Co Management Made Easy
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Co Management Made Easy

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By. Carolina Clavijo

By. Carolina Clavijo

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Co Management Made Easy Presentation Transcript

  • 1. Comanagement Made Easy By: J. Alberto Martinez, MD Carolina Clavijo, Practice Manager
  • 2. • Regulatory concerns • CMS instructions • Documenting comanagement in the record • Billing guidelines • Is it appropriate to co‐manage deluxe IOLs or refr active surgery? Comanagement Practice management angle
  • 3. • Value of post‐op care is ~20% of global package – Not all payers agree • Surgeon uses 54 modifier (surgery) • Surgeon does part or no posts‐op care • One or both doctors use 55 modifier • Some payers carve out 56 modifier for pre‐op care • Value of ‐55 postop care is apportioned by DOS Comanagement
  • 4. Comanagement CMS Instructions • Requires transfer agreement • Written documentation • Proper use of modifiers (54, 55) • Segregation of o post-op care based on responsible parties • Receiving doctor must see the patient • When no agreement exists, use E/M codes • Group members are ineligible
  • 5. Documentation Required • Written transfer, patient consent and disclosure • Transfer date • Available to Medicare upon request
  • 6. Postoperative Care Request Form • Patient’s consent to co‐manage -Usually written request, signed • Clinically appropriate • Competency • Provision for complications • Financial statements • Signatures (patient, both doctors)
  • 7. • On May 1 the patient underwent cataract surgery. The surgeon saw the patient on post op day 1 and 10. • Effective May 12 (11th post op day), the surgeon released th e patient to your care for the remainder of the post‐op care. • The patient is not scheduled to see you until May 31 (30 days post-op) • How many days of o post‐op care can you bill to Medicare? a) 90 days b) 80 days c) 60 days d) 0 days
  • 8. • How many day of postop care can you bill to Medicare? b) 80 days
  • 9. Cataract Comanagement – ONE eye M.D. CARE O.D. FOLLOW‐UP 0 10 90 May 1 May 12 July 30 SURGEON'S CLAIM OPTOMETRIST'S CLAIM 5/1 66984‐54 5/2 ‐ 5/11 66984‐55 5/12 ‐ 7/30 66984‐55 Refer to surgery DOS Reimbursement • Postop care is ~20% of global package • Some Claims require“# units”(days) of PO to appear on claims • Value of postop care is apportioned: – 10/90ths to Surgeon – 80/90ths to Optometrist
  • 10. Claim Format “Both the bill for the surgical care only and the bill for the postoperative care only, will contain the same date of service and the same surgical procedure code, with the services distin guished by the use of the appropriate modifier.” • Source: MCPM, Ch. 12, 40.2.A.3
  • 11. Claim Example – Surgeon
  • 12. Claim Example – Surgeon
  • 13. Claim Example – Optometrist
  • 14. Comanagement Bilateral Surgery 1/05/2012 – Cataract extraction OD 1/06/2012 –1 day post op visit OD by surgeon 1/12/2012 – 1 week post op visit by surgeon 1/19/2012 – Cataract extraction OS 1/20/2012 – 1 day post -op OS / 15 day post-op by surgeon 1/21/2012 – Patient released to Dr. Optometry for both eyes How many days of post‐op care does the optometrist bill for? a) 90 days for both eyes b) 80 days OD / 89 days OS c) 75 days OD / 89 days OS d) Too confusing to bill
  • 15. Comanagement Bilateral Surgery 1/05/2012 – Cataract extraction OD 1/06/2012 –1 day post op visit OD by surgeon 1/12/2012 – 1 week post op visit by surgeon 1/19/2012 – Cataract extraction OS 1/20/2012 – 1 day post op OS / 15 day post op OD by surgeon 1/21/2012 – Patient released to Dr. Optometry for both eyes How many days of post‐op care does the optometrist bill for? • c) 75 days OD / 89 days OS
  • 16. Cataract Co‐Management – TWO eyes Reimbursement • Postop care is ~20% of global package • Value of postop care is apportioned: • 15/90ths to Surgeon RT 75/90ths to Optometrist • 1/90ths to Surgeon LT 89/90ths to Optometrist
  • 17. Comanagement Premium IOLs • P-IOLs – Presbyopia‐correcting IOLs – Astigmatism‐correcting IOLs • Potential Risks – Balance billing in violation of assignment – Violations of state anti‐kickback laws – Fee splitting – Medical risks, mismanagement
  • 18. Do • Assign roles and responsibilities • Set discrete fees for additional services rendered that are not part of standard cataract surgery • Collect separate payment for non covered refractive services performed • Obtain two financial waivers for non‐covered services Do not • Extrapolate Medicare’s 80/20 rule to determine value of non covered services • Comingle funds • Fail to provide patient with clear description of co‐man agement arrangement
  • 19. Extended Care Package Typical Non‐covered professional services (excluded) • Corneal topography associated with refractive surgery • Contact lens trial fitting to assess refractive error • Wave front aberration testing to assess refractive error • Corneal pachymetry associated with refractive surgery • Routine eye care, wellness care, preventive care, extended post operative period • Refractive keratoplasty • LASIK enhancement • IOL exchange
  • 20. Financial Separation • Separate charges • Separate checks • Separate credit card charge slip • Separate money orders • Separate promissory notes
  • 21. Comanagement Example – Financial Separation For illustration purposes only
  • 22. Patient Consent • Patient understands logistics • Disclose financial arrangements • Competency • Authorization to share information • Provision for complications • Signatures (patient, both doctors)
  • 23. OIG Advisory Opinion: Comanagement • OIG publishes opinion on co‐management involving non‐co vered services associated with premium IOLs • Tightly worded favorable opinion • Based on the facts …for an advisory opinion … , we conclude that the Proposed Arrangement would not generate prohibited remuneration under the anti‐kickback statute. Accordingly, the OIG would not impose administrative sanctions on… under sections … of the Act (as those … relate to the commission of acts described in section … of the Act) in connection with the Proposed Arrangement. This opinion is limited to the Proposed Arrangement and, therefore, we express no opinion about any ancillary agreements or arrangements disclosed or referenced in your request for an advisory opinion or supplemental submissions • Source: OIG Advisory Opinion No. 11-14
  • 24. Comanagement P-IOLs Protocol • Surgeon decides suitability for surgery • Physicians and patient discuss post‐op care options • Co‐management depends on what is best for patient • Justify additional charge(s) • Financial separation
  • 25. Interested in comanagement? Call us (301) 896-0890 ext 124 or e-mail Carolina@visionaryeyedoctors.com