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Medicare
Changes & Issues
2014
Richard W. Whitten, MD, FACP
Contractor Medical Director - Medicare
Vice-Chair, AMA/Specialty Society RUC 2000-2006
Member, CPT® Assistant Editorial Panel 2007-2010
[email protected]
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Disclosure of Financial
Relationships
Richard W. Whitten, MD
Has no relationships with any entity
producing, marketing, re-selling, or
distributing health care goods or
services consumed by, or used on,
patients.
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Issue Updates
•
•
•
•
IPPS; OPPS & “Observation”
Other specific issues
Where we’re headed…
Q&A
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Issue Updates
• IPPS; OPPS & “Observation”
• Other specific issues
• Where we’re headed…
• Q&A
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Observation vs. Admit
• “2-Midnight Rule”: count time from the initial
outpatient clinical service
• If admission decision made after patient has
passed midnight as outpatient and MD expects
patient to require additional midnight, OK
• Unexpected transfer or death exceptions
• Treating MD must “certify” admission is
appropriate
• Treating MD must write admission order
• Verbal order must be signed
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Observation vs. Admit2
“…the physician should generally order an
inpatient admission when he or she has
determined either that the beneficiary
requires care at the hospital that is
expected to transcend at least 2 midnights
or that it will involve a procedure
designated by the OPPS as an inpatientonly procedure.”
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Observation vs. Admit3
• “…difficult to make a reasonable prediction, the
physician should not admit the beneficiary…”
• “regulation is framed upon a reasonable and
supportable expectation [of a 2-midnight stay],
not the actual length of care”
• “We do not believe beneficiaries treated in an
intensive care unit should be an exception to this
standard, as our 2-midnight benchmark policy is
not contingent on the level of care required.”
• Exception: New-onset mechanical ventilation
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Observation vs. Admit4
• “2 midnight presumption”
• Focus: “LOS crossing only 1 midnight” or less
• Monitor longer stays
• Admission must be medically necessary
• Documentation
• No social/convenience admits
• Billing time: starts after order and patient begins
receiving inpatient services
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Medical Review
Unaffected by 2-Midnight Rule
• Reviews to ensure that the services provided were medically
necessary
• Reviews to ensure that the stay at the hospital was medically
necessary
• Reviews to validate provider coding and documentation as
reflective of the medical evidence
• CERT Reviews under the Improper Payments Elimination
and Recovery Improvement Act of 2012 (Pub. L. 112-248)
• Reviews directed by CMS or other authoritative
governmental entity (including, but not limited to, the HHS
Office of Inspector General and Government Accountability
Office)
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Telehealth Services
• Expand the scope of telehealth originating sites
to include all rural health clinics (RHCs)
• Add Transitional Care Management services
codes: 99495 & 99496 and maintains 30 day
timeframe
“Chronic Care Management”
• CMS agrees with the logic, rationale & need Stay tuned ...
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FDA-Approved Investigational
Device Exemption Studies
• Establish criteria for Category A IDE trials to
conform to appropriate scientific and ethical
standards
• Same requirements for Medicare coverage of
Category B IDE device trials
• Voluntary centralized Medicare review process
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Chiropractors Billing E&M
Services
• “We solicited comments in the CY2014
proposed rule regarding the appropriateness of
the billing of E/M services by chiropractors
although we did not propose to pay
chiropractors for E/M services in 2014”
• “very few commenters submitted comments
that addressed all...”
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https://itunes.apple.com/us/app/open-paymentsmobile-for-physicians/id667567467?mt=8
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ICD-10-CM
• Updated LCDs on website as of April 10
• End-to-End Testing: July 21-25
• Only 32 selected per MAC
• Volunteer forms are available on website
• Completed volunteer forms are due March 24
• Front-end testing – available weekly
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Issue Updates
• IPPS; OPPS & “Observation”
• Other specific issues
• Where we’re headed…
• Q&A
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Medicare Functional Environment
Recovery
Audit
Contractors (RACs)
Qualified
Independent
Contractors (QICs)
Medicare
Secondary Payer
Recovery Contractor
(MSPRC)
Beneficiary
Contact
Center (BCC)
ZPICs
Program
Safeguard
Contractors (PSCs)
Medicare
Administrative
Contractors (MACs)
Healthcare Integrated
General Ledger
Accounting System
(HIGLAS)
Enterprise
Data
Centers (EDCs)
CERT
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Quality
Improvement
Organization
(QIO)
OIG
Administrative
Qualified
Independent
Contractors
(Ad QICs)
US Attorneys
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WELL…
The Bee-Watcher Watcher watched the BeeWatcher.
He didn’t watch well. So another HawtchHawtcher
had to come in as a Watch-Watcher-Watcher.
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…And today all the Hawtchers who live in
Hawtch-Hawtch
are watching on Watch-Watcher-WatcheringWatch,
Watch-Watching the Watcher who’s watching
that bee.
You’re not a Hawtch-Hawtcher. You’re lucky
you see.
[credit and thanks to THEODORE GEISSEL
(Dr. Suess) 1973]
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Think of Gertrude Stein
A rose
Is a
Is a
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No Matter Whatever else
happens…or what they call it A. Need to control capital expenditures
1. Property, “bricks and mortar”
2. Equipment
3. Infrastructure – communications, reporting and
fiscal control
B. Need to budget and then control all other
expenditures
1. Dollars expended
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http://innovation.cms.gov/
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What happens to:
• Quality…
• Outcomes…
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National Coverage Decisions
• Fewer Coverage & Analysis Group (CAG)
Staff (both analysts & physicians)
• Conflict/controversy avoidance
• Estimate 5-6/year
• Emphasis on prevention & screening benefits
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A/B MACs
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Example: FDG PET Scans
• Fluorodeoxyglucose (FDG) Positron Emission
Tomography (PET) for Solid Tumors
• By NCD 8468:
• …cover 3 FDG PET scans …used to guide
subsequent management of anti-tumor treatment
strategy
• Coverage of any additional…determined by the
local MAC
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Thank you. Comments/questions welcome:
Please remember to 1st check both the
Noridian website & Provider Call Center
Dick Whitten, MD, FACP
(206) 979-5007
[email protected]
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