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60.420A — Blister (nonthermal) of right index finger, initial encounternnS60.422A — Blister (nonthermal) of right middle finger, initial encounternnS60.424A — Blister (nonthermal) of right ring finger, initial encounternnW27.1XXA — Contact with garden tool, initial encounternnY93.H1 — Activity, digging, shoveling and rakingnnY92.017 — Garden or yard in single-family (private) house as the place of occurrence of the external cause
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nDoes your practice know how to preauthorize and get paid for investigational procedures such as Intacs?nDoes your billing department maximize reimbursement on unilateral and bilateral testing services?nDoes your billing department know when it is appropriate to unbundle Gonioscopy, Extended Ophthalmoscopy, and other office procedures to obtain maximum reimbursement?nnAMRS Does! We KNOW the new rules, the regulations and the hoops to jump through to get you paid more!n
nGeneral, Retina, Cornea, Oculoplastics, Cataracts, Glaucoma, Neuro Ophthalmology – AMRS does it all and can increase your revenue!n
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nWe provide complete coding services including CPT, ICD-9, and HCPCS assignment, surgical coding, coding and documentation audits, and provider training. We also provide ICD-10 Training for Physicians and Staff! Our coders are certified through AAPC and AHIMA.n
nWe have been doing this for years; we know where to look and the questions to ask.nnAllow us to quickly, professionally, and confidentially assess your practices’ revenue cycle. If we can help you we will let you know how, and why. If we can’t help, we will be straight up and tell you. You have nothing to lose and possibly a lot more reimbursement to gain! *Limited time offer through January 31, 2014.nnContact us today—ask for Jennifer Heuer! phone | email
nS91.341A — Puncture wound with foreign body, right foot, initial encounternnW34.01XA — Accidental discharge of airgun, initial encounternnY93.89 — Activity, other specified — huntingnnY92.73 — Farm field as the place of occurrence of the external cause
Are you confident that you will pass a Medicare Meaningful Use audit if you’re selected?nPrior to January 2013, CMS via the Figlozzi & Company firm has conducted meaningful use audits at random and only after the incentive money was distributed to the eligible provider. Since then Medicare providers who are eligible for the incentive money and those who have attested are subject to audits even before Medicare makes the incentive payment them!nnBe on the lookout for a letter from Figlozzi & Company (click here to see a sample letter). Eligible providers who receive this letter are required to submit the supporting or source documentation for the meaningful use attestation.nnBEFORE that happens, let Welter Healthcare Partners Meaningful Use Experts conduct a “mock audit” to determine your level of compliance, accuracy and preparedness. We can help you avoid the stress and headache of a real audit!nnIf you have successfully selected, purchased, implemented and are now utilizing a certified Electronic Health Record system meaningfully (according to CMS standards) and you have either already attested or you are about to attest to your achievements, we can give you peace of mind that your data is accurate and your practice and providers are in compliance.n
Contact us today for more information on our Meaningful Use Mock Audits!
S81.851A — Open bite, right lower leg, initial encounternnW51.01XA — Bitten by cat, initial encounternnY93.89 — Activity, other specified — trick-or-treatingnnY92.480 — Sidewalk as the place of occurrence of the external causennIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
The ACA, declining and slow reimbursement, billing and coding challenges including the ICD-10 transition, ongoing changes in the healthcare landscape, new payment methodologies, etc. are all obstacles (and in some cases, opportunities!) that EVERY physician and healthcare organization is facing.nnAdvanced Medical Revenue Specialists (AMRS) is your complete Revenue Management Service and a leading provider of Billing, Coding and Revenue Cycle Management services for practices across the country. AMRS can increase your revenue and provide unique expertise, knowledge, and experience in the healthcare arena. AMRS provides complete revenue management for the following specialties:n
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nAMRS is not just another medical billing service! AMRS’ services encompass the entire revenue cycle management for your practice! Let AMRS simplify your practice and deliver the financial results you deserve!n
Coding Services – Maximize Revenue on the Services You Provide!nWe provide complete coding services including CPT, ICD-9, and HCPCS assignment, surgical coding, coding and documentation audits, and provider training. We also provide ICD-10 Training for Physicians, Hospitals and Staff!n
nIn the ever-changing managed care world, with new lines of business, new amendments and new payment methodologies frequently hitting your desk, it is crucial to have knowledge and information at all times. Like the game of chess, in order to be successful you need to plan ahead and make strategic decisions. We provide complete independent research and strategic assistance with managed care contracting issues.nnFailure to stay on top of provider credentialing requirements, incomplete applications, or a failure to respond to requests can create a domino effect of negative actions including disruptions in your cash flow, claims denials, and improper reimbursement that your practice simply cannot afford. Our dedicated credentialing department will keep your providers and practice on track!n
What Makes AMRS Unique:nWe are a Complete Revenue Service – we understand the nuts and bolts of all reimbursement issues!nnFlexible to Meet YOUR Needs! We work off multiple billing and EMR systems and will create a custom arrangement that fits your practice perfectly!nnCPC’s and AHIMA-Approved ICD-10-CM/PCS on staff! More than 50% of our staff are Certified Coders to help ensure your charges and payments are maximized!nnComplete Management of the Landscape of Healthcare! Our healthcare knowledge is full-circle. We will be your partner in strategy, growth, and development!nnWant increased revenue and profitability? What’s in your wallet?n
The transition to ICD-10 will cost healthcare organizations and providers in a number of ways, not just in dollars and cents.nn“The cost is not necessarily in dollars,” says Sandra Macica, MS, RHIA, CCS, ROCC, product specialist for the Revenue Cycle, Coding and Compliance at MC Strategies, a segment of Elsevier. “It’s cost of time, too. Some of our clients over a year ago mapped out three hours of training a week, starting over a year ago. It’s not real dollars per se, but it’s the time that they’re having to take away from the job that they already have to do in order to learn the new coding.”nnThat’s not to say that financial resources are any less significant in terms of the cost associated with moving to ICD-10. Costs can escalate if it is determined that staff requires different forms of education. Limited budgets can easily become strained.nn“Learners don’t always learn one best way,” Macica explains. “Some people want online learning because then everyone has access to it, and other folks still want another component where they have actual live training with the speaker in front of the students, or combinations such.”nnWhile it’s common to look at leading healthcare organizations for examples of best practices, it’s not necessarily possible for other healthcare organizations and providers to follow their models.nnTake, for instance, one hospital that Macica is working with which is in the process of implementing dual coding.nn“They feel it’s necessary and certainly that would put them way more ahead of anyone else,” she observes. “But that surely is going to take a whole lot more time, and it might only be where they do a couple records or maybe want to date or just a few a week. At least they’re starting it. I don’t know what the investment in that is, but it certainly seems like a huge one.”nnIn the end, those required to be complaint with ICD-10 by Oct. 1, 2014, need to use whatever resources they have to get their affected staff some form of hands-on training. “Without actually working with it — you can read books you can listen to people talk and you can do lessons — but until you actually try to do it yourself (those were actual workers in the trenches), that’s where you see where you’re going to run into your issues,” argues Macica.nnAccording to Macica, that’s where you get to the heart of the matter. ICD-10 is a new experience for the industry. There is no history lesson to turn to. In this end, it comes down to be practical. “That’s not there right now, those support systems, so you just have to rely on commonsense sometimes,” she says.nnSource: www.ehrintelligence.com; Kyle Murphy, September 26, 2013.nn
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CHIEF ICD-10 Implementation Plan: 5 Steps to Success!( for Physicians and Outpatient Coding)nAs your CHIEF trainer for ICD-10, we will guide your practice and providers through the implementation process to help ensure your practice is ready on October 1, 2014! Our AHIMA-Approved ICD-10-CM/PCS trainers will utilize the CHIEF ICD-10 Implementation Plan, and work closely with your providers, coders, billers, and other staff through each step of the implementation and training process.n
Click Here To Request A Formal Proposal For ICD-10 Training
nSave 10% off your total ICD-10 training cost when you sign up for the CHIEF ICD-10 Implementation Plan by November 15, 2013!
S02.2XXA – Fracture of nasal bones, initial encounter for closed fracturennW18.39XA – Other fall on same level, initial encounternnY93.B2 – Activity, push-ups, pull-ups, sit-upsnnY92.39 – Other specified sports and athletic area as the place of occurrence of the external causennY99.8 – Other external cause statusnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!n
CHIEF ICD-10 Implementation Plan: 5 Steps to Success!( for Physicians and Outpatient Coding)nAs your CHIEF trainer for ICD-10, we will guide your practice and providers through the implementation process to help ensure your practice is ready on October 1, 2015! Our AHIMA-Approved ICD-10-CM/PCS trainers will utilize the CHIEF ICD-10 Implementation Plan, and work closely with your providers, coders, billers, and other staff through each step of the implementation and training process.nnStep 1: Collect data for your top 25 diagnosis codes (50 for Orthopedics!) and review your providers’ (physicians and mid-levels) current documentation to assess ICD-10 readiness. This step will also include forward-mapping of your top diagnosis codes with ICD-10 cheat-sheets for the providers and staff.nnStep 2: Highlight areas of needed training for your coding and billing staff. We will utilize your top diagnosis codes data and documentation reviews performed in step 1, and provide a 4 hour intensive, hands-on training and workshop for your coders and billers. We will also formulate a strategic plan for your coders and billers to continue the review and education process with the providers until the implementation date. CEU’s for your certified coders are given for this training!nnStep 3: Implement intensive provider training:nnProvider Training #1: A specialty-specific general overview of ICD-10 for all providers (2 hour group training).nnProvider Training #2: One-on-one education with each of the providers (1 hour per provider) to assess their ICD-10 readiness using results from the documentation reviews performed in step 1, and practical tips on how to improve documentation going forward. We recommend that your coding and/or billing staff participate in these one-on-one trainings so they are comfortable continuing the review and education process with the providers until the implementation date.nnStep 4: Evaluate EHR, PM, and Clearinghouse readiness. On your behalf we will prepare a “System(s) Readiness Guide” and query vendors on their readiness and routinely provide materials and updates on vendor status to help ensure your revenue stream will not be affected by this transition. We will also provide your staff with a plan to follow up on targeted vendor deadlines.nnStep 5: Follow-up provider ICD-10 documentation reviews and additional provider training. Final consultation with your staff on system and vendor readiness.n
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nAdditional ICD-10 Services and Products:nnStaff Augmentation: Pre and Post Implementation Support – avoid frustration! Welter Healthcare Partners’s coding department can assist your practice by catching up coding back-logs prior to the ICD-10 implementation deadline (catch up on ICD-9 coding) and assist with increased workloads during initial period after implementation. We are here to help you stay on track! Reserve ICD-10-CM and PCS trained coders now!nn[gravityform id=”9″ name=”ICD-10 Training Formal Proposal”]
S92.411A — Displaced fracture of proximal phalanx of right great toe, initial encounter for closed fracturennW20.8XXA — Other cause of strike by thrown, projected or falling object, initial encounternnY93.E6 — Activity, residential relocationnnY92.014 — Private driveway to single-family (private) house as the place of occurrence of the external causennIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Todd Welter laughs about it now. When first approached about offering his “Fundamentals of Managed Care” course online for students in Regis’ Division of Health Services Administration, he admits he was resistant.nn”Back then – it seems kind of silly nowadays – I thought teaching online was just a fad,” said Welter, an affiliate faculty member. “It’s amazing how fast that has taken off.”nnNow more than 10 years into teaching his signature course and more than 75 percent of that time teaching it online, he can’t imagine it any other way.nnWelter’s teaching philosophy is simple: Engage online students no differently than those in a campus-based class. He maintains regular contact by jumping online frequently throughout the day, responding promptly to questions and making himself available away from the computer – whether by phone or even in-person to work through material face to face.nnClass discussions are still energetic. Personal attention is still a focal point. And everyone, Welter included, comes away from each session learning something new.nnStudents also gain the benefit of his more than 25 years of health care industry experience. He is president and founder of Welter Healthcare Partners, Inc., which works with providers, hospitals, public health agencies and other facilities around the world on the business side of health care. Welter, who earned a Master of Science in Organization Leadership and Management, credits his own Regis education with helping him see the big picture, think outside the box and find solutions. Those skills are what give Regis graduates an edge in the job market and help them excel in a field that is exploding with opportunity, including the ability to join in efforts to move health care forward, he said.nn”I am part of changing health care,” he said. “And I want to drag students into it. I want to tell them, ‘Get in the storm and be part of the change.'”nnConnect and find out how Regis can position you as a change agent in health care.n
nSource: www.regis.edu; 2013.
The U.S. Health and Human Services (HHS) Centers for Medicare and Medicaid (CMS) announced on Thursday that Medicare will begin accepting a revised CMS-1500 form (version 02/12) on January 6, 2014.nnEmbedded in this is a requirement for some healthcare IT vendors to start supporting a component of the International Classification of Diseases version 10 (ICD-10) earlier than the anticipated October 1, 2014 date.n
Starting April 1, 2014, Medicare will accept only the revised version of the form. The revised form will give HIPAA Covered Entities who are health care providers the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes, which is important as the October 1, 2014, transition approaches. Effectively this means that any healthcare IT system that adjudicates, submits, or reports on claims data that was scheduled to be compliant as of October 1, 2014 with ICD-10 must actually comply with a component of the ICD-10 requirements related to claims data as early as of April 1, 2014.
nICD-9 codes must be used for services provided before October 1, 2014, while ICD-10 codes should be used for services provided on or after October 1, 2014. The revised form also allows for additional diagnosis codes, expanding from 4 possible codes to 12. ICD-10 CM must be used for all diagnosis for both inpatient and outpatient claims. ICD-10 PCS must be used for all inpatient procedures.nnOnly providers who qualify for exemptions from electronic submission may submit the CMS-1500 Claim Form to Medicare. For those providers who use service vendors, CMS encourages them to check with their service vendors to determine when they will switch to the new form.nnICD-10 promises to introduce better information to improve the quality of healthcare by providing more granular data on the condition of the patient, how the patient acquired a condition, how the patient was treated for the condition and why. This in turn it is hoped, will improve population health management and other components of healthcare.nnAt the same time ICD-10 is viewed as disruptive because it requires a re-write of healthcare IT systems, processes, and substantial re-training of medical coders, billing personnel, physicians, and other clinical staff.nnFrom a financial perspective ICD-10 introduces a new payment paradigm including opportunities for improved reimbursement and potential risks of decreased reimbursement for HIPAA Covered Entities who do not carefully examine the nuances of the ICD-9 to ICD-10 transition.nnHIPAA Covered Entities and healthcare IT vendors who are building test plans must take this into consideration as they plan for the ICD-10 transition.n
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nSource: www.govhealthit.com; Michael F Arrigo; September 6, 2013.
S93.411A – Sprain of calcaneofibular ligament of right ankle, initial encounter.nnW03.XXXA – Other fall on same level due to collision with another person, initial encounter.nnY93.61 – Activity, American tackle football.nnY92.126 – Garden or yard of nursing home as the place of occurrence of the external cause.
For the ICD-10 transition to be successful, there will need to be a huge effort on the part of medical coders, IT staff, and physicians to put all the pieces together. However, the new code set also presents an opportunity for healthcare organizations to make some big-picture decisions about the future of data governance and the role of healthcare analytics. 2011 AHIMA President Bonnie Cassidy, MPA, RHIA, FAHIMA, FHIMSS, Senior Director of HIM Innovation for Nuance, sat down with EHRintelligence to explain how the ICD-10 decisions you make now can affect your organization in the months and years after October 1, 2014.n
nOne of the things I’m seeing a lot is a focus on contingency planning. In the work plans or roadmaps, if the organization didn’t allow for contingency planning, they’re now realizing that it’s really something that’s very important. There’s a domino effect. If you find out that you didn’t address something that is critical to the mission or there’s a wrinkle in the plan, they must ask themselves: what did you do to allow for a contingency? It’s like business disaster planning. Maybe one of the vendors went out of business. Or maybe you never approached all of your payers. Whatever the case may be, good contingency planning is an important element to building a strong ICD-10 transition plan.nnProviders are also finding out about all of the challenges of working with payers or working with the vendors while they’re addressing everything that has to do with making sure that all their ducks are in a row for ICD-10 readiness. If one of those is out of alignment, it can disrupt your whole plan. Business partners, business associate agreements, IT vendors, contracts…all of those things need to be built in and accounted for in your contingency plan.n
nThe whole concept of information technology (IT) testing is going to be significant. It’s been announced that CMS will not be conducting testing for providers and payers, so I think there’s a renewed energy around the concept of testing. A lot of organizations are delaying it because they have underestimated the amount of time that it will take to thoroughly and properly evaluate and test their systems. It is a huge effort and many organizations haven’t even gotten to the point of thinking about it. But if you think about all of the systems and all of the databases that have to convert from ICD-9 to ICD-10, you have to test everything because you need to see if the data will flow. You need to prioritize what those systems are, and build separate test databases so you’re not disrupting your actual live transactions.nnDo you have a Clinical Documentation Improvement (CDI) program? If you do, what is the goal and focus of the program? You need to do an evaluation, a gap analysis, of your current CDI program –what is your ideal result, and what’s falling in between? You should really look at your specialties, your physician population, and your patient population to see what you need to focus on. You have to get laser focused on your own patient population so you know what your top 25 DRG codes are, and you know what’s missing in your education and documentation. You already know what areas are going to be important to you. If you had to switch to ICD-10 today, you can predict where the trouble spots will be. That’s what CDI programs need to shift to right now.nnYou most likely also need to have more physician champions to get your physicians practicing the behaviors they need for ICD-10. That means you’re either hiring or contracting with physician consultants or finding physician champions in your organization. In order to do that education in your CDI program, you’ll need to think about what each specialty really needs to know. Physicians communicate best with each other, so physician-to-physician communication is your best strategy for enhancing your CDI program.nnThe other thing to focus on is your own staff. Have you really thought about what happens if one of your key players leaves the organization? The employee retention program is important. Be certain that you’ve really worked with human resources and established a program to retain your talented resources. Who are your critical success individuals?nnIf you spend all that investment in getting your coders educated and trained, as well as your clinical documentation improvement (CDI) staff, but you didn’t make the investment in an employee retention program, with the law of supply and demand, we’re going to have major capacity concerns. If those people leave, you might be left without the right staff to get the job done.n
nICD-10-PCS coding for ambulatory surgery. Have you made a decision in your organization about what you’re going to do with ambulatory surgery? Are you going to code ICD-10-PCS for your procedures even though we know we only have to code CPT? The reason I introduce that under clinical documentation improvement is that CDI traditionally is not in the ambulatory setting.nnBecause of the need for very specific documentation in ambulatory surgery, if you’re going to use that for ICD-10 on the diagnosis side or the PCS side, you will then have clinical documentation requirements that are far more specific in ICD-10 than they are in CPT. You will probably need a CDI effort in that regard, because otherwise you won’t have enough information to code in ICD-10. You’ll have enough for CPT, but you won’t get the specificity necessary for ICD-10.nnMany people ask, “Well, why would I want to do that if the only thing that’s required is CPT?” But that connects to the overarching goal of analytics. If you want to be a progressive organization, you need to embark on something that allows you to have better information for analytics. You then will be a step ahead of the game because you’ll have that ICD-10 data in addition to your CPT data.nnAs we know, the world’s going to go from inpatient to ambulatory with the focus on outcomes and chronic disease management. So that’s going to be another push for CDI, but it’s also a huge organizational decision. It’s very much a strategic decision if you’re focused on your own data analytics in the future.n
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nSource: www.ehrintelligence.com; Jennifer Bresnick; August 26, 2013.
T20.16XA – Burn of first degree of forehead and cheek, initial encounternnX03.0XXA – Exposure to flames in controlled fire, not in building or structure, initial encounternnY93.G2 – Activity, grilling and smoking foodnnY92.017 – Garden or yard in single-family (private) house as the place of occurrence of the external cause.nnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
Under the current fee-for-service (FFS) payment system, specialists developed practice styles and business models that flourished by maximizing the delivery of highly reimbursed services. Specialists today, however, are likely to be concerned about forthcoming global payment models that are designed to reduce the inexorable increase in health care expenditures by promoting high-value services, eliminating low-value services, and improving care coordination and integration. For many specialists, this new world of global payments is slowly evolving from an amorphous concern to a potential threat to their livelihoods.nnThis disruption to the current norms of specialty practice, and both the concerns and opportunities presented by global payments, are evident in discussions occurring throughout the country, although likely with greater urgency in physician organizations already transitioning to global payment systems such as those participating in the Medicare accountable care organization programs. As this transition accelerates, even though much of the clinical revenue from specialists will continue to be generated from standard FFS payments, increasing numbers of patients will be covered under global budgets, even if in many cases another care system is “at risk.”nnNationwide, specialists likely are considering potential innovations to better manage patients under global risk arrangements.For instance, specialists in some areas can envision designing aggressive team-based programs aimed at reducing hospitalizations for high-risk cases of diabetes or chronic obstructive pulmonary disease with the assistance of a nurse or case manager. Others might note the opportunity for improved coordination with primary care. While currently specialists might be seeing patients with chronic medical conditions such as asthma or kidney disease 3 or 4 times per year (often with diagnostic testing that provides additional revenue, but little new information), they may recognize that many of these cases could easily be sent back to primary care physicians for the majority of their care, which would free up specialists’ schedules so that they could offer more timely access to those who truly needed their specialized knowledge and consultative services.Yet current incentives and financial models are not in place to support these innovations, which would all result in decreased FFS revenue. Additionally,and perhaps more importantly, there currently are financial disincentives to innovate, to hire practice extenders, or to offer additional consultative services, by phone or e-mail. Neither in the current FFS payment model nor in most global payment models with incentives targeted solely for primary care practitioners are there mechanisms to support such innovations in care delivery.nnThe current systemic constraints and contradicting incentives beg the question, how should the delivery of and compensation for specialty services be structured under global payments? Specialists ideally would be motivated to not only provide optimized patient care and enhanced consultative services to their primary care colleagues but also be actively involved in redesigning practices, coordinating care, reducing unnecessary care, and improving efficiency. To achieve these goals, however, specialists must be incentivized to provide timely, thoughtful,and value-added care,even if it means changing the way that care is delivered. Such change will require overcoming years, if not decades, of deeply ingrained (and currently lucrative) behaviors that have evolved under the current FFS system.nnFor both patients and primary care practitioners, a key need is to obtain appropriate specialty input, but that input need not be in the form of face-to-face visits.The medium for this message may vary widely ranging from telephone consultations to e-mail or other messaging platforms, as well as asynchronous web- or video-based interactions. Traditional visits likely will remain the norm, but increasingly interactions may involve such non–visit based encounters. Thus,under these models,job descriptions and the day-to-day activities of many specialists will change markedly, and specialist compensation methods must account for these new activities. Several likely outcomes may result, although the extent to which each of these becomes common in individual practices, organizations, and markets will vary considerably.nnFirst, in more integrated delivery markets with prior experience with risk contracting, there is likely to be resurgence of risk-based models of specialty compensation wherein groups of specialists receive a fixed per-member-per-month fee to provide specialty care.These fees (or budgets) can be based on an entire enrolled population or can be triggered when a patient first sees a specialist. Specialist physicians may continue to receive FFS payments with intermittent reconciliation, or they might shift to mixed compensation models with salary or specific remuneration for currently uncompensated activities. Under such models, specialists will have more freedom to allocate their fixed resources to providing higher-value services and will have less incentive to see patients more frequently or perform procedures. Organizations,however, will need to put systems in place to ensure continued clinical productivity.nnSecond,when used,the current FFS system compensation models will need to be adapted to cover unreimbursed activities that may be valuable. Compensating physicians for services such as e-mail,telephone,and curbside consultations will need to be paired with new metrics documenting the value of these services. In addition, specialists also will need to be responsible for and incentivized to improve population-based care (eg, endocrinologists responsible for reducing an entire population’s mean hemoglobin A1C) with active outreach,peer practice review,and physician education on how to determine when, whom, and why to refer to specialty care.nnThird, it is likely that increasing numbers of specialists will become salaried employees of hospitals or health systems and that compensation will become less linked to actual FFS revenue generated by direct physician services. For instance, “cognitive” specialists, such as infectious disease physicians, are crucial to hospitals’ functioning; yet these physicians receive lower pay than many other specialties. Thus, to ensure the availability of infectious disease consultants, hospitals may need to supplement their pay beyond the level of typical FFS payments.nnFourth, as care becomes more tightly managed, certain specialists may see substantial decreases in the demand for their services. Low value services will diminish or be eliminated and peer education will allow for care that does not require specialty input to be provided by primary caregivers, possibly leading to less frequent initial and follow-up consultation sand fewer procedures in some specialties. Practice style evolution as described above (eg, e-mail/telephone consults, enhanced disease management, incorporation of mid-level providers such as nurse practitioners or physician assistants,and care managers) will also put downward pressure on demand.nnFifth, specialists also should be prepared to see a reduction in income, particularly when compared with primary care and cognitive specialties that have been under reimbursed in the current FFS system. Current relative payment levels have been codified in the fee schedule used by Medicare that also serves as a model for FFS payment by most private health plans. Even capitated systems that do not use FFS reimbursementmust pay market-level salaries to attract qualified specialists.Many health policy experts have long noted the current inequities,and current Medicare Payment Advisory Commission (MedPAC) recommendations call for a rebalancing of primary care and specialty pay to address these inequities. 1-3 Combined with the likely decreased demand noted above, it is difficult to envision a future in which both payment levels and pay relative to primary care are not adjusted down for many specialties.nnThe coming tide of payment reform as well as continued, if not escalating, cost pressures as the Affordable Care Act is implemented and an additional 30 million individuals obtain some form of health insurance present great opportunities for innovations in how health care services are organized and delivered. For the first time in US history, more patients and physicians will operate in a system in which there are defined boundaries for costs. There may be substantial shifts in how resources are spent, whether shifting from specialists to primary care physicians or from inpatient to outpatient settings. These changes will have dramatic effects on specialist practice, with implications both for how specialists practice as well as for the forms and levels of their compensation. Although changes in specialist roles and responsibilities will better align specialists with the goals of integrated care systems, with likely benefit to the health care system overall, these changes are also likely to result in substantial changes in specialist pay and number.n
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nSource: www.jama.jamanetwork.com; Thomas Jefferson University — Michael Barr; July 23, 2013.
S61.452A — Open bite of left hand, initial encounter.nnW55.21XA — Bitten by cow, initial encounter.nnY93.K2 — Activity, milking an animal.nnY92.73 — Farm field as the place of occurrence of the external cause.nn nnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
S93.431A — Sprain of tibiofibular ligament of right ankle, initial encounternnW03.XXXA — Other fall on same level due to collision with another person, initial encounternnY93.41 — Activity, dancingnnY92.252 — Music hall as the place of occurrence of the external causenn nnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!
WASHINGTON — In another setback for President Obama’s health care initiative, the administration has delayed until 2015 a significant consumer protection in the law that limits how much people may have to spend on their own health care.nnThe limit on out-of-pocket costs, including deductibles and co-payments, was not supposed to exceed $6,350 for an individual and $12,700 for a family. But under a little-noticed ruling, federal officials have granted a one-year grace period to some insurers, allowing them to set higher limits, or no limit at all on some costs, in 2014.nnThe grace period has been outlined on the Labor Department’s Web site since February, but was obscured in a maze of legal and bureaucratic language that went largely unnoticed. When asked in recent days about the language — which appeared as an answer to one of 137 “frequently asked questions about Affordable Care Act implementation” — department officials confirmed the policy.nnThe discovery is likely to fuel continuing Republican efforts this fall to discredit the president’s health care law.nnUnder the policy, many group health plans will be able to maintain separate out-of-pocket limits for benefits in 2014. As a result, a consumer may be required to pay $6,350 for doctors’ services and hospital care, and an additional $6,350 for prescription drugs under a plan administered by a pharmacy benefit manager.nnSome consumers may have to pay even more, as some group health plans will not be required to impose any limit on a patient’s out-of-pocket costs for drugs next year. If a drug plan does not currently have a limit on out-of-pocket costs, it will not have to impose one for 2014, federal officials said Monday.nnThe health law, signed more than three years ago by Mr. Obama, clearly established a single overall limit on out-of-pocket costs for each individual or family. But federal officials said that many insurers and employers needed more time to comply because they used separate companies to help administer major medical coverage and drug benefits, with separate limits on out-of-pocket costs.nnIn many cases, the companies have separate computer systems that cannot communicate with one another.nnA senior administration official, speaking on condition of anonymity to discuss internal deliberations, said: “We knew this was an important issue. We had to balance the interests of consumers with the concerns of health plan sponsors and carriers, which told us that their computer systems were not set up to aggregate all of a person’s out-of-pocket costs. They asked for more time to comply.”nn
Health plans are free to set out-of-pocket limits lower than the levels allowed by the administration. But many employers and health plans sought the grace period, saying they needed time to upgrade their computer systems. “Benefit managers using different computer systems often cannot keep track of all the out-of-pocket costs incurred by a particular individual,” said Kathryn Wilber, a lawyer at the American Benefits Council, which represents many Fortune 500 companies that provide coverage to employees.nnLast month the White House announced a one-year delay in enforcement of another major provision of the law, which requires larger employers to offer health coverage to full-time employees. Valerie Jarrett, Mr. Obama’s senior adviser, said that the delay of the employer mandate showed “we are listening” to businesses, which had complained about the complexity of federal reporting requirements.nnAlthough the two delays are unrelated, together they underscore the difficulties the Obama administration is facing as it rolls out the health care law.nnAdvocates for people with chronic illnesses said they were dismayed by the policy decision on out-of-pocket costs.nn“The government’s unexpected interpretation of the law will disproportionately harm people with complex chronic conditions and disabilities,” said Myrl Weinberg, the chief executive of the National Health Council, which speaks for more than 50 groups representing patients.nnFor people with serious illnesses like cancer and multiple sclerosis, Ms. Weinberg said, out-of-pocket costs can total tens of thousands of dollars a year.nnDespite the delay, consumers in 2014 will still have many new protections. They cannot be denied health insurance or charged higher premiums because of pre-existing conditions, and many will qualify for subsidies intended to lower their costs.nnIn promoting his health care plan in 2009, Mr. Obama cited the limit on out-of-pocket costs as one of its chief virtues. “We will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick,” Mr. Obama told a joint session of Congress in September 2009.nnAdvocates for patients said the promise of the law was being deferred. “We have wonderful new drugs, the biologics, to treat rheumatoid arthritis, but they are extremely expensive,” said Dr. Patience H. White, a vice president of the Arthritis Foundation. “In the past, patients had to live in constant pain, often became disabled and had to leave their jobs. The new drugs can make a huge difference, and we were hoping that the cap on out-of-pocket costs would make them affordable. But now many patients will have to wait another year.”nn
The American Cancer Society shares the concern and noted that some new cancer drugs cost $100,000 a year or more.nn“If a prescription drug plan does not currently have a limit, then it will not have to have one in 2014,” said Molly Daniels, deputy president of the lobbying arm of the American Cancer Society. “Patients who require expensive drugs could continue to have enormous financial exposure, despite the clear intent of the law to limit a patient’s total out-of-pocket exposure.”nnFederal officials said they were offering transition relief to certain health plans in 2014. But, they said, by 2015, health plans must comply with the law and must have an overall limit on out-of-pocket costs for medical, drug and other benefits combined.nnTheodore M. Thompson, a vice president of the National Multiple Sclerosis Society, said: “The promise of out-of-pocket limits was one of the main reasons we supported health care reform. So we are disappointed that some plans will be allowed to have multiple out-of-pocket limits in 2014.”nnThe law also requires coverage of dental care for children, but these benefits can be offered in a separate health plan with its own limit on out-of-pocket costs.nnFederal rules say that a free-standing dental plan must have “a reasonable annual limitation on cost-sharing.” In states where the new health insurance marketplace will be run by the federal government, the limit on out-of-pocket costs for pediatric dental benefits can be no more than $700 for coverage of one child and $1,400 for a plan covering two or more children in the same family.n
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nSource: www.nytimes.com; Robert Bear; August 12, 2013.
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S00.83XA — Contusion of other part of head, initial encounter.nnY93.82 — Activity, spectator at an eventnnW21.03XA — Struck by baseball, initial encounter.nnY92.320 — Baseball field as the place of occurrence of the external cause.nn nnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2014 implementation date. Please don’t hesitate to contact us for all of your training and education needs!