CMS Proposed Rule Could Scale Back Mandatory Bundled Payment Programs
CMS released a proposed rule earlier this month that could cancel two bundled payment programs, and significantly limit a third.nnTwo bundled payment programs could be canceled before they begin, and the scope of a third will be significantly limited if a proposed rule released by CMS August 17 is finalized.nnThe agency proposes cancellation of Episode Payment Models (EPM) and the Cardiac Rehabilitation (CR) incentive payment model in the rule. In addition, CMS proposes to make participation in the Comprehensive Care for Joint Replacement model (CJR) voluntary in 33 of the 67 geographic areas where participation is currently mandatory. The agency also suggests making participation in the CJR voluntary for low-volume and rural hospitals in all areas.nnThe EPM and CR models were mandatory programs for certain providers that were originally scheduled to begin months ago, but multiple delays pushed that start date back to January 1, 2018. The models were created to institute bundled payments for episodes of care for treatment of acute myocardial infarctions, coronary artery bypass grafts, surgical hip and femur fractures, and cardiac rehabilitation by linking payment to quality outcomes.nnParticipation in the CJR model began in April 2016, and therefore CMS will not cancel that program but proposes to substantially reduce the number of providers who must participate.nnWhile cutting these programs may seem like a shift away from value-based care, CMS said in a press release that it hopes canceling these programs would allow stakeholders to devote time and resources toward creating other episode-based models.n
nThis article originally posted on RevenueCycleAdvisor.com.
Welter Healthcare Partners is excited to present our helpful career advancing tips and strategies to sharpen the skills prospective employers look for in a coder!nnTeamwork – Ever heard of the expression – “Team Work Makes the Dream Work”? This idea serves as the foundation for many successful movements, companies and organizations. One person can only do so much and when we allow others to contribute their talents and ideas, extraordinary things can happen! There is no “I” in team and there are no lone rangers. Think about Julius Caesar, Napoleon, Gandhi, Steve Jobs, and many other life-changing leaders – they never could have influenced the world without millions of people working alongside them and supporting their efforts. Teams come in all shapes and sizes and it is important to be a team player. Group effort is always more effective than individual effort!
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is leading to changes in the realm of clinical and operational demands in health care. Read more, below, to learn about balancing reporting requirements while simultaneously ensuring optimum patient care.nnConcerns over the cost of health care and apparent lower health outcomes in the United States compared to other developed countries have significantly influenced program development by the Centers for Medicare and Medicaid Services (CMS). New reimbursement strategies intended to address cost and drive quality—specifically the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)—are placing new clinical and operational demands on the health care industry.nnSo in the era of MACRA, providers need to balance reporting requirements (which can be time-consuming) while continuing to put patients first. One of the best ways to do this is to ensure patient care is well coordinated.nnMoving Forward with MACRAnnMACRA made fundamental changes in the way health care providers are paid for Medicare patients. MACRA included the repeal of the Sustainable Growth Rate (SGR) and moved toward rewarding providers for performance through the Merit-based Incentive Payments System (MIPS) and, ultimately, the Advanced Alternative Payment Model (AAPM).n
Welter Healthcare Partners is excited to present our monthly Code Spotlight! Each month, Welter Healthcare Partners will spotlight a unique CPT or ICD-10 code to profile and discuss practice applications of the code, as well as pertinent guideline reminders.nnICD-10 Code – E11.65 – Type 2 Diabetes Mellitus with HyperglycemiannICD-10 code E11.65 represents the appropriate diagnosis code for uncontrolled type 2 diabetes without complications.nnClinical documentation must support the following: Elevated glucose (sugar) levels, length of condition, severity of illness, if insulin use is required, and any associated manifestations or underlying chronic diseases. High blood glucose levels in diabetes mellitus are indicative of inadequate or poorly controlled diabetes. Reporting specificity is increasingly important if you participate in an HCC risk adjustment payment model. Clinical documentation must support the complexity of the diagnosis code(s) reported.
In a final rule published Wednesday, the Centers for Medicare and Medicaid Services have established new requirements for the use of electronic health records. Check out the article, below, for more information! nn”We are establishing new requirements or revising existing requirements for eligible professionals, eligible hospitals, and critical access hospitals participating in the Medicare and Medicaid Electronic Health Record Incentive Programs,” stated the rule, which goes into effect October 1, 2017.nnFor 2018, CMS will allow a 90-day reporting period. This is a significant difference from the complete year that CMS had aimed for under the Obama administration. This change applies to hospitals and physicians in the Medicare and Medicaid meaningful use programs.nnAlso in 2018, CMS will allow healthcare providers to use 2014-certified EHRs, 2015-certified EHRs, or a combination. Initially, CMS was requiring 2015-edition EHRs beginning in January 2018. However, healthcare organizations had raised concerns that the 2015-certified EHRs were more sophisticated and that they would not have enough time to install and test the systems.nnIn a statement, CMS administrator Seema Verma said this final rule will provide flexibility for acute and long-term care hospitals as they treat Medicare’s sickest patients.n
As part of the new coding format for our newsletter, Welter Healthcare Partners is excited to offer you a new surgery coding series in which we want to help you! The 2nd week of every month we will highlight a complicated surgical case. This week we are highlighting a general surgery case. We want to hear from you! If you have a complicated surgery case and need help with coding, please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. Click Here To Submit Redacted Surgery Case Study. 
Known for putting patient experience first, the Cleveland Clinic revolves around relationship-centered communication. Check out this article, where experts dissect this philosophy and explain why it makes moral and financial sense! nnHospitals and providers are more aware than ever that communication and empathy can make all the difference in how a person feels about a hospital stay or medical encounter. But with competing priorities such as patient safety, quality, and other elements that visibly impact the bottom line, the ‘why’ for investing in patient experience can be a tough sell. Experts from the Cleveland Clinic note the following ways doing the right thing translates to dollars.nnThe Centers for Medicare & Medicaid Services began tying Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores to hospital reimbursement in 2012.nnWhile the penalties for sub-par performances have increased slowly, the dollars now are substantial. As of this year, HCAHPS scores determine up to 2% of a hospital or health system’s Medicare payments.nn”The risk for not giving patients a good experience financially now becomes very high, so hospitals or practices that don’t stand behind the fact that we need to take care of our patients both behaviorally and clinically stand to lose a significant amount of money,” says Lori Kondas, MBA, senior director for the office of patient experience at the Cleveland Clinic.nn n
Medicare Wellness Services:nBilling for Medicare wellness services can be a huge pain point for any primary care practice. However, the pain is well worth it when you consider that providing these services can result in tens of thousands of additional reimbursement dollars for your practice. These services can reimburse up to $174 per visit.nnListed below are some strategies to ensure success and compliance with Medicare Wellness Services:n
The Health Care Freedom Act, which would have repealed employer and individual mandates while leaving some part of the ACA in place, was voted down by the Senate early this morning.nnIn a session that lasted into the wee hours Friday morning, the Senate voted down a “skinny” bill to repeal the Affordable Care Act (ACA), dealing a big blow to the chamber’s Republican leadership.nnThe vote was 49-51 to defeat the bill — known as the 
Due to the recent interest to repeal and replace Obamacare, healthcare-provider groups have called on Congress to cut a bipartisan deal on healthcare reforms!nn”The best approach would be for Congress members to reach across the aisle and address some of the specific problem areas of the Affordable Care Act,” Elizabeth “Betsy” Ryan, JD, president and CEO of the New Jersey Hospital Association, told HealthLeaders.nn”To me, letting Obamacare fail would be a dereliction of government’s responsibility to the people. This is not just a political fight to be won—these are real people, real families, whose healthcare is at stake.”nnPartisan congressional approaches to repealing, replacing, or repairing the PPACA are likely destined for the scrapheap, Nicholas Schilligo, MS, vice president of public policy at the Chicago-based American Osteopathic Association (AOA), told HealthLeaders. “Any meaningful solution is going to require bipartisan discussion, including hearings that thoroughly examine and vet a lot of the issues that are going to be put forward.”nnThis past weekend’s collapse of the Senate’s Obamacare repeal-and-replace bill, the Better Care and Reconciliation Act (BCRA), prompted Majority Leader Mitch McConnell to call on his Senate colleagues to pass repeal-only legislation. The Kentucky Republican’s repeal-only plan includes a two-year grace period to give Congress time to craft a replacement for the Patient Protection and Affordable Care Act (PPACA).n
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nnAs a group, doctors are ill-prepared to meet the requirements of a law that will change the way they are paid, shows a survey of a thousand physicians by the American Medical Association and Big Four auditing firm KPMG.nnThat lack of preparedness could hit them in the pocketbook, even amid new flexibility shown by CMS in last week’s proposed changes that would delay mandatory reporting data for another year and reduced reporting burdens for small physician practices.nnPhysicians must choose one of two reimbursement tracks under the Medicare Access and CHIP Reauthorization Act (MACRA). One, known as the Merit-based Incentive Payment System, is where most physicians will start, but some will participate in approved Advanced Payment Models (APMs) that will reward physicians with as much as 5% annual payment bonuses in return for taking more upside and downside risk based on value measures.nnIn either scenario, physicians rate themselves as less prepared than they should be, with half calling MACRA requirements “very” burdensome, according to the survey.nnMore than 56% of those surveyed still planned to participate in the MIPS program in 2017, while 18% are expected to quality for higher and more stable payment as an APM participant.n
nnCheck out this article about a half-dozen changes to the adjudication of Medicare claims-denial appeals that are designed to ease a backlog of cases.nnThe new rules for Medicare claim-denial appeals feature several changes crafted to ease administrative burdens and speed reductions in a backlog nearing 1 million cases. The new rules went into effect March 20. “This final rule streamlines administrative appeal processes, increases consistency in decision making across appeal levels, and improves efficiency for both appellants and adjudicators,” a Department of Health and Human Services fact sheet on the new rules says.nnThursday afternoon, three officials at the Office of Medicare Hearings and Appeals (OMHA) led a presentation to walk healthcare providers through more than a dozen significant changes in the new rules. OMHA reports directly to Health & Human Services Secretary Tom Price, MD.nnDisputed Medicare claims of more than $160 can be appealed to Administrative Law Judges (ALJs) and attorney adjudicators for reviews that can include a hearing. The last stop before federal court is the Medicare Appeals Council.nnThursday’s Medicare Learning Network (MLN) presentation featured a half-dozen changes to the claims-denials appeals process at the ALJ-level that are designed to either quicken or streamline adjudication:n
nnSmall practices could add points to their total performance scores in the merit-based incentive payment system and may qualify for an exemption from EHR requirements.nnMore small practices may qualify for exclusions from the Quality Payment Program (QPP), claim hardship exceptions from electronic health record (EHR) requirements, and earn automatic bonus points if the proposed QPP rule released June 20 is finalized.nnThe Centers for Medicare & Medicaid Services has proposed increasing two low-volume thresholds that would grant additional exclusions in 2018:n
nnEmotional Intelligence (EI) – Many of us are familiar with IQ tests, which measure our intellectual abilities and intelligence. Many of us also believe that having a high IQ makes you the best candidate for any job. However, employers are focusing more on emotional intelligence rather than academic aptitude. Emotional intelligence is the capability of individuals to recognize their own and other people’s emotions, discern between different feelings and label them appropriately, using emotional information to guide thinking and behavior, and manage and/or adjust emotions to adapt to environments or achieve one’s goal(s). EI can be a huge asset to employers because it is the one part of the human psyche that we can develop and improve by learning and practicing new skills. We’ve all met very clever and intelligent people who nonetheless had no idea about how to deal with people, and the reverse. How we manage ourselves and the relationships we have with others can have a lasting impact on future opportunities.
Check out this article regarding the announcement that Anthem has calmed controversy over Colorado’s health insurance by submitting its proposed plan for 2018 to the state. nnHealth insurance giant Anthem announced late Monday that it has submitted proposed 2018 plans to the state, easing fears that it might back out of Colorado’s health insurance exchange and leave residents of several counties without an insurance choice.nnBut an Anthem spokesman declined to provide specifics on those plans — including where the company expects to offer them — meaning it remains unclear if Anthem will continue to provide coverage to the same number of Coloradans it currently does.nnMonday was the deadline for insurers hoping to participate next year on the Connect for Health Colorado exchange to file their proposed plans and rates with the state Division of Insurance for review. The exchange is a one-stop shop for health insurance on the individual market — where people buy their own plans, instead of receiving coverage through an employer or the government.n
nnCPT code 20680 requires the provider to incise through muscle layers and into the bone, necessitating a more complex, layered closure. The physician makes an incision overlying the site of the implant using deep dissection to visualize the implant (usually below the muscle level and within bone), using instruments to remove the implant from the bone. The physician repairs the incision in multiple layers using sutures, staples, etc. CPT Assistant and the AAOS (American Academy of Orthopedic Surgeons) direct that the 20680 code is to be billed once per fracture site, rather than based on the number of pieces of hardware removed or the number of incisions made to remove the hardware from one fracture site or original area of injury. Billing 20680 more than once is only appropriate when hardware removal is performed in a different anatomical site unrelated to the first fracture site or area of injury. It is fraudulent to send a patient to the OR/ASC for the sole purpose of seeking reimbursement for 20680, when medical necessity is not supported.