medical practice; structure limits number of new codes; many ICD-9 categories are full.

•  ICD-10 Codes everywhere since 1994 (except the US and Italy).

Medicare Update


New ICD-10 Codes

•  ICD-9-CM is 30 years old; produces limited data about medical conditions; uses outdated terms; is inconsistent with current medical practice; structure limits number of new codes; many ICD-9 categories are full.

•  ICD-10 Codes everywhere since 1994 (except the US and Italy).

Medicare Update


Thinking ICD-10 Codes?

SITE

• Cornea? • Conjuctiva? • Lid? • Retina?

LATERALITY

• Right Eye? • Left Eye?

LOCATION

• Central? • Peripheral? • Macula?

SPECIFICS OF

DOCUMENTATION

Medicare Update




Thinking ICD-10 Codes?

INJURY

• How? • Where? • What?

INFECTION

• Organism? • Related to? • Specifies for each

condition?

SYSTEMIC

• Type of disease • Body system(s) • Complication? • Long Term TX?

SPECIFICS OF

DOCUMENTATION

Medicare Update


ICD -10 Coding Process Determine conditions for coding from medical documentation following ICD rules.

Use Alphabetical Index to locate condition and allocate code.

Use Tabular Listing to review all coding instructions related to code.

Use Instruction Manual for any rules regarding selection for reporting mortality and/or morbidity.

Medicare Update


Treatment Code Changes

•  The 2015 CPT coding manual contains myriad new codes, revisions and deletions applicable to Optometry and Ophthalmology.

•  Coverage and payment for Category III codes remain at carrier discretion.

Medicare Update


Treatment Code Changes Status CPT Description NEW 66179 Aqueous shunt to

extraocular equatorial plate reservoir, external approach; without graft

Revised 66180 Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft (CPT instructs: Do not report 66180 in conjunction with 67255)

Medicare Update


Treatment Code Changes Status CPT Description NEW 66184 Revision of aqueous

shunt to extraocular equatorial plate reservoir; without graft

Revised 66185 Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft

Medicare Update


Treatment Code Changes Status CPT Description Deleted 66165 Fistulization of sclera

for glaucoma; iridencleisis or iridotasis

NEW 92145 Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report (Note: replaces 0181T)

Medicare Update




Treatment Code Changes Status CPT Description NEW 0378T Visual field assessment,

with concurrent real-time data analysis and accessible data storage with patient-initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health-care professional

Medicare Update


Treatment Code Changes Status CPT Description NEW 0379T Technical support and

patient instructions, surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health-care professional

Medicare Update


Treatment Code Changes Status CPT Description NEW 0380T Computer-aided

animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report

Medicare Update


Treatment Code Changes Status CPT Description Revised 0191T Insertion of anterior

segment aqueous drainage device, without extraocular reservoir, internal approach, into trabecular meshwork; initial insertion

Medicare Update


Treatment Code Changes Status CPT Description NEW +0376T Each additional device

insertion (list separately in addition to code for primary procedure) (Note: add-on code used with 0191T)

Revised 0253T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into suprachoroidal space

Medicare Update


Treatment Code Changes Status CPT Description NEW 0341T Quantitative

pupillometry with interpretation and report, unilateral or bilateral

NEW 0356T Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into lacrimal canaliculus, each lacrimal canaliculus.

Medicare Update




Treatment Code Changes Status CPT Description NEW C9447 Injection,

phenylephrine and ketorolac, 4-ml vial (Note: the proprietary combination of phenylephrine 1.0% combined with ketorolac 0.3% (Omidria, OmerosTM) received pass-through status on Oct. 30, 2014, effective Jan. 1, 2015

Medicare Update


Transparency in Action? •  Office of Inspector General (OIG) •  Comprehensive Error Rate Testing

(CERT) •  Recovery Audit Contractors (RAC) •  Medicare Secondary Payer Recovery

Contractor (MSPRC) •  Zone Program Integrity Contractors

(ZPIC) •  Program Safeguard Contractors (PSC)

Medicare Update


OIG Work Plan

•  The Office of Inspector General (OIG) publishes a work plan iyearly

•  It contains project areas believed to be “vulnerabilities” of the Department of Health and Human Services programs.

Medicare Update


OIG Outcome Anaylsis

•  Total corrections since the Medicare Fee-for-Service Recovery Audit Program began in October 2009 stand at $7.26 billion, including $6.8 billion in overpayments.

Medicare Update


2015 OIG Work Plan

•  Place of Service Errors •  Payments for drugs •  Ambulatory Surgical Centers -

Payment System •  Ophthalmological Services -

Questionable billing during 2012 •  Imaging Services - Payment for

practice expenses

Medicare Update


2015 OIG Work Plan

•  Medicare Incentive Payments for adopting Electronic Health Records

•  Anesthesia services – Payments for personally performed services

•  Payment for compounded drugs under Medicare Part B

Medicare Update




2015 OIG Work Plan

•  Security of Certified Electronic Health Record Technology under Meaningful Use

Medicare Update

http://oig.hhs.gov/reports-and-publications/archives /workplan/2015/FY15-Work-Plan.pdf


EHR Bonus Audits

•  CMS has hired a CPA firm to audit individual clinicians and hospitals who earned Meaningful Use (MU) bonuses

http://www.cms.gov/Regulations-and- Guidance/Legislation/EHRIncentivePrograms/ RegistrationandAttestation.html

Medicare Update


EHR Bonus Audits

•  Letter requests 4 types of documentation with 2 week deadline: 1.  EHR is certified 2.  ER admissions 3.  Claims satisfied MU objectives and

measures 4.  Claims satisfied voluntary MU objectives

and measures

Medicare Update


E/M Services: Potentially Inappropriate Payments “We will determine the extent to which CMS made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated…

Medicare Update


E/M Services: Potentially Inappropriate Payments …with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service on the basis of the content of the service and have documentation to support the level of service reported.”

Medicare Update


Recovery Audit Contractor (RAC) Program •  CMS is consolidating its efforts with

new program integrity contractors that will look at billing trends and patterns across Medicare.

•  They will focus on companies and individuals whose billings for Medicare services are higher than the majority of providers and suppliers in the community.

Medicare Update




Recovery Audit Contractor (RAC) Program •  CMS is also shifting its traditional

approach to fighting fraud by working directly with beneficiaries by ensuring they received the durable medical equipment or home health services for which Medicare was billed and that the items or services were medically necessary.

Medicare Update


Recovery Audit Contractor (RAC) Program •  In its FY 2014 Agency Financial

Report, The Department of Health and Human Services reported an overall fee-for-service error rate of 12.7 percent, representing $46.3 billion in improper payments.

Medicare Update


Recovery Audit Contractor (RAC) Program •  The Recovery Audit Program

jurisdictions match the DME MAC jurisdictions.

•  Program expanded to include Part C and D RACs

•  Development of Medicaid RAC program – individual states to contract with RAC

Medicare Update


Recovery Audit Contractors (RAC) •  Region A (Vermont (VT), New

Hampshire (NH), Maine (ME), Massachusetts (MA), Rhode Island (RI), Connecticut (CT), New York (NY), New Jersey (NJ), Delaware (DE), Maryland (MD), Washington DC, Pennsylvania (PA)): Performant Recovery

Medicare Update


Recovery Audit Contractors (RAC) •  Region B (Minnesota (MN),

Wisconsin (WI), Michigan (MI), Ohio (OH), Indiana (IN), Illinois (IL), Kentucky (KY)): CGI Technologies and Solutions, Inc.

Medicare Update


Recovery Audit Contractors (RAC) •  Region C (West Virginia (WV),

Virginia (VA), Tennessee (TN), North Carolina (NC), South Carolina (SC), Georgia (GA), Alabama (AL), Mississippi (MS), Florida (FL), Arkansas (AR), Louisiana (LA), Texas (TX), Oklahoma (OK), New Mexico (NM), Colorado (CO)): Connolly Healthcare

Medicare Update




Recovery Audit Contractors (RAC) •  Region D (Washington (WA),

Oregon (OR), Idaho (ID), Montana (MT), North Dakota (ND), South Dakota (SD), Wyoming (WY), Utah (UT), Nebraska (NE), Iowa (IA), Kansas (KS), Missouri (MO), California (CA), Nevada (NV), Arizona (AZ), Hawaii (HI), Alaska (AK)): HealthDataInsights, Inc.

Medicare Update


Medicare Fee-For-Service RAC Program Myths •  Myth: RACs have a contingency

fee between 30 and 50 percent

•  Fact: Recovery Auditors are paid based on a contingency fee basis. The contingency fee is a percentage of the amount of the improper payment. The contingency fees ranged from 9.0% - 12.5%.

Medicare Update


Medicare Fee-For-Service RAC Program Myths •  Myth: Every RAC denial is

overturned on appeal •  Fact: The appeals process is a

multilevel approach that allows providers to appeal a Recovery Auditor’s overpayment determination. To date, only 2.4 percent have been overturned on appeal.

Medicare Update


Medicare Fee-For-Service RAC Program Myths Myth: RAC have non-clinicians conduct review of medical records •  Fact: Each RAC employs: certified

coders, nurses, therapists, and a physician who is designated as the Contractor Medical Director (CMD)

Medicare Update


Medicare Fee-For-Service RAC Program Myths Myth: RAC create their own policies and are not bound by CMS regulations, NCDs, or LCDs •  Fact: The Recovery Auditor shall

comply with all National Coverage Determinations (NCDs), Coverage Provisions in Interpretive Manuals, national coverage and, local coverage determinations (LCD’s).

Medicare Update


Digital Database Resource

NCDs, LMRPs/LCD and local coverage/coding articles can be found in the Medicare Coverage Data Warehouse http://www.cms.hhs.gov/mcd/overview.asp).

Medicare Update




Medicare Fee-For-Service RAC Program Myths Myth: RACs can review as many claims as they want from a provider Fact: CMS has limited the look-back period for Recovery Auditor reviews to a maximum of 3 years.

Medicare Update


Reality Check?

In April, Dr. Uninformed receives letter from CMS stating he is an outlier for a new patient office visits: •  95.3% of all new patients billed as 99204 •  Detailed letter with very specific statistics

(not a form letter) •  Letter shows typical patterns •  Recommends reviewing E/M guidelines

Medicare Update


Reality Check?

Dr. Uninformed never sees letter (misplaced in front office area), therefore: •  No Response •  No Internal Review •  No Education

Medicare Update


Reality Check?

In December Dr. Uninformed receives another letter from CMS stating: “We informed you in April that you were an outlier, your utilization pattern has not changed, therefore we are now placing you on prepayment review for new patient E/M coding.”

Medicare Update


Medicare Utilization Patterns in Optometry Examination CPTs

Medicare Update

CPT New Patients

λ CPT Established Patients

λ

99205 Level 5 E/M 1% 99215 Level 5 E/M <1% 99204 Level 4 E/M 12% 99214

92014 Level 4 E/M

Comprehensive Eye

56%

99203 92004

Level 3 E/M Comprehensive

Eye

77% 99213 92012

Level 3 E/M Intermediate Eye

36%


Medicare Update

CPT New Patients

λ CPT Established Patients

λ

99202 92002

Level 2 E/M Intermediate

Eye

10% 99212 Level 2 E/M 7%

99201 Level 1 E/M <1% 99211 Level 1 E/M <1%

Medicare Utilization Patterns in Optometry Examination CPTs




Medicare Update

CPT Procedure λ CPT Established Patients

λ

92250 Fundus Photos 12% 92133 SCODI - RET 4% 9208x Perimetry 9% 92020 Gonio 2% 92133

SCODI - ON 6% 76514 Pachymetry 1%

9222x EO 6% 99285 Ext Photos 1%

Medicare Utilization Patterns in Optometry Diagnostic CPTs


Lesson 2

•  Compliance Programs •  Physician Compare •  Physician Quality

Reporting System (PQRS)

•  Medicare Physician Fee Schedule (MPFS) Final Rule

Medicare Update

MEDICARE UPDATE


Compliance Programs

•  The Patient Protection and Affordable Care Act (PPACA) requires practices to implement a compliance program to maintain enrollment with Medicare or Medicaid.

•  Final details regarding a deadline or the extent of the program have not yet been described.

Medicare Update


Compliance Programs

•  It is anticipated that the Compliance Program outline will resemble the OIG voluntary guidance published in 2000.

•  The document outlines seven elements for an effective plan.

•  The 2000 guidance can be found at: http://oig.hhs.gov/authorities/docs/physician.pdf

Medicare Update


Physician Compare

•  CMS launched a Website called Physician Compare listing doctors by location, specialty and other criteria.

•  The information in this database comes from the Provider Enrollment, Chain, and Ownership System (PECOS) and an external data source.

Medicare Update


Physician Compare

•  CMS post information about physicians performing in PQRS (i.e. Success Rates).

•  CMS has also stated that it is also considering adding other content, such as Board Certification.

Medicare Update




Physician Compare

•  Physicians can check their listing at: http://www.medicare.gov/find-a-doctor/provider-search.aspx

•  If your information is incorrect or has changed, please go to the following website for correction: http://www.medicare.gov/find-a-doctor/staticpages/note/overview.aspx

Medicare Update


Physician’s Quality Reporting System (PQRS) •  The Patient Protection and

Affordable Care Act made the Physician Quality Reporting System (PQRS) mandatory in 2015.

Medicare Update


Physician’s Quality Reporting System (PQRS) •  Eligible professionals who did not

successfully report PQRS in 2013 will be penalized 1.5% off the MPFS in 2015.

•  Providers who did not successfully report in 2014 will be penalized 2% in 2016.

Medicare Update


2015 Medicare Physician Fee Schedule (MPFS) Final Rule •  2017 Payment Adjustments •  Physician Quality Reporting System

(PQRS) •  Electronic Health Record (EHR)

Incentive Program •  Public Reporting •  Value-Based Payment Modifier (VM) •  Medicare Shared Savings Program

Medicare Update


2017 Payment Adjustments Program Applicable to Adjustment Amount Based

on PY PQRS All eligible

professional (EP’s)

-2.0% of Medicare Physician Fee Schedule (MPFS)

2015

Medicare EHR Incentive Program

Medicare physicians (if not a meaningful user)

-3.0% of MPFS 2015

Medicare Update



on PY Value-based Payment Modifier

All physicians in groups with 2+ EP’s and physicians who are solo practitioners

Mandatory Quality-Tiering for PQRS reporters- Groups with 2-9 EPs and solo practitioners: Upward or neutral VM adjustment only based on quality-tiering (+0.0% to +2.0x of MPFS)

2015

Medicare Update







Mandatory Quality-Tiering for PQRS reporters- Groups with 10+ EPs: Upward, neutral, or downward VM adjustment based on quality-tiering (-4.0% to +4.0x of MPFS)

2015

Medicare Update





Non-PQRS reporters- Groups with 2-9 EPs and solo practitioners: automatic -2.0% of MPFS downward adjustment.

2015

Medicare Update





Non-PQRS reporters- Groups with 10+ EPs: Automatic -4.0% of MPFS downward adjustment

2015

Medicare Update


Public Reporting Update Medicare Update

•  The 2015 final rule outlines further expansion of public reporting on Physician Compare.

Groups •  All PQRS GRPO measures via the GPRO Web

Interface, Registry, & EHR and all ACO measures •  Consumer Assessment of Healthcare Providers &

Systems (CAHPS) for PQRS and CAHPS for ACOs


Public Reporting Update Medicare Update

•  The 2015 final rule outlines further expansion of public reporting on Physician Compare.

Individuals •  All 2015 individual PQRS measures via Registry, EHR,

& Claims. •  2015 QCDRs Measures Data include Individual EP-

level, PQRS and Non-PQRS and No first year measures.


Lesson 1 1.  What does the Privacy

Rule cover? 2.  What Covered Entities

such as the Practice Can Do with that information?

3.  How Much Information Can the practice Use and Disclose, and to Whom?

4.  What to do if a Breach of PHI has occurred?

HIPPA UPDATE

HIPPA Update




Why HIPAA Training?

•  July 23, 2012. Texas woman pleads guilty in federal court for violations of HIPAA—improperly accessing and disclosing patient’s names, dates of births and social security numbers. The woman faces up to 10 years in prison.

HIPPA Update


Why HIPAA Training?

•  May 2012. A California man was convicted of violating HIPAA’s privacy provisions after accessing and reading the medical records of his supervisor, coworkers and other patients. He was sentenced to 4 months in prison followed by a one year parole.

HIPPA Update


•  Range from $100 per negligent violation up to $50,000 per willful violation, with a maximum penalty of $1.5 million for all violations committed in a year.

•  Also has criminal penalties, including imprisonment up to ten years.

HIPPA Penalties HIPPA Update


•  HIPAA Regulates Electronic Health Transactions (EHT’s) for certain “Covered Entities” and has three rules.

HIPAA Regulates EHT’s HIPPA Update


1.  Security Rule protects electronic protected health information (PHI).

2.  Privacy Rule safeguards the confidentiality and integrity of PHI in any form-including discussions. The Privacy Rule regulates how a Covered Entity may use or disclose PHI in its daily functions.

HIPAA’s 3 Rules HIPPA Update


3. Breach Notification Rule requires Covered Entities to notify individuals if there is a breach of their unsecured PHI.

HIPAA’s 3 Rules HIPPA Update




HIPAA Privacy Rules…

Covers Protected Health Information (PHI) which is . . .

•  Individually Identifiable Health Information

•  Transmitted or maintained in any form or medium by a Covered Entity

HIPPA Update


Individually Identifiable Health Information •  Health information, including

demographic information; •  Medical Record Number, Beneficiary

Number •  Information that relates to an

individual’s physical or mental health or the provision of or payment for health care; or

HIPPA Update


Individually Identifiable Health Information •  Diagnosis information, Medications

or Plan of Care Information •  Identifies the individual. •  Age, Address, Social Security

Numbers, Telephone Number, Birthdates, Admission/Discharge Dates, etc.

HIPPA Update


Individually Identifiable Health Information •  A Covered Entity may de-identify

the health information. This means the information will no longer be PHI, and therefore, no longer subject to HIPAA.

•  The information must be purged of the following 18 identifiers:

HIPPA Update


Individually Identifiable Health Information •  Name •  Address •  Dates (except year)-e.g., birth,

admission, discharge, etc. •  Telephone number •  Fax Number •  Email Address •  Social Security Number (SSN) •  Medical record Number •  Health plan beneficiary number

HIPPA Update


Individually Identifiable Health Information •  Account Numbers •  Certificate/License Number •  Vehicle ID/License Number •  Device identifiers & Serial Numbers •  Uniform Resource Locator (URLs) •  Internet Protocol address numbers •  Biometric Identifiers (fingerprints) •  Full face photos •  Any other unique ID number

HIPPA Update




What is a Covered Entity?

•  A h e a l t h p l a n , h e a l t h c a r e clearinghouse, or a health care provider that conducts electronic standard transactions (billing and funds transfers).

HIPPA Update


What is a Covered Entity?

•  Doctors, Hospitals, Insurance Plans-including self-insured components of an entity.

•  West Tennessee Eye, PLC., (the “Practice”) is a Covered Entity under HIPAA.

HIPPA Update


Security Rule Protects e-HPI Protects Electronic PHI •  The Practice must implement

administrative, physical, and technical safeguards designed to reasonably protect electronic PHI.

•  The Security Rule also includes requirements for HIPAA policies and procedures.

HIPPA Update


•  Administrative Safeguards: Ex. Identify a Privacy Officer

•  Physical Safeguards: Ex. How will the Practice Dispose of e-PHI?

•  Technical Safeguards: Ex. Emergency Access procedures- how will the Practice access e-PHI during an emergency?

Security Rule Protects e-HPI

HIPPA Update


Privacy Rule Uses & Disclosures of PHI •  The Practice may not use or

disclose PHI, except as required or permitted by the Privacy Rule.

HIPPA Update


Required Disclosures

•  The Practice must disclose PHI to an individual when requested for purposes of accessing their PHI and providing the individual with an accounting of all disclosures of that individual’s PHI.

Ø  Ø The Practice must disclose PHI to the Department of Health and Human Services pursuant to an investigation or to determine compliance with the Privacy Rule.

HIPPA Update




Required Disclosures

•  The Practice must disclose PHI to the Department of Health and Human Services pursuant to an investigation or to determine compliance with the Privacy Rule.

HIPPA Update


Permitted Uses & Disclosures •  For Treatment, Payment and

Healthcare Operations (TPO) •  If the Practice Gives the Patient an

Opportunity to Agree or Object •  For Purposes of Public Policy •  “Incident To” another required/

permitted disclosure.

HIPPA Update


Permitted Uses & Disclosures •  Pursuant to an Authorization- if the

patient has signed a HIPAA authorization, you may disclose information in accordance with that authorization.

HIPPA Update


Treatment Purposes •  Treatment means the provision,

coordination, or management of healthcare by one or more healthcare providers.

Permitted Uses & Disclosures

HIPPA Update


Treatment Purposes •  Ex. The Practice may provide a

patient’s PHI to other Covered Entities that have a relationship with that patient for treatment purposes without first obtaining the patient’s authorization.


HIPPA Update


Payment & Healthcare Operations •  Payment means activities of the

Practice to obtain payment or reimbursement for its services.

•  Healthcare operations are administrative, financial, legal and quality improvement activities that are necessary to support core functions of treatment and payment.


HIPPA Update




Payment & Healthcare Operations •  Ex. The Practice may release patient

PHI (without the patient’s express authorization) to its accountants when the accountants are representing the Practice in a fiscal matter.


HIPPA Update


Opportunity for an Individual to Agree or Object •  The Practice may disclose PHI to

the patient’s family or friends if the patient first has the opportunity to agree or object to the disclosure.


HIPPA Update


Opportunity for to Agree or Object •  For example, the Practice may

discuss a patient’s treatment with the patient in the presence of a friend when the patient brings the friend to an appointment and asks if the friend can come into the treatment room. In this situation, the Practice may infer the patient agrees to the disclosure.


HIPPA Update


Opportunity for to Agree or Object •  The Practice may also discuss the

patient’s payment or treatment information to a friend or family member that the patient identifies, if that person is directly involved in the patient’s care or payment for services.


HIPPA Update


“Incident To” Disclosures •  This rule allows the Practice to use

or disclose PHI incident to an otherwise permitted use or disclosure, provided that the Practice disclose only the minimum necessary and that safeguards are in place.


HIPPA Update


“Incident To” Disclosures •  Ex. It is permissible to call out a

patient’s name in the waiting room. This disclosure is incident to the permitted use of the patient’s name for treatment of that patient.”


HIPPA Update




“Incident To” Disclosures •  However, only the minimum

necessary (i.e., the patient’s name) must be used. It would be improper to call out, “Mr. Smith, we are now ready for you to get your eyes dilated.”


HIPPA Update


“Incident To” Disclosures •  It is also permissible to use a sign in

sheet. The names do not have to be marked through after the patient signs in. However, the sign in sheet cannot ask for specific information related to the patient’s treatment/condition, etc.


HIPPA Update


A Few More Examples •  The Practice may leave messages

on patients’ voicemail, but should limit the message information. Ex. This is West TN Eye, calling for Mr. Smith to confirm his appointment on May 5th. Please call us back at your earliest convenience to confirm.


HIPPA Update


A Few More Examples •  The Practice may leave a similar

message to a family member that picks up the phone. Use your best professional judgment to keep all disclosures to the minimum necessary!


HIPPA Update


A Few More Examples •  The Practice may speak to third

parties involved in the patient’s payment. Ex. Mrs. Jones’s daughter handles Mrs. Jones finances. The Practice may call Mrs. Jones’s daughter to discuss payment arrangements for Mrs. Jones’s medical bills.


HIPPA Update


•  According to the Privacy Rule, the Practice maintains a Notice of Privacy Practices for PHI that provides its patients with notice of how the Practice may use and disclose PHI about the patient, as well as his or her rights and the Practice’s obligations with respect to that information.

Notice of Privacy Practices

HIPPA Update




• As part of this Notice, the Practice must provide patients with contact information for the Practice Privacy Officer.

•  WHO IS THE PRIVACY OFFICER AT YOUR PRACTICE?


HIPPA Update


•  A Privacy Officer is required by HIPAA and is responsible for handling questions and concerns related to HIPAA; implementing HIPAA policies and procedures; and managing alleged privacy incidents.


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• HIPAA Authorizations are required for any use or disclosure not otherwise permitted or required by the Privacy Rule.

That is…

Authorized Uses & Disclosures

HIPPA Update


•  If the use/disclosure is not for treatment, payment, or healthcare operations, is not a situation where the person may verbally agree or object to the use or disclosure, or is not an “incident to” disclosure, or any other permissible use or disclosure, then the Practice must first obtain the patient’s authorization on a HIPAA authorization form before making the use/disclosure of PHI.

Authorized Uses & Disclosures

HIPPA Update


HIPAA Authorizations

•  Must meet the standards set out in the Privacy Rule.

•  Who is authorized to receive the information? (ex. Patient’s employer, spouse, child, etc.)

HIPPA Update



•  What information is the Practice authorized to disclose to that person? (ex. All medical records, records covering a specific treatment date, etc.)

•  Must be signed and dated by the patient.

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•  The Practice cannot condition the patient’s treatment on the authorization;

•  Must provide examples of how the Practice may use/disclose PHI without an authorization (e.g., treatment, payment, healthcare operations).

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HIPAA Authorization Recap •  If the use or disclosure of PHI is not

permitted or required by HIPAA, you must have a proper HIPAA Authorization to release the PHI.

• Example as follows:

HIPPA Update


HIPAA Authorization Recap •  Mrs. Brown’s employer calls the Practice

and requests the Practice to fax medical paperwork to the employer. This is not a permitted or required disclosure. The Practice cannot disclose any of Mrs. Brown’s information to her employer unless Mrs. Brown has signed a HIPAA authorization allowing the Practice to discuss her information with the employer.

HIPPA Update


Minimum Necessary Rule

Exceptions to this Rule: •  Disclosures to or requests by

providers for treatment •  Disclosures to the patient •  Uses and disclosures with an

authorization

HIPPA Update


Minimum Necessary Rule

•  The Practice must make reasonable efforts to limit any use or disclosure of, and requests for, PHI to the minimum amount necessary to accomplish the intended purpose.

HIPPA Update


Breach Notification Rule

•  The HIPAA Breach Notification Rule requires the Practice to recognize when “unsecured” PHI has been subject to a “breach.”

•  PHI is unsecured when it has not been rendered unusable, unreadable, or indecipherable to unauthorized individuals.

HIPPA

Update




Breach Notification Rule

•  PHI is secure when it is encrypted or destroyed.

•  Destruction. If PHI is stored or recorded on media that has been destroyed in one of the following ways, it is deemed secure:

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Secured PHI by Destruction •  Paper, film, or other hard copy

media that has been shredded or destroyed so that the PHI cannot be read or reconstructed.

•  Electronic media that has been cleared, purged or destroyed such that the PHI cannot be removed.

HIPPA Update


What is a “Breach”?

•  Generally, any unauthorized acquisition, access, use or disclosure of unsecured PHI is presumed to be a “breach” unless the Practice can demonstrate that it is unlikely such event “compromises” the patient’s PHI.

HIPPA Update


Exceptions to a “Breach”

•  Where the recipient of the PHI could not reasonably retain the disclosed information. (Sending or receiving an errant email, which is promptly deleted or confirmed that the receiver promptly deleted).

HIPPA Update



•  Unintentional access or use by a Practice employee who is acting in good faith within the scope of his/her employment (assistant picks up wrong patient file).

HIPPA Update



•  Inadvertent disclosures among authorized persons (Practice faxing/emailing the wrong patient’s information to another physician/medical provider).

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•  If you think a breach of PHI has occurred, do not assume it falls under an exception—all breaches should be reported to the Privacy Officer.

HIPPA Update


A Potential Breach

•  IMPORTANT: If you suspect there has been a breach of PHI, you must immediately contact the Privacy Officer.

•  HIPAA requires that the Practice notify the affected patients within 60 days of discovering a breach- so please do not wait if you think a breach has occurred!

HIPPA Update


Breach Barriers?

•  Most HIPAA breaches occur from the theft or loss of a laptop or other portable electronic device.

HIPPA Update


Reporting HIPAA Concerns •  Before disclosing PHI, if you are not

sure it is permitted, contact the Privacy Officer.

•  Also, employees are required to report possible or known Privacy violations to the Privacy Officer.

HIPPA Update


Reporting HIPAA Concerns •  The Practice has a policy of non-

retaliation for any employee making a good faith report of Privacy violations.

•  Immediately notify the Privacy Officer if you believe you are being punished for making a good faith report so it can be investigated and reported.

HIPPA Update


HIPPA Homework

•  What Information is Covered by the Privacy Rule?

•  What Covered Entities such as the Practice Can Do with that Information?

HIPPA Update




HIPPA Homework

•  How Much Information Can the Practice Use and Disclose, and to Whom?

•  What to do if a Breach of PHI has Occurred?

HIPPA Update


Listserv

•  Receive the latest important updates and changes from Center for Medicare & Medicaid Services (CMS).

•  Sign up for CMS Listserv E-mail Notification by going to: https://subscriptions.cms.hhs.gov/service/multi_subscribe.html?code=USCMS&custom_id=566 3/22/15 David K. Talley, O.D., F.A.A.O. 146


Listserv

•  Receive the latest important updates and changes from Cahaba Government Benefit Administrators (GBA), J10 A/B Medicare Administrative Contractor (MAC)

•  Sign up for Cahaba GBA Listserv E-mail Notification by going to: https://www.cahabagba.com/forms/subscribeForm.htm



Listserv

•  Receive the latest important updates and changes from CIGNA Government Services, DME MAC Jurisdiction C.

•  Sign up for CIGNA Listserv E-mail Notification by going to: http://www.cignagovernmentservices.com/jc/help/listserv/index.html



AOA/IOA Benefit

•  Frequently Asked Questions (FAQ) on Coding provides questions asked by AOA members and the answers provided by AOA volunteers and staff.

•  To assess this resource go to: http://www.aoa.org/x15187.xml



AOA/IOA Benefit

•  Ask the Codehead exist to offer AOA members the opportunity to E-mail Coding Questions and have them answered by an AOA staff or volunteer who is very knowledgeable in medical records and coding.






AOA/IOA Benefit

•  Coding Webinars are available to educate physicians and staff on medical recording keeping and coding.




AOA/IOA Benefit

•  A Social Networking Site featuring a Coding and Billing Group exist where information that specifically relates to coding and billing can be shared.

•  To assess this resource go to: http://sso.aoa.org/ConnectLogin.aspx?return=htt%3%2%2fconnect.aoa.org%3a80%2fapp%2frender%2fgo.aspx%3fxsl%3dtp_community.xslt



AOA/IOA Benefit

•  AOACodingToday.com, a web based source of information related to codes and services.

•  Current AOA members are able to subscribe at no cost.

•  To assess this resource go to: http://www.aoacodingtoday.com/



References

•  Cahaba Government Benefit Administrators®, LLC (Cahaba GBA) J10 A/B Medicare Administrative Contractor (MAC) https://www.cahabagba.com/

•  CIGNA Government Services, LLC DME MAC Jurisdiction C http://www.cignagovernmentservices.com/jc/index.html



References

•  Ophthalmology Coding Alert http://www.codinginstitute.com/products/physician-practice/ophthalmology-coding-alert.html

•  Ophthalmology Coding Companion http://www.shopingenix.com/SearchResults.aspx?SearchTerm=%20%20opthalmology



References

•  Administrative Eye Care http://shop.asoa.org/product/administrative-eyecare-subscription-domestic-14.cfm

•  Corcoran Consulting Group(CCG) http://www.corcoranccg.com/





Disclaimer •  This presentation was prepared as a tool

to assist Optometrist and their staff. •  Every reasonable effort has been made to

assure the accuracy of the information. •  The speaker make no representation,

warranty, or guarantee that this information is error free and will bear no responsibility or liability for the results or consequences of the use of this document.



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Contact Information

E-Mail: [email protected] Office: 901-357-0371 Cell: 901-481-0449



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