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Payment "Patch" for Physicians in '08
By Maxine I. Collins, MBA, CPA, CMC, CMOM, CMIS

On July 15, 2008 Congress met demands made by the "grassroots" of the medical profession, other medical organizations, and the public by overriding the President's veto of the Medicare Improvements for Patients and Providers Act, 2008. In so doing, Congress prevented the 10.6% pay decrease for physicians which became effective on July 1, 2008. According to the American Medical Association, this action from Congress may have prevented a major exodus by physicians currently participating in the Medicare Program. Any such shortage of physicians will hamper the coverage of medical care of thousands of patients.

Under MIPPA, the .5% increase in the conversion factor that was placed in effect on January 1, 2008 will remain in place through December 31, 2008. In addition, the bill provides a 1.1% increase in the conversion factor for 2009, extends the Geographic Practice Cost Index (GPCI) adjustment, provides parity for Medicare mental health benefits, and increases coverage for preventive services. The new law also reinstates the therapy caps exceptions process as of July 1st and delays the Durable Medical Equipment Competitive Bidding Program which affected 10 competitive bidding areas.

However, many experts see this as another "temporary patch" or "band-aide" for the physician fee schedule. Although Congress had six months to come up with a proposal for a permanent solution to the "flawed" reimbursement system, they failed to act in time again and, therefore, there is still no permanent solution.

The current conversion factor is lower than it was in 2001! Expenses have continued an upward spiral and many physician practices are struggling to provide efficient operations during the current turbulent economy. Because Congress has not provided a long-term fix in Medicare payments, the issue, according to many healthcare experts, will continue to haunt the next president and Congress.

Everyone seems to agree that the current formula used to compute physician reimbursement is "broken", but no one seems to know how to fix it economically. Therefore, we get the "patch" treatment for this "broken system" diagnosis and the "plan of care" for successful treatment continues to elude the powers that be. Although we have received this temporary reprieve from reduced reimbursement through 2009, we still must face the fact that, by law, the physician fee schedule is structured to decrease by around 5% a year over the next several years. These reductions can only be prevented by Congressional action. Under the current bill, Doctors will still face a cut of more than 20% by 2010.

The Government has the challenge of finding an equitable reimbursement for Providers while, at the same time, controlling health care cost in the U.S. This represents a major challenge and issue for the future. It appears that "Pay for Performance" or for reporting and accomplishing quality of care will be part of any solution proposed. MIPPA provides for the incentive bonus for Medicare's Physician Quality Reporting Initiative to increase from 1.5% to 2% in 2009. In addition, providers who "e-prescribe" will receive a 2% bonus for 2009 which is reduced in subsequent years. The goal is to provide the opportunity to earn additional incentive bonuses for those physicians who participate in the effort to provide and report "quality" care and make progress toward the move into electronic processing of scripts and medical records.

Since the law has now reversed the cuts retroactive to July 1, 2008, Medicare carriers are switching back to the June 2008 rates as well as implementing the increased rates for certain mental health services. Many have already done so at this point in time and others make take a week or so to get the revisions in place. CMS has issued instructions that they will automatically reprocess any claims paid at the reduced rates and provide any balances due to physician practices that have been underpaid. They have indicated that any shortage will probably be processed as a single batched check. However, any practice that billed at a lesser amount than the level of the Jan. 1 - June 30, 2008 fee schedule will necessitate these providers to contact their local contractor for direction on obtaining adjustments. This will also affect non-participating physicians who submitted unassigned claims at a reduced nonparticipating amount. In this case, these physicians will need to request an adjustment. CMS also states that "claims submitted with the therapy cap exception modifier will be processed as soon as the new payment rates are activated. Claims submitted without the modifier, and rejected or denied, can be resubmitted with the modifier for reimbursement"(www.cms.hhs.gov).

Please visit the American Medical Association's list to join the campaign for a long-term solution to these problems. You do not have to be a member of the AMA to join this "grassroots" effort, nor does it cost you anything. You can have a voice in shaping the future of our industry!

Critical Care... The New Rules
By: Regina Mixon, IRO, TPA, CPC-I, CMC, CMIS, CMOM
Director of Associate Facility Development

9 Keys Revisions to Critical Care Policy

It is important to familiarize yourself with the following key critical care changes:

• You can now bill for both an E/M service and a critical care service on the same date of service when a patient comes into the emergency department for an E/M, then crashes suddenly and requires critical care.
• NOTE: CMS has always permitted both E/M and critical care service to be billed on the same date of service in office or hospital settings, but not in an emergency department.

• For the first time, physicians are required to document whether a patient receiving critical care meets all four criteria needed for family discussion time to count as critical care time.
• Criteria:
  • Patient is unable to competently provide history or make treatment decisions.
  • There is a strong necessity for family discussion, such as a case in which there is no other source of history, or the patient was deteriorating so rapidly that it necessitated discussion of treatment options with family members.
  • Medically necessary treatment decisions requiring discussions.
  • The medical record supports the medical necessity of the discussion.

• Added for the 1st time, language describing critical illness or injury as that which "acutely impairs one or more vital organ systems such as that there is a high probability of imminent or life threatening deterioration in the patient's condition," according to the transmittal.

• The CPT definition of critical care is added to the claims processing manual. In addition a guideline stating explicitly that all critical care services must be medically necessary was also added.
• Services not meeting critical care code guidelines or critical care services performed on a patient who doesn't fit the CPT definition of being critically ill or injured must be billed under other E/M codes such as those for subsequent hospital care.

• Qualified NNPs may bill for critical care services under their NPI so long as they meet all definitions for critical care. NNP care must fall within the scope of practice and licensure requirements in the state in which the services are performed.

• Address longstanding issues discussed previously.

• Critical care won't be paid on the same calendar date that a provider also bills a code with a global surgical period, unless the critical care code is billed with modifier 25, indicating that the critical care procedure was "a significant, separately identifiable evaluation and management service."

• A teaching physician can not count time spent teaching a resident as critical care time. This subsection also states that teaching physicians can not bill for critical care services unless they were in the room with the resident when the critical care services were performed.

• Codes for ventilator management (94002-94004,94660 and 94662) will not be paid on the same date as any E/M code (including critical care codes) unless the ventilator code is billed with modifier 25 appended to the EM code.

J.H O'Dell Scholarship Recipients for the months of May-July

Congratulations to the J.H. O'Dell Scholarship recipients: Sarah Powers, Tiffany Smith, and Mandy Bakner!

The scholarship recipient for the month of May was Sarah Powers, a Certified Medical Coder (CMC) ® and an Administrative Assistant, of Avon, NY. The June recipient was Tiffany Smith, a Certified Medical Coder of Houston, TX. Tiffany is currently working on the Certified Medical Office Manager (CMOM) ® self study certification program. Mandy Bakner, a Financial Consultant and a Certified Medical Office Manager (CMOM) ® through PMI of Waynesboro, PA, was the July scholarship recipient. Mandy elected to receive a Certified Medical Coder (CMC) ® Self Study Certification program.

All three recipients are excited to have the opportunity to obtain another certification that will allow them to take their practice to the next level. Recipients are randomly selected each month from the pool of electronic applications to be awarded a self-paced certification training package. The scholarship application is available online at the NetworkPMI Web site: www.pmiMD.com.

Sign up today at www.pmiMD.com/network for a chance to be the next month's recipient.

Hiring the Right Employee

If an office manager could have one wish from a genie, it might be – make sure I hire the right employees.  It seems that the subject of employee management comes up frequently and many experienced managers begin to think there is nothing new to do that will help achieve that “perfect staff”.
One company that checks backgrounds of applicants (InfoLink Screening Services) estimates that 14% of job applicants in the U.S. lie about their education on their resumes.  Background checking is becoming more prevalent.  Resources for background checking include:

Here are some recommended publications on personnel management for medical office managers and administrators available at www.practicesupport.com:

1. 222 Secrets of Hiring, Managing, and Retaining Great Employees in Healthcare Practices
2. How to Recruit, Motivate, and Manage a Winning Staff
3. Employee Management Tools for the Physician Office
4. Managing Medical Office Personnel

This month’s quick tip provided by Practice Support Resources, a leading provider of information and educational tools for medical practice management, physician relations and physician recruitment.