In addition, CMS reps cite present Medicare law and says that practices should report just one inpatient care code per patient, per day. Even though CMS has done away payment for consult codes, it will continue to honor split/shared visits — as long as they are billed using E/M codes and follow the payment rules already in place. That’s the word from CMS where staffers wanted to do away with the confusion stemming from the January MLN Matters article SE1010, which offered various questions and answers regarding how to bill Medicare following the elimination of consult code payment. Here, CMS noted that “the split/shared rules applying to Evaluation/Management services remain in effect, including those cases where services would previously have been reported by CPT consultation codes.” CMS’s Rebecca Cole noted during an April 13 CMS Open Door Forum, “We understand that this has led to some confusion, as there were — and are — different split/shared rules for consultation services compared to E/M services.” “We would like to clarify that Q&A,” said Cole. “As we are no longer recognizing the consultation CPT codes for purposes of payment under Part B, the split/shared rules regarding consultation services are no longer applicable. Since Evaluation/Management visit codes are being billed for services that were previously reported by the CPT consultation codes, the split/shared rules pertaining to E/M services apply when billing E/M CPT codes,” stressed Cole. Do not forget: You can still report shared/split visits as per the regulations using E/M codes; however you cannot collect from Medicare for any consultation codes. CMS is thinking about issuing a clarification in writing to do away with any confusion pertaining to the shared/split billing rule, noted Cole. CMS Asks Practices to Rein in Initial Inpatient BillingOne caller wanted clarification on billing for hospital care now that consult codes are not payable. She asked whether a physician can go for two initial hospital care codes for the same patient on the same date — for example, if the physician saw the patient before surgery for one reason, and then saw the patient post surgery for another reason. “I think you should consult the CPT rules in addition to the manual, however I think our reaction to that is no,” CMS’s William Rogers, MD, said during the call. Rogers said that the initial hospital care codes refer to that physician’s first visit with the patient. He advised that later evaluations should be billed by means of subsequent hospital care codes. On the other hand, CMS reps pointed to the fact that they’ll look into the issue further to find out whether doctors should be able to report a second initial hospital care code if specifically requested to review a different condition. “We can think about this further and decide what our next steps will be,” Rogers said. Until then, CMS staffers urged practices to continue billing according to published rules. In black and white: Both initial inpatient hospital care codes and following hospital care codes are ‘per diem’ services and may be reported only once a day by the same doctor or doctors of the same specialty from the same group practice,” CMS Transmittal 1545 notes. Use Present Bone Density CodesOne caller was happy that, owing to the new health care reform legislation, CMS will be boosting payment for bone density tests, but said that the legislation listed old bone density test codes 76075 and 76077. He enquired whether MACs will be requesting those codes going forward, or whether practices should continue going for new codes 77080-77082. Advice: You should use the present codes 77080-77082 and not the old ones, CMS’s Amy Bassano said.
Posts Tagged ‘Rule’
CMS spells out split/shared visit rule now that consults are no longer payable
Sunday, July 4th, 2010Medi Care Rule Change by Peter Menkin
Thursday, July 1st, 2010Medi Care payment rules changed in October, 2008. They will no longer pay the extra costs of treating patients who develop eight serious, preventable conditions after hospitalization. The list includes falls from bed, cathers-associated urinary tract infections and pressure ulcers. News reports indicate large insurance companies are considering similar policies. “Never Events”, hospital attributable medical errors, make up part of the list of the rule changes.
The Center for Medi Care and Medicaid (CMS) notes, “On February 8, 2006 the President signed the Deficit Reduction Act (DRA) of 2005 that required there be an adjustment in Medicare DRG (Diagnosis Related Group) payment for certain hospital-acquired conditions.”
Asking key questions of Health and Human Services regarding the rule changes:
(1) Who pays, and how/why if Medi Care no longer will pay?
The hospital absorbs the cost of treating the hospital-acquired condition, and may not bill the beneficiary for the difference between the two Medicare Severity Diagnosis Related Groups (MS-DRGs).
(2) Is there a limit on their payment, should the infection prove long and difficult in severity and length? Is there the likelihood of long severity of non-covered infection?
In unusual cases in which the costs of treatment greatly exceed the payment rate for the case based on the assigned MS-DRG, Medi Care may pay the hospital an outlier payment. In these cases, after the hospital’s costs of treatment exceed the MS-DRG payment rate by an outlier threshold, Medicare will begin to pay 80 percent of any additional costs. .. [T]he final rule included a tentative outlier threshold for fiscal year 2009 of $20,185. CMS plans to announce the final outlier threshold, after taking into account the MIPPA changes, soon.
(3) Why this change in the rule (budget issue?)?
These changes were mandated by the Deficit Reduction Act of 2005.
(4) Why have they picked these diseases?
These are not all diseases. They are properly called “hospital-acquired conditions,” because they also include things like falls. .. [T]he public was given 60-days to comment, and were selected based on a review of the submitted comments. According to criteria established in the Deficit Reduction Act of 2005, each condition had to be:
(5) What do they expect to be the result of the new policy? An opinion is desired
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CMS Acting Administrator Kerry Weems says:
“While it may be some time before we can begin to assess the real impact of these steps on patient care, we are hearing from hospitals around the country about efforts they have undertaken in the past year to improve staff training and other measures to reduce the incidence of these preventable conditions.”
Many experts believe that these important changes will drive payment methods and criteria in the near future, and that the adjustments will motivate hospitals to reduce “Never Events.”
–Peter Menkin, San Francisco
The 2009 Medicare Physician Fee Schedule ? Medicare?s Anti-Markup Rule and IDTF Enrollment Requirements for Mobile Imaging
Thursday, June 17th, 2010Medicare’s Anti-Markup Rule – CMS Finalizes Two Alternatives
On October 30, 2008, CMS released the 2009 MFPFS. In the 2009 MFPFS, with respect to the application of the anti-markup rule to the provision of certain diagnostic testing services, effective January 1, 2009, CMS adopted two alternative tests for determining the applicability of the anti-markup rule.
The Final Anti-Markup Rule
Specifically, the following principles determine the applicability of the anti-markup rule:
(1) Alternative 1 – “Substantially All Test.” Arrangements should first be analyzed under this Alternative. If the performing physician (i.e., the physician who supervises the TC or performs the PC, or both) performs substantially all (at least 75 percent) of his or her professional services for the billing physician or other supplier, the services will not be subject the anti-markup rule payment limitations. If the “substantially all” services requirement is not satisfied, an analysis under Alternative 2 may be applied.
(2) Alternative 2 – “Site of Service Test.” TCs conducted and supervised in, and PCs performed in, the “office of the billing physician”, which includes the “same building”, by an employee or independent contractor physician avoid the anti-markup payment limitation.
These alternative tests measure whether or not a performing or supervising physician “shares a practice” with the billing physician or other supplier. A physician is no longer required to exclusively work for one physician practice; rather, a physician need only “share a practice” with a physician or physician organization. This change aligns certain provisions of the Stark group practice definition with the anti-markup provisions.
Additionally, the 2009 MFPFS provides that a billing physician or other supplier satisfies Alternative 1 if he or she has a reasonable belief, at the time he or she submits a claim, that either: (1) the performing physician furnished substantially all of his or her professional services through the billing physician or other supplier for the period of 12 months prior to and including the month in which the service was performed; or (2) the performing physician is expected to furnish substantially all of his or her professional services through the billing physician or other supplier during the following 12 months (including the month the service is performed).
With respect to Alternative 2, CMS aligns the location test with the Stark Law “same building” test by clarifying that a physician or other supplier may have more than one “office of the billing physician or other supplier”. Such space is one in which the ordering physician or ordering supplier regularly furnishes patient care (and with respect to physician organizations or group practices, the space in which the ordering physician performs substantially the full range of patient care services that the ordering physician provides generally). Additionally, CMS requires the physician supervising the TC to be an owner, employee, or independent contractor of the billing physician or other supplier. With respect to the PC, the performing physician must be an employee or independent contractor of the billing physician or supplier.
As a practical matter, the final anti-markup provisions permit the use of shared space imaging arrangements between physicians that occur in the “same building”. Nevertheless, CMS notes that centralized building locations raise concerns for over-utilization and are not permitted for the provision of diagnostic tests. CMS further cautions that despite its flexibility, it has concerns with the present use of the IOAS exception under Stark and may issue future changes.
Of particular significance for those physicians providing imaging services in reliance on Alternative 2, the TC must be both conducted and supervised in the “office of the billing physician or other supplier” (“the Same Office Requirement”). While Stark Law generally applies the Medicare coverage and payment regulations governing supervision of tests (“Medicare Coverage Requirements”), providers seeking to rely on Alternative 2 must meet the Same Office Requirement. This is due to CMS’s belief that the Same Office Requirement is necessary to minimize the potential for overutilization and program abuse.
Arrangements that fall within the ambit of the anti-markup provisions are subject to restrictive payment limitations, such that payment to the billing entity will be limited to the lowest of the following: (1) the performing physician’s or other supplier’s net charge to the billing entity; (2) the billing entity’s actual charge; or (3) the fee schedule amount for the test that would be allowed if the performing physician or supplier billed directly.
Significantly, the net charge amount must be determined without reference to any charge that is intended to reflect the cost of equipment or space leased to the performing supplier by or through the billing physician or other supplier. Therefore, the billing physician, or other supplier may only recover costs for the salary and benefits it paid to the performing supplier of the TC or PC. As a result, billing physicians or other suppliers who implicate the anti-markup rule will likely receive reimbursement that fails to even cover the costs of providing the services.
Below are two examples of the final anti-markup provisions and their application to common imaging services arrangements:
(1) Group Practice Independent Radiologist Arrangement. A physician in a multi-specialty group practice orders an x-ray and the part-time technician employee performs the x-ray in the group’s office. The ordering physician works exclusively for the multi-specialty group and supervises the test in the group’s office. A radiologist, who is an independent contractor with the multi-specialty group practice, performs the PC of the test in the group’s office and reassigns his right to payment to the group. The radiologist provides professional services to several groups and hospitals in the area. He performs approximately 20 percent of his professional services for the multi-specialty group practice. The anti-markup rule does not apply to the group’s billing of the TC because the supervising physician (i.e., the performing physician) “shares a practice” with the billing group insofar as he performs at least 75 percent of his professional services for the group. With respect to the PC of the test, the independent contractor (i.e., the performing physician) does not perform substantially all of his professional services to the group (he performs approximately 20 percent). Thus, an analysis under Alternative 2 applies. Under the “site of service” test, the anti-markup rule does not apply because the performing radiologist provided the interpretation on-site in the group’s office.
(2) IDTF Arrangement. A physician orders a diagnostic test from an IDTF. The IDTF bills globally for the test (TC and PC). The anti-markup rule does not apply because the IDTF did not order the test; rather, it was ordered by an outside physician.
IDTF Performance Standards for Mobile Imaging Providers
Conclusion
Through a series of regulatory actions, CMS has been targeting diagnostic imaging arrangements. Diagnostic imaging providers and suppliers should be attentive to developments with future rulemakings, which may significantly affect the structure of many current imaging arrangements. As a result, we advise providers to incorporate mechanisms into their current contractual arrangements that will permit these arrangements to adopt a more stringent regulatory framework. Finally, the regulatory changes discussed in this article likely will not be CMS’s final word on diagnostic imaging. Providers should be mindful of this before entering into structures that cannot be unwound or modified.
