Protecting and Maximizing Your Orthopedic Revenue Cycle in 2014


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Healthcare Information Services' Presentation on January's AAOE Hot Topic Webinar.

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  • Everything that is Scheduled, Ordered, Performed is Billed for and billed accurately.
  • Protecting and Maximizing Your Orthopedic Revenue Cycle in 2014

    1. 1. Protecting and Maximizing your Revenue Cycle in 2014 2014 Coding and Fee Schedule Updates, Revenue Cycle Management Strategies and ICD-10
    2. 2.  HIS is a Physician management organization that specializes in managing the revenue cycle for Orthopaedic practices.  HIS has over 20 years of experience partnering with Orthopaedic practices.  We have earned the trust of our clients and we are viewed as experts and leaders in the Orthopaedic community.  HIS is an organization that partners with Orthopaedic practices to maximize reimbursements, increase workflow efficiency, ensure compliance and improve overall profitability 2
    3. 3. 2014 Coding and Fee Schedule Update Stay up to date and compliant to protect your Revenue Cycle in 2014
    4. 4. 2014 Coding and Fee Schedule Updates  Revisions to CPT tumor codes  Coding Changes  Shoulder and Elbow  New Category III codes  CMS Final Rule changes 2014  NCCI Policy Changes 2014  E&M Audits 4
    5. 5. Revision to Subcutaneous Soft Tissue Tumors  All sub-sections of 20000’s have revisions to these CPT® codes  Clarifies that these tumors are in the soft tissue below the skin. 5
    6. 6. 2014 CPT Revision Example of “malignant neoplasm” has been removed from all codes for radical resection of a tumor and replaced with sarcoma. 24077- Radical resection of tumor (eg, malignant neoplasm sarcoma), soft tissue of forearm and/or wrist area; less than 3 cm 6
    7. 7. 2014 CPT Changes  23333- Removal of foreign body, shoulder; deep  23334- Removal of prosthesis, included debridement and synovectomy when performed; humeral or glenoid component  23335- humeral and glenoid components  Removal should only be billed if not being replaced 7
    8. 8. Shoulder Prosthesis  Deleted 23331, 23332- old codes needed update  Technique changed- removal more difficult  Replaced with  23333- Removal of foreign body deep (below fascia and/or intramuscular  23334- Removal of prosthesis, humeral or glenoid component- debridement and synovectomy included  23335- Removal of prosthesis, humeral and glenoid components (total shoulder) 8
    9. 9. Elbow Prosthesis Removal  RUC requested 24160 code description be revised.  24160 and 24164 describe prosthesis vs. implant  Current method of elbow arthroplasty includes the use of cement which makes removal more difficult  Special machines are needed for removal 9
    10. 10. 2014 Category III Additions  0334T- Sacroiliac joint stabilization for arthrodesis, percutaneous or minimally invasive(indirect visualization), includes obtaining and applying autograft or allograft when performed, includes image guidance (CT or fluoro) when performed  Several parentheticals that note to use this code for percutaneous arthrodesis  0335T-Extra-osseous subtalar joint implant for talotarsal stabilization 10
    11. 11. CMS Physician Fee for Service Final Rule 2014 Misvalued Codes: Consistent with amendments made by the Affordable Care Act, CMS has been engaged in a vigorous effort over the past several years to identify and review potentially misvalued codes, and make adjustments where appropriate. We are continuing to make strides as the values for around 200 codes were finalized and approximately 200 additional codes had their work relative value units changed on an interim basis for 2014. Included in these are services for hip and knee replacements, mental health services and GI endoscopy services. These rates are open for public comment until January 27, 2014.  Sheets/2013-Fact-Sheets-Items/2013-11-272.html?DLPage=1&DLSort=0&DLSortDir=descending 11
    12. 12. Hip and Knee Arthroplasty 27130, 27447- CMS High Expenditure 27446- Harvard-valued service annual approved charges exceed $10 million Methods have changed causing this to be possibly misvalued 12
    13. 13. Intra-operative Minutes 2005 Current 27130 135 100 27446 105 90 27447 124 100 13
    14. 14. 2014 Final Rule Code Description 2013 2014 27130 Total Hip $1,662.85 $1,581.00 27447 Total Knee $1,774.92 $1,579.89 76942 Ultrasound Guidance $220.46 14 $78.71
    15. 15. 2014 NCCI Policy Manual l?redirect=/nationalcorrectcodinited/ 15
    16. 16. 2014 Chapter 4 Page IV- 6 4. With the exception of the knee joint, arthroscopic debridement should not be reported separately with a surgical arthroscopy procedure when performed on the same joint at the same patient encounter. For knee joint arthroscopic debridement see the following paragraph. 16
    17. 17. 2014 Chapter 4 Page IV-7 6. Arthroscopic synovectomy of the knee may be reported with CPT codes 29875 (limited synovectomy, “separate procedure”) or 29876 (major synovectomy of two or three compartments). A synovectomy to “clean up” a joint on which another more extensive procedure is performed is not separately reportable. CPT code 29875 should never be reported with another arthroscopic knee procedure on the ipsilateral knee. CPT code 29876 may be reported for a medically reasonable and necessary synovectomy with another arthroscopic knee procedure on the ipsilateral knee if the synovectomy is performed in two compartments on which another arthroscopic procedure is not performed. For example, CPT code 29876 should never be reported for a major synovectomy with CPT code 29880 (knee arthroscopy, medial AND lateral meniscectomy) on the ipsilateral knee since knee arthroscopic procedures other than synovectomy are performed in two of the three knee compartments 17
    18. 18. 2014 Chapter 4Page IV- 10 14. If a single cast, strapping, or splint treats multiple closed fractures without manipulation, only one closed fracture treatment without manipulation CPT code may be reported. Additionally, if a single cast, strapping, or splint treats multiple fractures without manipulation in addition to one or more fracture(s) with manipulation, a closed fracture without manipulation CPT code should not be reported separately. These policies also apply to the closed treatment of multiple fractures not requiring application of a cast, strapping, or splint. If a cast, strapping, or splint applied after an open or percutaneous treatment of a fracture also treats a closed fracture without manipulation, a closed fracture without manipulation CPT code should not be reported separately. 18
    19. 19. CMS Allows ’97 Extended HPI with ’95 Guidelines September 27th, 2013 Effective Sept. 10, the Centers for Medicare & Medicaid Services (CMS) has revised its Evaluation and Management (E/M) Documentation Guidelines (DG), to allow physicians to use the 1997 DG for an extended history of present illness (HPI) with the other elements of the 1995 DG to document an E/M service. As a result, “the status of three or more chronic conditions” qualifies as an Extended HPI for either set of DGs. The revised guideline is presented as a Question and Answer on the CMS website: 19
    20. 20. 20
    21. 21. Who’s Looking  OIG  CMS-CERT, RAC  Cigna  Humana  Workers Compensation 21
    22. 22. NGS Prepay Audits Current procedural terminology (CPT) codes 99205 and 99215 are in the top 15 codes identified for improper payment rates. If one of your claims is selected for review, you will receive an Additional Documentation Request (ADR) letter. You will have 30 days from the date of the ADR to submit the requested documentation  Part B New Article October 1, 2013 22
    23. 23. New Patient Visits 2011 Orthopaedics 1600000 1400000 1200000 1000000 800000 600000 400000 200000 0 1 2 3 23 4 5
    24. 24. Established Patient Visits 2011 Orthopaedics 6000000 5000000 4000000 3000000 2000000 1000000 0 1 2 3 24 4 5
    25. 25. Purpose of Auditing  Bills are accurately coded and accurately reflect the services provided (as documented in the medical records);  Documentation is being completed correctly;  Services or items provided are reasonable and necessary; and  Any incentives for unnecessary services exist. 25
    26. 26. What to Audit  How many records reviewed per provider?  Medicare or All patients  Prospective not Retrospective 26
    27. 27. Reporting Results  Document findings and keep as permanent records  Medical Records  Summary  Information shared with Provider(s)  Spreadsheet 27
    28. 28. After the Audit  Create protocol  Determine training means  Mandate Training 28
    29. 29. Provider Training  In Person (one-on-one)  Webinar/Module  Newsletter/Worksheet 29
    30. 30. Audit Summary 30
    31. 31. Questions 31
    32. 32. 4 Critical Functions of Your Revenue Cycle that Cannot be Ignored
    33. 33. Customer Service & Satisfaction  Customer service  Patient focused effort  Managing Patient expectations and complaints 33
    34. 34. Front End Strategy  Time of Service Collections  Pre-Cert and Authorizations  Pre-Verification  Scheduling  Patient phone call management  Inbound and outbound 34
    35. 35. Optimal Coding  ICD-9 (10) and CPT selection  Documentation  Appeals  Measuring  Audits 35
    36. 36. Education & Training  Certified Coders  One on One Relationship with physician  Open communication  Physician training  ICD-10 36
    37. 37. Charge Capture & Reconciliation  System of accountability  Every service rendered accounted for and billed  Reconciliation  Frequent reconciliation with multiple check points through out your revenue cycle  Missing Encounter report  Including DME  Inventory management  Ensure everything is billed and accounted for  Cost of goods analysis  Strategic Audits 37
    38. 38. Developing a complete Accounts Receivable Strategy  Thorough understanding of your payors  Know Your Contracts  Credentialing and revalidation  Certification and Pre-Authorization Requirements  Timelines relative to submission and appeals  Contract rates and payment adherence  Reimbursement Tracking  Fee schedule changes  Are your rates competitive with the prevalence of transparency in cost 38
    39. 39. Developing a complete Accounts Receivable Strategy  Managing Insurance Denials  Consistent methods, efficient protocols and resolution  Denial Trending  What are you doing with that information ?  Identify systemic issues  Rectify and route to appropriate personnel 39
    40. 40. Establish your A/R Assembly Line  Detailed Management of the A/R  CPI (Critical Performance Indicators)  Reporting and Trending  By Payor  By Physician  By Service Type  Pay attention to the details in the Reports  Understanding the details behind the reports will mean increased collections and lowered D/O  Payor claim habits  Set up protocols  Control over processes and measure to the details 40
    41. 41. Collecting from the Patient  Patient Balances  Toughest position in your Rev Cycle  Right people in the right job  Follow a practice policy  Do you see patients w/ outstanding balances ?  Speed and efficient techniques  Staff training and motivation  Do not ignore small balances 41
    42. 42. Create a Successful & Repeatable Process Measure Manage Modify And Repeat 42
    43. 43. Questions 43
    44. 44. ICD-10 Readiness Actionable steps to get your practice ready for the October 2014 transition
    45. 45. ICD-10 Facts to Consider  There are two code sets for ICD-10  ICD-10-CM- Fee for service code set  ICD-10-PCS- Facility code sets  Transaction code sets were officially approved in HIPAA Act of 1996  CPT,ICD-9, HCPCS  Workers Compensation, auto, and personal liability insurance are exempt from HIPAA 45
    46. 46. How To Prepare  Impact Analysis  Education  Costs  Preparedness  Revenue 46
    47. 47. Impact Analysis  Choose representative from each area of the practice  Analysis is performed  Readiness survey is given  ICD-10-CM Committee should analyze all of the needs  Identify and mitigate risks  Create the Analysis based on results  Classify issues by impact 47
    48. 48. Impact Analysis Impact Definition Affects fundamental functions Objectives will be accomplished Can cause some negative affects Very High High Moderate Low Can cause minor affects 48
    49. 49. Impact Analysis  Create document to report each business area that will need to be adjusted by:  Policy  Process  System  This will allow for better assignment of work based on impact 49
    50. 50. Education  Who needs education  Everyone  Administrative  Front Office  Clinical  Coders  Other Back Office Staff  Physicians and NPP  Recommendations for Coder Training range from 16-40 hours with a refresher in Anatomy and Physiology 50
    51. 51. Impact Analysis - Education Impact Definition Very High Coding Staff Training High Physician Training Moderate Clinical Staff Training Low All Others 51
    52. 52. What is this missing? PRESENT HISTORY: Ms. returns to see me now one year from her operation at her midfoot. She has been doing reasonably well in the sense that she does feel that she does have improvement of her pain relief as she had been prior to her surgical reconstruction. I wanted to make this clear today with her and I asked her if she is better off than she was prior to surgery and she says yes. PHYSICAL EXAMINATION: Examination shows that her surgical wounds look good. Her foot alignment is neutral. She still does have complete restoration of her medial column or arch. Her tenderness is present dorsally about the first metatarsophalangeal joint. She has equal tenderness present plantarward, which is at the site of the FHL tendon. Now this is at the level of the proximal phalanx. She however does have good push-off power against resistance. She has no evidence of hallux flexus deformity and no evidence of a claw toe deformity present there. IMPRESSION:  Healed first metatarsocuneiform joint arthrodesis with osteotomy, modified McBride bunionectomy, Akin osteotomy, second metatarsocuneiform joint arthrodesis, ostectomy medial cuneiform and navicular for bossing with removal of loose body and anterior tibial tendon repair.  Two hallux rigidus, osteoarthritis, first metatarsophalangeal joint with flexor hallucis longus tenosynovitis plantar grade toe.  Residual inflammation midfoot 52
    53. 53. Site and Laterality  Most codes related to musculoskeletal conditions have site and laterality designations.  Site represents  Bone  Joint  Muscle  Multiple sites code  If there is no multiple site code, multiple codes should be used 53
    54. 54. Acute Vs. Chronic or Recurrent  Many musculoskeletal conditions result of previous injury or trauma to a site, or are recurrent conditions.  Chapter 13 has  Chronic or recurrent bone, joint, or muscle conditions  Conditions that are the result of healed injury  If it is difficult to determine acute or chronic, query the provider  Acute injury coding is in Chapter 19 54
    55. 55. Fractures  Displaced or non-displaced  Fracture type (2,3,or 4 part)  What kind (greenstick, communited, transverse)  Routine healing, delayed healing, malunion, nonunion  Open or closed  Open breaks down further (Type I, II,IIIA,IIIB,IIIC)  Salter-Harris Fractures 55
    56. 56. Sneak Peak at ICD-10-CM 824.1 Fracture of ankle; medial malleolus, open S82.56XC Nondisplaced fracture of medial malleolus of unspecified tibia, initial encounter for open fracture type IIIA, IIIB, or IIIC S82.56XB Nondisplaced fracture of medial malleolus of unspecified tibia, initial encounter for open fracture type I or II S82.53XC Displaced fracture of medial malleolus of unspecified tibia, initial encounter for open fracture type IIIA, IIIB, or IIIC S82.53XB Displaced fracture of medial malleolus of unspecified tibia, initial encounter for open fracture type I or II 56
    57. 57. Fracture Comparison POSTOPERATIVE Left open femoral shaft fracture INDICATIONS FOR PROCEDURE:  The patient is a 27-year-old female involved in a high-speed motor vehicle accident, sustained a grade 2 open left distal femoral shaft fracture with comminution. Femoral neck was visualized and seen to be okay.  X-ray showed excellent reduction.  ICD-9 821.11  ICD-10 S72.355B 57
    58. 58. Preparedness  No grace period  Coding based on date of service  Premature coding  Testing 58
    59. 59. Impact Analysis - Preparedness Impact Definition Very High Practice Management System High System Testing Moderate Pre-Coding Low EHR 59
    60. 60. Costs  Training  Practice Management Upgrades  Temporary staffing or over time 60
    61. 61. Impact Analysis- Costs Impact Definition Very High Training High Software Programs Moderate Staffing Low Encounters/Superbills 61
    62. 62. Office Superbill/Encounter  Paper Superbill/Encounter may be impossible  Providers document in writing to be coded  Electronic Encounter  EMR capabilities 62
    63. 63. Revenue  Reduced revenue:  4th Quarter of 2014 & 1st Quarter 2015  Loss in Productivity  Delays in reimbursement  Increase in claims denials 63
    64. 64. Impact Analysis- Revenue Impact Very High Definition Insurance Carrier /Delays in Claims Processing High Staffing Moderate Slow down in office flow Low Holiday Season 64
    65. 65. Questions 65
    66. 66. For follow up questions feel free to contact us: Andy Salmen, Business Development HIS P: (847) 720-7007 E: 350 S. Northwest Highway, Suite 200 Park Ridge, Illinois 60068 (855) RING-HIS 66