Wednesday, June 20, 2018

OCMA Blog

Physician Advocate Tip of the Month: CPT® Modifier 22 – Reporting & Reimbursement

Tip comes from G. John Verhovshek, managing editor for AAPC, a training and credentialing association for the business side of health care.

CPT® modifier 22 increased procedural services allows a provider to gain additional reimbursement for an unusually difficult or time-consuming procedure. To realize that extra payment, your billing staff will have to make a special effort, as well.

Per CPT® Appendix A, modifier 22 may be appended to a CPT® code to indicate that the work performed was “substantially greater than typically required…. ” CPT® does not define a “substantially greater” effort, although some payors do offer guidelines (e.g., the effort and/or time to perform the procedure should be “at least 25 percent greater than usual”). Regardless of payor, you should append modifier 22 infrequently, and for only the most unusual procedures.

Specific circumstances that may call for modifier 22 include:

  • Intra-operative hemorrhage resulting in a significant amount of increased operative time.
  • Emergency situations that require significant effort beyond the normal service. This does not include minor intra-operative complications that sometimes occur.
  • Abnormal pathology, anatomy, tumors and/or malformations that directly and significantly interfere with the normal progression of a procedure.

Also, keep in mind these caveats:

  • Additional time, by itself, does not justify the use of modifier 22.
  • Do not use modifier 22 when the existing CPT® code describes the service.
  • Do not use modifier 22 to indicate that a specialist (no matter how specialized) performed the service.
  • Do not use modifier 22 if the complication is due to the surgeon’s choice of surgical approach.

CPT® guidelines require that provider documentation support “the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of the procedure, severity of patient’s condition, physical and mental effort required).” The provider should explain and identify additional diagnoses, pre-existing conditions, or unexpected findings or complicating factors that contributed to the extra time and effort.

Use comparisons to clarify how the procedure differed, using quantifiable criteria. For example: The patient lost 800 cc’s of blood, rather than the usual 100-200 cc’s lost during a procedure of the same type. Time is also quantifiable (e.g., “the surgery took four hours instead of the usual 1½-2 hours”).

Payors may request a full operative report to verify the unusual nature of the coded procedure. Because most claims are now sent electronically, you should include comments in the narrative field, using everyday language, to explain precisely why (and how much) additional effort and/or time were required to complete the procedure, along with the statement, “Request documentation if needed.” If the payer requests the additional details, be prepared to send the full operative note, along with a cover letter (with provider signature) detailing the unusual nature of the procedure.

The Centers for Medicare & Medicaid Services and other payers scrutinize modifier 22 claims, and primary payor claims submitted with a 22 modifier are often subject to a full medical review. If your claim is correctly coded and well supported by documentation, be persistent in pursuing payment.

Lastly, when submitting your claim with modifier 22, you have to ask for additional payment. Payors won’t automatically increase reimbursement. Instead, you should recommend an appropriate fee. For instance, if a surgical procedure takes twice as long due to unusual clinical circumstances, you could ask the payor to increase the intra-operative portion of the payment by 50 percent. 


MICRA Alert and Prop 46 Resources for Physicians

In less than 100 days, voters will be asked to weigh in on the MICRA health care lawsuit measure known as Prop. 46, which will hugely jeopardize the privacy of patients' personal prescription medical information.
 
The initiative will force doctors and pharmacists to use a massive statewide database known as the Controlled Substance Utilization Review Evaluation System (CURES), which is filled with patients' personal prescription drug information. Though the database already exists, it is underfunded, understaffed and technologically incapable of handling the massively increased demands that this ballot measure will place on it.
 

Most concerning, the massive ramp up of this database will significantly put patients' private medical information at risk and the ballot measure doesn't contain any provisions or funding to help upgrade the system or increase the database's security standards. As many of you know, the CURES database contains highly sensitive patient information including personal and potentially stigmatizing details about their health. Prescription information including medication used to treat obesity, narcolepsy, conditions related to cancer and AIDS, asthma and other sensitive information are all contained within the CURES database. 

In recent weeks and months, the coalition to oppose the MICRA health care lawsuit initiative continues to grow. Teachers, health care workers, local community groups and hundreds of others have pledged to vote NO in November because they too understand the implications this measure would have on patients, taxpayers and consumers across the state.

We know that if this measure passes, it won't just be putting patients' personal medical information at risk, but malpractice lawsuits and payouts will also skyrocket, adding "hundreds of millions of dollars" in new costs to state and local governments, according to an impartial analysis conducted by the state's Legislative Analyst. State and local governments face higher costs in two ways: 
 
  • They provide health care for current and retired employees;
  • They provide health care for low-income residents through Medi-Cal and other locally run health care programs like community clinics and hospitals.

Someone will have to pay for these increased costs, and that someone is you (physicians), taxpayers and consumers/patients.
 
The campaign opposed to the initiative - "Patients and Providers to Protect Access and Contain Health Costs" - is a diverse and growing coalition of trusted doctors, community health clinics, hospitals, family-planning organizations, local leaders, public safety officials, businesses, and working men and women formed to oppose this costly, dangerous ballot proposition that would make it easier and more profitable for lawyers to sue doctors and hospitals. A full and updated list of groups opposing the campaign can be found here.
 
United as one voice, advocating for patients across the state, we can defeat this ballot measure in November, but we need everyone to commit and become engaged along the way. Thank you in advance for all that you do and all that you'll continue to do. 

Join the Fight

CMA and the campaign to defeat Prop. 46 need each and every one of you to help spread the word and educate your colleagues about the critical importance of MICRA. To that end, CMA has developed a MICRA Commitment Card.

We ask that you fill out one of these cards and pledge that you will vote no on the anti-MICRA measure known as Prop. 46.

Campaign Materials

The CMA can provide your office with campaign materials such as patient brochures, posters, buttons, campaign stickers and more. Just fill out the No on 46 order form.

More information

Visit these websites in order to learn more about MICRA so that you can educate your colleagues, friends, peers and family:

- The CMA website

- No on 46 campaign website

- Californians Allied for Patient Protection (CAPP) Website

What else can you do to support MICRA?

- "Like" the No on 46 Facebook page

- Follow the No on 46 Twitter page

- Visit the offical campaign website at www.noon46.com


CDC Health Advisory: Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease

CDC HEALTH ADVISORY: EBOLA VIRUS

Summary
The Centers for Disease Control and Prevention (CDC) continues to work closely with the World Health Organization (WHO) and other partners to better understand and manage the public health risks posed by Ebola Virus Disease (EVD). To date, no cases have been reported in the United States. The purpose of this health update is 1) to provide updated guidance to healthcare providers and state and local health departments regarding who should be suspected of having EVD, 2) to clarify which specimens should be obtained and how to submit for diagnostic testing, and 3) to provide hospital infection control guidelines.
 
U.S. hospitals can safely manage a patient with EVD by following recommended isolation and infection control procedures. Please disseminate this information to infectious disease specialists, intensive care physicians, primary care physicians, hospital epidemiologists, infection control professionals, and hospital administration, as well as to emergency departments and microbiology laboratories.

 
Background
CDC is working with the World Health Organization (WHO), the ministries of health of Guinea, Liberia, and Sierra Leone, and other international organizations in response to an outbreak of EVD in West Africa, which was first reported in late March 2014. As of July 27, 2014, according to WHO, a total of 1,323 cases and 729 deaths (case fatality 55-60%) had been reported across the three affected countries. This is the largest outbreak of EVD ever documented and the first recorded in West Africa.  

EVD is characterized by sudden onset of fever and malaise, accompanied by other nonspecific signs and symptoms, such as myalgia, headache, vomiting, and diarrhea. Patients with severe forms of the disease may develop hemorrhagic symptoms and multi-organ dysfunction, including hepatic damage, renal failure, and central nervous system involvement, leading to shock and death. The fatality rate can vary from 40-90%. 
 
In outbreak settings, Ebola virus is typically first spread to humans after contact with infected wildlife and is then spread person-to-person through direct contact with bodily fluids such as, but not limited to, blood, urine, sweat, semen, and breast milk. The incubation period is usually 8-10 days (ranges from 2-21 days). Patients can transmit the virus while febrile and through later stages of disease, as well as postmortem, when persons touch the body during funeral preparations. 

Patient Evaluation Recommendations to Healthcare Providers
Healthcare providers should be alert for and evaluate suspected patients for Ebola virus infection who have both consistent symptoms and risk factors as follows: 1) Clinical criteria, which includes fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND 2) Epidemiologic risk factors within the past 3 weeks before the onset of symptoms, such as contact with blood or other body fluids of a patient known to have or suspected to have EVD; residence in-or travel to-an area where EVD transmission is active; or direct handling of bats, rodents, or primates from disease-endemic areas. Malaria diagnostics should also be a part of initial testing because it is a common cause of febrile illness in persons with a travel history to the affected countries.
 
Testing of patients with suspected EVD should be guided by the risk level of exposure, as described below:

CDC recommends testing for all persons with onset of fever within 21 days of having a high-risk exposure. A high-risk exposure includes any of the following:

  • percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or suspected case of EVD without appropriate personal protective equipment (PPE),
  • laboratory processing of body fluids of suspected or confirmed EVD cases without appropriate PPE or standard biosafety precautions, or
  • participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring without appropriate PPE.

For persons with a high-risk exposure but without a fever, testing is recommended only if there are other compatible clinical symptoms present and blood work findings are abnormal (i.e., thrombocytopenia <150,000 cells/µL and/or elevated transaminases) or unknown.  

Persons considered to have a low-risk exposure include persons who spent time in a healthcare facility where EVD patients are being treated (encompassing healthcare workers who used appropriate PPE, employees not involved in direct patient care, or other hospital patients who did not have EVD and their family caretakers), or household members of an EVD patient without high-risk exposures as defined above. Persons who had direct unprotected contact with bats or primates from EVD-affected countries would also be considered to have a low-risk exposure. Testing is recommended for persons with a low-risk exposure who develop fever with other symptoms and have unknown or abnormal blood work findings. Persons with a low-risk exposure and with fever and abnormal blood work findings in absence of other symptoms are also recommended for testing. Asymptomatic persons with high- or low-risk exposures should be monitored daily for fever and symptoms for 21 days from the last known exposure and evaluated medically at the first indication of illness. 

Persons with no known exposures listed above but who have fever with other symptoms and abnormal bloodwork within 21 days of visiting EVD-affected countries should be considered for testing if no other diagnosis is found. Testing may be indicated in the same patients if fever is present with other symptoms and blood work is abnormal or unknown. Consultation with local and state health departments is recommended.  
 
If testing is indicated, the local or state health department should be immediately notified. Healthcare providers should collect serum, plasma, or whole blood. A minimum sample volume of 4 mL should be shipped refrigerated or frozen on ice pack or dry ice (no glass tubes), in accordance with IATA guidelines as a Category B diagnostic specimen. Please refer to http://www.cdc.gov/ncezid/dhcpp/vspb/specimens.html for detailed instructions and a link to the specimen submission form for CDC laboratory testing. 

Recommended infection control measures
U.S. hospitals can safely manage a patient with EVD by following recommended isolation and infection control procedures, including standard, contact, and droplet precautions.  Early recognition and identification of patients with potential EVD is critical.  Any U.S. hospital with suspected patients should follow CDC's Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals (http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html). These recommendations include the following:

  • Patient placement: Patients should be placed in a single patient room (containing a private bathroom) with the door closed. Healthcare provider protection: Healthcare providers should wear: gloves, gown (fluid resistant or impermeable), shoe covers, eye protection (goggles or face shield), and a facemask.  Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to double gloving, disposable shoe covers, and leg coverings.
  • Aerosol-generating procedures:  Avoid aerosol-generating procedures. If performing these procedures, PPE should include respiratory protection (N95 filtering facepiece respirator or higher) and the procedure should be performed in an airborne isolation room.
  • Environmental infection control: Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is paramount, as blood, sweat, emesis, feces and other body secretions represent potentially infectious materials. Appropriate disinfectants for Ebola virus and other filoviruses include 10% sodium hypochlorite (bleach) solution, or hospital-grade quaternary ammonium or phenolic products. Healthcare providers performing environmental cleaning and disinfection should wear recommended PPE (described above) and consider use of additional barriers (e.g., shoe and leg coverings) if needed. Face protection (face shield or facemask with goggles) should be worn when performing tasks such as liquid waste disposal that can generate splashes. Follow standard procedures, per hospital policy and manufacturers' instructions, for cleaning and/or disinfection of environmental surfaces, equipment, textiles, laundry, food utensils and dishware. 

Physician Advocate Mid-Year Report: 127,000 Reasons to be Member

127,000 REASONS TO BE A MEMBER


The California Medical Association's (CMA) Center for Economic Services' (CES) reimbursement specialists have recouped $127,168 on behalf of physician members of OCMA since the beginning of 2014!

Mitzi Young is OCMA's Physician Advocate from CMA's CES team. Since the start of 2014, Mitzi has met with over 43 physician practices to assist with practice management needs and perform complimentary practice assessments. 

Your Personal Physician Advocate
Meet Mitzi Young, staff member and CMA Center for Economic Services (CES) Physician Advocate for the OCMA. Mitzi is dedicated to handling your practice management issues and is only a phone call away!

Mitzi brings 21 years of practice management experience and expertise in the health care industry. She has worked in numerous health care settings including county organized health programs, surgery centers and specialty health care practices. 
 
Mitzi understands the needs of physicians and their staff, the challenges that face medical practices, and is very passionate about advocating on behalf of doctors in the ever-changing healthcare environment.

 

When do you call Mitzi?

  • When you have questions about Covered California
  • When your claims are not being paid in a timely manner
  • When you are not being paid according to your contract
  • When your claims are being denied after obtaining prior authorization or verifying eligibility
  • When you receive unreasonable requests for medical records or untimely requests for refunds
  • When you are having difficulty obtaining fee schedules and/or payment rules
  • When your claims are denied despite timely filing
  • When you've been presented with a managed care contract and you're not sure if the terms are consistent with California law
  • When you've done everything you can to resolve an issue with a payor and have been unsuccessful
  • When you need help evaluating your practice
  • When you need ANY practice management guidance

Would you like a FREE Practice Assessment?

Find opportunities to increase revenue through the billing process, accounts receivable and collections. Increase efficiency with patient scheduling, appointments and check-in process and discuss all of your practice-related concerns. Contact Mitzi to schedule your member-only practice assessment.
 
Receiving practice management guidance from Mitzi Young is a FREE OCMA member benefit!
 
Contact Mitzi to schedule a one-on-one consultation to discuss your practice management needs: 
Mitzi Young
Physician Advocate, CMA Center for Economic Services
(888) 236-0267
myoung@cmanet.org

Not a member?

Join today!  
Contact Mark Morones, Director of Membership:
(949) 398-8103
mmorones@ocma.org


Physician Advocate Tip of the Month: Identify Covered California patients who are in months two and three of the Grace Period

July Tip:

Identify Covered California patients who are in months two and three of the Grace Period using the following verification codes:

Plan Name 

Eligibility Code

 Anthem Blue Cross  "Inactive pending investigation"  
 Blue Shield of California   "Pended" 
 Health Net  "Eligibility suspended"

 

What are your options if a patient presents with inactive coverage? Download "Surviving Covered California: Tip Sheet #4" (a member-only resource) at www.cmanet.org/exchange.

Would you like a FREE Practice Assessment?

Find opportunities to increase revenue with the billing process, accounts receivable and collections and discuss all of your concerns. Increase efficiency with patient scheduling, appointments and check-in process. Contact Mitzi to schedule your member-only practice assessment.
 
Receiving practice management guidance from Mitzi Young is a FREE OCMA member benefit!
Mitzi Young
Physician Advocate, CMA Center for Economic Services
888.236.0267
myoung@cmanet.org


MICRA lawsuit measure assigned proposition number

Via the California Medical Association-

The unprecedentedly broad and diverse coalition working to defeat the trial lawyers’ MICRA lawsuit measure is now officially the “No On 46” campaign, following the assignment of proposition numbers to qualified ballot measures by the Secretary of State’s Office on Monday.

If approved by voters, Proposition 46 would increase health costs, reduce access to care and threaten patient privacy, all to make it easier and more profitable for lawyers to sue doctors and hospitals. In addition to increasing the overall number of medical lawsuits and the cost of health care across the board, Proposition 46 contains a number of unrelated provisions designed to mislead and deceive voters – including a little-discussed mandate relying on a massive expansion of a government-run prescription drug database, which third-party analysts say cannot be implemented as written and will leave personal medical information vulnerable to privacy breach.

For these reasons, health providers, education groups, labor unions, business organizations, working men and women, and community clinics have all announced their opposition to Proposition 46.

On Monday, two additional groups – the State Building and Construction Trades Council of California (SBCTC) and the California NAACP – joined the “No On 46” campaign, pointing out the devastating effects it would have on California.

“This initiative will cost state and local governments hundreds of millions dollars and raise health costs for everyone,” said Robbie Hunter, President of the SBCTC. “That hurts job creation and will negatively impact California’s future.”

According to California’s independent Legislative Analyst, the proposed measure could increase state and local government health costs by “hundreds of millions of dollars annually.”

“This measure is terribly flawed and will reduce access to quality health care for underserved communities,” said Alice Huffman, President of the California NAACP. “At a time when we’re working hard to cover as many Californians as possible under the ACA, Proposition 46 takes us in the wrong direction. Proposition 46 will disproportionately hurt minority communities. It’s bad medicine for California.”

These two organizations join the growing list of California public entities and private organizations that have announced their formal opposition. For a complete list, please visit the campaign website, www.noon46.com.


IMQ Expands Peer Review Services

Does your medical staff need help with peer review? The Institute for Medical Quality is expanding its services to include Clinical Case Review of individual cases and Judicial Review services in addition to our existing Comprehensive Peer Review services.
 

Through off-site patient chart review, an IMQ Clinical Case Review consultation provides an objective evaluation of the clinical practice of one or more physician members of a hospital medical staff, physician group, or ambulatory care practice through peer review of selected cases. IMQ's involvement is especially helpful when an organization will benefit from expert review of one or more patient cases, but needs physicians of the appropriate specialty who have no real or perceived conflicts of interest.

Additionally, IMQ is seeking physicians to support this expansion of services. For more information about any of IMQ’s peer review services, or about becoming a physician reviewer, please contact Julie Hopkins at 415-882-5165 or jhopkins@imq.org


Physician Advocate Tip of the Month: Give your patients the answers they need about Covered CA

June Tip:

Give your patients the answers they need about the Covered California networks and more.

Download "Frequently Asked Patient Questions about Covered California."

With the recent launch of California's health benefit exchange, Covered California, millions of Californians are now eligible to obtain insurance through this new online marketplace. Understandably, patients have many questions. Download this document to provide answers to the most common patient questions.

Receiving practice management guidance from Mitzi Young is a FREE OCMA member benefit!
 
Contact Mitzi to schedule a one-on-one consultation to discuss your practice management needs: 
 
Mitzi Young
Physician Advocate, CMA Center for Economic Services

888.236.0267
myoung@cmanet.org


Orange County Medical Association Selects Universal Financial Systems as its Business Partner

Universal Financial Systems will extend special offers to OCMA Physician Members 

Irvine, Calif., June 3, 2014 - The Orange County Medical Association is pleased to announce another benefit of membership.  The OCMA has designated Universal Financial Systems as its Business Partner for physicians seeking collections and pre-collections help on past due receivables. Universal Financial Systems is a full-service collection agency based in Southern California. 

Free Insurance and Patient Collection Performance Analysis ($300 Value)

  • Patient Collection Analysis
  • Insurance Collection Analysis
  • Accounts Receivable Analysis
  • Full Detailed Report

 
Pre-Collection Program - Offering a "5 %" rate for account referrals received and collected within 120 days from the date of service

  • This is exclusive for OCMA members. All other clients get the "5%" until 90 days from date of service

 
Standard Collection Program: 120+ days from date of service -> 30% of collected revenue

  • Competitors' rates can be as much as 40 to 50% rates of collected revenue
  • State-of-the-art tools to locate debtors
  • Active Account Monitoring - allows tracking and notification when debtor's finances improve, purchase assets, etc.
  • Month-end Status Reports
  • Client Account Reviews
  • Judgment Collections Expertise
  • Litigation Services Available 

 
For more information, please contact:
Greg Apostolou
(310) 386-9085
Grega@ufsworks.com


OCMA CEO Advocacy & Legislative News Update


Local: CalOptima

Thanks in part to OCMA advocacy, in March, the CalOptima Board of Directors approved establishing a 'Community Network', allowing direct contracts with physicians in order to provide greater access to services for CalOptima enrollees.
 
Also in March, the County Board of Supervisors modified the county ordinance governing CalOptima to require an additional supervisor be added to the CalOptima Board of Directors. As a result, Supervisor Todd Spitzer has joined Supervisor Janet Nguyen on the CalOptima Board. 
 
For details and resources on the state's Coordinated Care Initiative (CCI) - Dual Eligibles Demonstration, please click here.

State: Health Care Bills

SB 1215 (Hernandez): Healing arts licensees: referrals (CMA Position: OPPOSE) - which aimed to eliminate the in-office exception to the self-referral law for advanced imaging, anatomic pathology, radiation therapy, and physical therapy. This bill would have been a major blow to the integrated care model, resulting in increased costs as these services would have been driven toward the more expensive hospital setting and inhibit the development of practices that integrate and coordinate care. We have successfully managed to defeat this harmful bill in committee.
 
SB 1000 (Monning) the Sugar-Sweetened Beverages Safety Warning Act (CMA Position: SPONSOR)  - passed the Senate Floor after receiving 21 yes votes. Facing significant opposition from the beverage industry, it was a hard-won vote. 
 
AB 1771 (V.M. Perez) Telehealth Reimbursement (CMA Position: SPONSOR)  - was approved through a 76-1 vote. This bill seeks to require health insurance companies licensed in the State of California to pay contracted physicians for telephone patient management. 
 
AB 2400 (Ridley-Thomas) Health care coverage: provider contracts (CMA Position: SPONSOR) - was approved through a 55-8 vote. If signed into law, this bill will prohibit contracts issued, amended or renewed after January 1, 2015, from including a provision that terminates a provider if he or she exercises the right to negotiate, accept or refuse a material change to the contract. It would also prohibit plans from requiring participation in unspecified current and future products or product networks, unless the plan discloses the reimbursement rate, method of payment and any other contract terms that are materially different from those of the underlying commercial agreement. 

National: Medicare SGR

Over CMA's strong opposition to another short term patch, on March 31, the night before the SGR cut, the House and Senate voted on the 17th patch in a decade.  With the President's signature, the bill takes effect and provides the following: 

  • Stops the 24% Medicare physician payment cut for 1 year until April 2015.
  • Provides a 0.5% payment increase through Dec 31, 2014; 0% through April 1, 2015.
  • Delays the burdensome ICD-10 coding system until October 2015.
  • Permanently Reforms the California physician payment localities. 


For the full OCMA CEO Advocacy & Legislative Report, click here.


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