POINTS OF INTEREST . . . . . . . . . . . . . . . . . . . . . .

Partial Code Freeze

for ICD-9-CM and ICD-10 Finalized. See page 2.

CDC publishes

guide to protecting outpatients from infection. See page 3 for details.

New K-Codes for

Wound Suction Pumps and Associated Dressings - Coding Guidelines . See page 6 for more information.

Attorney General

Kamala D. Harris Announces Largest False Claim Settle-ment In CA History. See page 9.

Virtual AuthTech®

OPPS Calculator- PCG releases APC and ASC Pricing module to customers at no charge. See page 10.

Virtual Reporter

Work Queue has added new advanced functionality: user defined sorting on multiple fields . See page 12.

VOLUME 3, ISSUE 3 July 2011

OVER DOCUMENTATION AND CLONING A feature of many electronic healthcare records (EHR) is the ability to automatically copy information from previous visits into the current record. This feature can lead to a False Claims Act violation. In reviewing client records, we have seen increasing levels of up-coding of claims and over-documentation of services. This is validated in the Virtual Examiner® Fraud and Abuse Module reports of physician bell-shaped curve analysis of evaluation and management services. Providers with EHRs should be reviewing their medical records for identical documentation. The Office of the Inspector General issued a new warning on May 18th, 2011 that can be shared with your networks as they move to EHRs. The presentation materials from the OIG Health Care Fraud Prevention and Enforcement Action Team are available at:

http://oig.hhs.gov/compliance/provider-compliance-training/index.asp.

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CMS STEPS UP CLAIMS REVIEW EFFORTS CMS recently allowed MAC auditors to review and consider claim history for data mining in determining whether payments made were appropriate. Examination of claim history can identity other providers with information that can support a claim or an event that would support medical necessity for services or to identify duplication and overutilization of services. Instead of the highly retrospective review of claims, on July 1, 2011, Medicare will deploy analytic technology aimed at identifying fraudulent claims prior to payment. Virtual Examiner’s analytics allow you to perform the same types of prepayment reviews. If you need assistance in using these types of reports, please call us.

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PARTIAL CODE FREEZE ICD 9-CM AND ICD-10 FINALIZED The ICD-9-CM Coordination and Maintenance Committee will implement a partial freeze of the ICD-9-CM and ICD-10 (ICD-10-CM and ICD-10-PCS) codes prior to the implementation of ICD-10 on October 1, 2013. There was considerable support for this partial freeze. The partial freeze will be implemented as follows: Payers need to be aware that CMS is also scrutinizing all CMS payments. The full report can be reviewed at: www.oig.hhs.gov/oas/reports/region7/ 71004154.pdf.

● The last regular, annual updates to both ICD-9-CM and ICD-10 code sets will be made on October 1, 2011.

● On October 1, 2012, there will be only limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases as required by section 503(a) of Pub. L. 108-173.

● On October 1, 2013, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by section 503(a) of Pub. L. 108-173. There will be no updates to ICD-9-CM, as it will no longer be used for reporting.

● On October 1, 2014, regular updates to ICD-10 will begin.

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VIRTUAL EXAMINER 3RD QUARTER RELEASE NOTES VE Program Versions

Virtual Examiner ® (VE) 5.28.7 Virtual AuthTech® (VA) 4.2 Virtual Reporter™ (VR) 1.12.19

3rd Quarter Coding Changes

ICD-9-CM use is coming to an end but the code set still is growing with 180 changes that are planned for the October 1, 2011 update. Most of the 125 new codes are related to new diseases and/or technology changes. There were 25 deleted codes and 30 revised codes. The complete change list is found at: https://www.cms.gov/ICD9ProviderDiagnostic Codes/04_addendum.asp: Each quarter, CMS updates the list of “ASC approved procedures” that CMS allows reimbursement in POS 24. Please review this list and share it with your UM Depar tments : h t tp : / /www.cms.gov /ASCPayment/11_addenda_Updates.asp. CMS has also discontinued payment for the implant of new technology intraocular lenses. HCPC Q1003 has been discontinued. The fee for Q1003 applies only to the ASC and not to the provider’s reimbursement. There are errata changes to the 2011 AMA CPT® codes that are available for review at the AMA website: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-bil l ing-insurance/cpt/about-cpt/errata.page. CCI version 17.2 which takes effect on July 1, 2011, had very few changes from the previous version. They were 2.703 changes with 2,367 new code pairs (49% affecting G-codes), 336 deleted code pairs, 322 new mutually exclusive code pairs and 7 deleted mutually exclusive code pairs.

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EVALUATION AND MANAGEMENT FRAUD TrailBlazer’s recent evaluation and manage-ment review demonstrated that the Review of Systems and exam did not match the presenting systems of the patient. As a result, the physician billed for a higher than necessary level of care. The TrailBlazer E/M audit review results can be downloaded at: w w w . t r a i l b l a z e r h e a l t h . c o m / T o o l s /Notices.aspx?DomainID=1&ID=14182 . A key focus of the audit tool is this statement-”Bill the level of E/M service appropriate to treat the patient’s presenting problems.” Documentation of E/M services billed for Medicare payment must ensure the patient’s clinical condition and reason for the service are documented in enough detail for a reasonable observer to understand the patient’s need and the practitioner’s thought process. The E/M code billed must reflect patient’s needs, work performed and medical necessity. Though an E/M service may code to a high level based on the documentation of key component work, it is inappropriate to request Medicare payment when the patient’s effective management does not require the code’s work.

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SAMPLING GUIDANCE It is challenging to perform 100% audits of medical records when a billing compliance issue is identified. We are frequently asked how many records need to be reviewed to identify the actual scope of the problem. For years, NCQA has used and “8 and 30” methodology to look at medical records and other health care organization data. In those instances, eight records are looked at initially

for an element of concern. If all eight records pass and no issues are identified, then the assumption is made that all records are correct. If there is a problem identified in any of the eight records, then all thirty records are reviewed for the audited element. The OIG has also developed sampling guidelines and their methodology can be reviewed at w w w . o i g . h h s . g o v / a u t h o r i t i e s / d o c s / selfdisclosure.pdf. The section on sampling includes the following text “Sample Size—The size of the sample must be determined through the use of a probe sample. Accord-ingly, the plan should include a description of both the probe sample and the full sample. At a minimum, the full sample must be designed to generate an estimate with a ninety (90) percent level of confidence and a precision of twenty-five (25) percent. The probe sample must contain at least thirty (30) sample units and cannot be used as part of the full sample.”

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CDC PUBLISHES GUIDE TO PROTECTING OUTPATIENTS FROM INFECTION The CDC, along with the Healthcare Infection Control Practices Advisory Committee, has issued a guide to curbing infection rates in ambulatory care settings. It also reiterates basic precautions for infection prevention in all settings and has links to full recommenda-tions and source documents. The agency's move is a response to the increasing number of patients who seek care at outpatient clinics, providers' offices and community-based centers. PDF can be downloaded f rom: ht tp : / /www.cdc.gov/HAI /pdfs /guidelines/standatds-of-ambulatory-care-7-2011.pdf.

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3rd Quarter Code Changes (Edit Assignments)

64561 (Implant neuroelectrodes): now can be billed bilaterally

22212 (Revision of thorax spine): Co-surgeon allowed

22222 (Neck spine fuse&remov bel c2): Co-Surgeon allowed

3rd Quarter Code Changes (Deleted effective 7/1/2011)

HCPC Description

C9273 Sipuleucel-T, per infusion C9729 Percut lumbar lami S9075 Smoking cessation treatment APC Description

09267 Wilate injection

CODE ORIGINAL REVISED

88177 Cytp c/v auto thin lyr addl Cytp fna eval ea addl

0251T Remov bronchial valve addl Remov bronchial valve

0252T Bronchscpc rmvl bronch valve Remov bronch valve addl

22551 Neck spine fuse&remove addl Neck spine fuse&remov bel C2

22900 Exc back tum deep < 5 cm Exc abdl tum deep < 5 cm

22901 Exc back tum deep 5+ cm Exc abdl tum deep 5+ cm

3rd Quarter Code Changes (Description)

65779 Cover eye w/membrane stent Cover eye w/membrane suture

74176 Ct abd & pelvis w/o contrast Ct abd & pelvis

74177 Ct abdomen&pelvis w/contrast Ct abd & pelv w/contrast

74178 Ct abd&pelv 1+ section/regns Ct abd & pelv 1/> regns

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3rd Quarter Code Additions (effective 7/1/2011)

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HCPC Description

0262T Impltj pulm vlv evasc appr

0263T Im b1 mrw cel ther cmpl

0264T Im b1 mrw cel ther xcl hrvst

0265T Im b1 mrw cel ther hrvst onl

0266T Implt/rpl crtd sns dev total

0267T Implt/rpl crtd sns dev lead

0268T Implt/rpl crtd sns dev gen

0269T Rev/remvl crtd sns dev total

0270T Rev/remvl crtd sns dev lead

0271T Rev/remvl crtd sns dev gen

0272T Interrogate crtd sns dev

0273T Interrogate crtd sns w/pgrmg

0274T Perq lamot/lam crv/thrc

0275T Perq lamot/lam lumbar

C9283 Injection, acetaminophen

C9284 Injection, ipilimumab

C9285 Patch, lidocaine/tetracaine

C9365 Oasis Ultra Tri-Layer Matrix

C9406 Dx I-123 ioflupane, per dose

C9730 Bronchial thermo, 1 lobe

C9731 Bronchial thermo, >1 lobe

K0741 Portable gaseous oxygen sys

K0742 Portable gaseous oxygen

K0743 Portable home suction pump

K0744 Absorp drg <= 16 suc pump

K0745 Absorp drg >16 <=48 suc pump

K0746 Absorp drg >48 suc pump

Q2041 Wilate injection

Q2042 Hydroxyprogesterone caproate

Q2043 Sipleucel-T auto CD54+

Q2044 Belimumab injection

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APC Description Status Indicator

01352 Wilate injection G

01353 Belimumab injection G

01354 Hydroxyprogesterone caproate K

09283 Injection, acetaminophen G

09284 Injection, ipilimumab G

09285 Patch, lidocaine/tetracaine G

09365 Oasis Ultra Tri-Layer Matrix G

09406 Dx I-123 ioflupane, per dose G

New K-Codes for Wound Suction Pumps and Associated Dressings—Coding Guidelines Four (4) New HCPCS codes have been created to describe wound suction pumps and the dressing sets associated with them. These new K-codes are effective for claims with dates of service on or after July 1, 2011. The new codes are:

● K0743 - Suction Pump, Home Model, Portable, For use on wounds

● K0744 - Absorptive Wound Dressing for use with Suction Pump, Home Model, Portable, Pad size 16 square inches or less

● K0745 - Absorptive Wound Dressing for use with Suction Pump, Home Model, Portable, Pad size 16 square inches but less than or equal to 48 square inches

● K0746 - Absorptive Wound Dressing for use with Suction Pump, Home Model, Portable, Pad size greater than 48 square inches

Wound suction is provided with an integrated system of components. This system contains a pump (K0743) and dressing sets (K0744 – K0746). It does not include a separate collection canister (A7000), a defining com-ponent of Negative Pressure Wound Therapy (NPWT). Instead, exudate is retained in the dressing materials. Therefore, wound suction systems are not classified as NPWT systems. These codes will be added to the Suction Pump LCD in a future revision to that policy. Systems that do not contain all of the required components are not classified as wound suction systems. See below for com-ponent specifications. Code K0743 describes a suction pump for wounds which provides controlled subatmos-pheric pressure that is designed for use with dressings (K0744 – K0746) without a canister. Codes K0744 - K0746 describe an allow-ance for dressing sets that are used in conjunction with a stationary or portable

3rd Quarter Code Additions (effective 7/1/2011) Continued

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suction pump (K0743) but not used with a canister. Each of these codes (K0744 – K0746) is used for a single, complete dressing change, and contains all necessary components, including but not limited to non-adherent porous dressing, drainage tubing, and an occlusive dressing which creates a seal around the wound site for maintaining subatmospheric pressure at the wound. These dressing sets are selected based upon wound size using the smallest size necessary to cover the wound. For multiple wounds located close together, a single large dressing must be used rather than multiple smaller dressing sets if it is possible to fit the wounds under a single larger dressing set. Disposable wound suction system pumps must be coded A9270 (Noncovered item or service). Supplies, including dressings, used with disposable wound suction systems must be coded as A9270 (Noncovered item or service).

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CODING ISSUES PCG recently reviewed physical therapy evaluation billing where the therapist billed a 97001 Physical Therapy Evaluation for each body part that was requested by the attending physician. The 97001 is reported once per episode of care regardless of how many body parts are evaluated. This error was reported by Virtual Examiner for unusual quantities. Staged procedures are indicated by the use of Modifier 58. There must be a promotion on the use of this modifier as we are seeing incorrect usage of the code all over the country. Modifier 58 is used for a Staged or Related Procedure or Service by the Same

Physician During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical proce-dure. This circumstance may be reported by adding Modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating or procedure room (e.g., unanticipated clinical condition), see Modifier 78. It is not appropriate to use the staged or related procedure modifier to mask the changing of the splint, or cast or dressing. Section 40.1 of the CMS Physician and Non Physician Practitioners Billing Manual on the global surgical package includes this bullet point of the included services:

● Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

Insufficient documentation at diagnostic radiology services in the Emergency Depart-ment has caused overpayments of nearly 38 million from an audit of 2008 claims by the OIG. The OIG report stated that 70% of the claims for CT, MRI and x-ray services did not meet the American College of Radiology documentation guidelines. Since CMS con-tractors are to pay for the interpretation and report that directly contributed to the

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diagnosis and treatment of the individual patient, it is important to make sure that the interpretation in the emergency department contributed to the care of the patient. Physicians’ orders were not present in medical record documentation for 12 percent of CT and MRI interpretation and report claims, amounting to nearly $18 million. Physicians’ orders were not present in medical record documentation for 9 percent of x-ray interpretation and report claims, amounting to $5 million. Documentation was not provided to support that interpretation and reports had been performed for 12 percent of CT and MRI claims, amounting to nearly $19 million, and 8 percent of x-ray claims, amounting to $5 million. The full report can be read at http://oig.hhs.gov/oei/reports/oei-07-09-00450.pdf. Follow up visits during the postoperative period are included in the global surgical package even when performed by another physician or provider in the same practice. Unless the provider is addressing an unrelated issue, all complications and care that do not require a return to the surgery suites are included. If the postoperative care is provided by a provider in another practice, the billing provider should use the 55 modifier to indicate postoperative management only. The global fee is then apportioned based on the percentages from the Medicare Physician Fee Schedule Database which is shown in Virtual AuthTech® on the Adjudication Details screen. The full documentation on the Global Surgical Package can be reviewed at: w w w . c m s . g o v / m a n u a l s / d o w n l o a d s /clm104c12.pdf.

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COMPLIANCE TRAINING FOR PHYSICIANS AND STAFF The OIG has produced a free pre-written presentation for training your new (and old) physicians about fraud, abuse, and waste. The PowerPoint presentation reviews both prohibited activities and includes a booklet for self study to avoid Medicare and Medi-caid compliance issues. The OIG program is available for download at: http://oig.hhs.gov/fraud/PhysicianEducation/. The University of California at Los Angeles Health System (UCLA), Massachusetts General Hospital and Cignet Health Center in Temple Hills, MD, have all agreed to settlements with the Office for Civil Rights. In the case of UCLA, an employee looked into the electronic medical records of two celebrities. A Massachusetts General employee left confidential paperwork on the subway and the Cignet Health medical group had refused to give some patients copies of their medical records and also failed to cooperate in the OCR investigation. UCLA’s settlement was $865,500. The UCLA employee is scheduled for jail. Please make sure that your privacy and security policies and procedures are in place. The OIG compliance tools are readily available on line. In addition, the latest vulnerability to patient privacy are iPhones and other smartphone or iPad devices. Please review the PCG Policy and Procedure, PCG Policy No. 276 in Section 4, Security Risks of Smartphones and Portable Computer Devices, Revised April 2011.

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FRAUD, ABUSE, AND WASTE HEADLINES Largest False Claim Settlement In CA History: Attorney General Kamala D. Harris announced a $241 million settlement – the largest recovery in the history of California’s False Claims Act – with Quest Diagnostics, the state’s biggest provider of medical laboratory testing, of a lawsuit alleging illegal overcharges to the state’s medical program for the poor. The settlement with Quest is the result of a lawsuit filed under court seal in 2005 by a whistleblower and referred to the Attorney General’s office. The lawsuit alleged that Quest systematically overcharged the state’s Medi-Cal program for more than 15 years and gave illegal kickbacks in the form of dis-counted or free testing to doctors, hospitals and clinics that referred Medi-Cal patients and other business to the labs. California law states that “no provider shall charge [Medi-Cal] for any service more than would have been charged for the same service to other purchasers of comparable services under comparable circumstance.” Yet, Quest charged Medi-Cal up to six times as much as it charged some other customers for the same tests. For example, Quest charged Medi-Cal $8.59 to perform a com-plete blood count test, while it charged some of its other customers $1.43. Similar cases are still pending against four other defendants, including Laboratory Corporation of America, commonly known as LabCorp, the second largest medical laboratory service provider in California. Trial is scheduled for early next year.

● Dr. Rene de Los Rios, 72, of Miami will spend some of his retirement paying restitution of $11.7 million dollars to the Medicare fund and 235 months in jail. The court found that de Los Rios who worked at multiple HIV infusion clinics billed 46 million in fraudulent billings to Medicare.

● In another Florida case, Sommo-Medics used unlicensed sleep technicians to submit approximately 5800 claims to Medicare and TRI-CARE. SommoMedics received approximately $3.3 million in reim-bursement for these services. The owner, Edward Killmer, Jr., knew that it was a violation to use unlicensed staff to perform sleep studies. The case was originally filed by one of the unlicensed staff members in July 2010 and the Department of Justice has now intervened.

● A St. Paul, Minnesota, home health care company has been charged with defrauding the Minnesota Depart-ment of Human Services for billing services not provided by Palm Healthcare Services, Inc. The owner, Mr. Joseph Van Lavien, has been charged but has not entered a plea in this estimated $500,000 fraudulent billing scheme.

● RL Medical Supply owned by Petros Odachyan, was sentenced in Los Angeles after pleading guilty to fraudulently billing over $1 million for unneeded electric wheelchairs, hospital beds and other DME. Mr. Odachyan received about $600,000 in reimbursement from Medicare. He was sentenced to 51months in a federal prison.

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VIRTUAL AUTHTECH® APC AND ASC CALCULATOR After many months of testing PCG is releasing, at no charge, the APC/ASC OPPS module to all customers using Virtual AuthTech®. Changes to VA Version 4.2 reflect the new “mode”. To start working in the OPPS pricing mode, place a checkmark on the option: [Adjudicate in OPPS Calc Mode?]. Enter your codes

and click the [Adjudicate] button. Unlike other applications, there is no need to enter a massive amount of information simply to ascertain payment- VA’s goal is to price the APC and ASC and apply standard coding edits/unbundling. We let your adjudication system determine benefits and LMRP. In the example below (clicking the OPPS button at the bottom right), note that VA displays grouping, coding errors and pricing for both APCs and ASCs.

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On the Procedure Code detail level, Virtual AuthTech® will display the OPPS price for both APC and ASC. Take care, the total APC net may vary depending on how the

grouper applies procedure codes to APCs. To reach the screen below:

● Enter 60100 into HCPC code

● Click on [Search] button (Flashlight)

● Click on [Code Details] TAB

● Click on [APC/ASC] TAB located at bottom of window

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VIRTUAL REPORTER WORK QUEUE Virtual Reporter Work Queue has added new advanced functionality: user defined sorting on multiple fields. Currently, you sort on a single Work Queue field by simply clicking on the summary title.

Great, but this limited your sort to just one field. Now you have the ability to create any sort on any amount of fields- and we’ve made it extremely easy to use!

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Once you click the [SORT] button, you’re presented with the menu below. Clicking on any field listed on the right automatically marks it and adds it to the sort algorithm. Click on the field again and VR removes it from the sort.

Equally important: to save time, you have the ability to make your sort option the default every time you create a VR Work Queue. After making your sort selections, simply click on the [Save Sort Order] button. This way you won’t have to recreate the sort anytime you open a queue!