Some HCPCS codes are not payable by Medicare because they represent transportation and transportation related services. The Centers for Medicare and Medicaid Services (CMS) released a transmittal that instructs contractors to modify their claims processing systems to allow these codes to be reported.

Certain codes have an I indicator, meaning that they are “Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services.” Other codes have an X indicator, which is defined as “Statutory Exclusion.” CMS will now allow these codes into the Medicare claims processing system. This will give providers the option to submit “no-pay claims” to Medicare, so they may obtain a Medicare denial to submit to the beneficiary’s secondary insurer.

The full transmittal can be viewed in .pdf form at: http://www.cms.gov/MLNMattersArticles/Downloads/MM7489.pdf

The Department of Health and Human Services (HHS) adopted additional Guidelines for Women’s Preventative Services, under the Patient Protection and Affordable Care Act (PPACA). The new items that will be covered include well-woman visits, support for breastfeeding equipment, contraception, and domestic violence screening. This new regulation will require that these services be covered without any cost sharing in all new health plans starting in August 2012.

These new guidelines were taken upon the recommendation of Institute of Medicine (IOM). Additional screenings that will be covered without cost sharing include Gestational diabetes screening, HPV DNA testing, STI counseling and HIV screening and counseling.

The full guidelines can be viewed at:

http://www.hrsa.gov/womensguidelines/

An interim final rule was also proposed to provide exemptions for religious organizations that wish to buy or sponsor group health insurance plans that do not cover contraception, if it is inconsistent with their tenets. HHS invites public comment on this proposed rule. The rule can be viewed in .pdf form at:

http://www.ofr.gov/OFRUpload/OFRData/2011-19684_PI.pdf

The Centers for Medicare and Medicaid Services (CMS) have proposed the 2012 rates for dialysis treatment facilities that see End Stage Renal Disease patients with Medicare. The rule will affect services provided on or after January 1, 2012

CMS estimates that payments to these facilities will increase by 1.8 percent, or roughly $8.3 billion in 2012. In addition to the new payment structure, the Quality Incentive Program (QIP) is also being updated.

CMS is removing the quality measure requiring keeping hemoglobin levels above 10 g/dL based on new findings by the Food and Drug Administration (FDA). New medical evidence questions the safety of a common treatment of anemia, administration of erythropoiesis-stimulating agents (ESAs). CMS is currently looking for new ways to incentivize anemia treatment for dialysis patients, without compromising the patients’ safety.

For Payment Year 2014, CMS is proposing adding the following measures:

• Dialysis adequacy, as measured through the Kt/V method, which is widely recognized as a more accurate measure of whether dialysis cleanses blood effectively
• Anemia management, as measured by the rate of patients with a hemoglobin level greater than 12 grams per deciliter;
• Percent of patients receiving treatment through an arteriovenous fistula – a type of vascular access used to connect patients’ bloodstreams to dialysis equipment for cleansing;
• Rates of infection of the vascular access sites;
• Ratios of hospitalization rates among dialysis clinic patients;
• Whether the facility reports certain dialysis-related infections to the Centers for Disease Control & Prevention;
• Whether the facility administers a patient experience of care survey; and
• Whether the facility monitors phosphorus and calcium levels on a monthly basis.

More information can be found at: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1

The Centers for Medicare and Medicaid Services (CMS) has released a proposed rule to determine the 2012 payment rates for home health care. The rule was on display July 5^th on the Federal Register.

The new rule proposes a 3.35 percent decrease in Medicare payments to home health agencies in 2012. CMS estimates this to amount to a net decrease of $640 million in payments compared to 2011.

The proposed rule also removes two hypertension codes from the case-mix system. Home health agencies must submit quality-reporting data, or the home health market basket percentage will be reduced by 2 percentage points.

In a separate rule, CMS defined the conditions of a beneficiary being eligible for home health benefits. The beneficiary “must be under the care of a physician, have an intermittent need for skilled nursing care, or need physical or speech therapy, or continue to need occupational therapy,” according to CMS’ website.

A new program mandated by the Affordable Care Act (ACA) will provide up to $500 million to “Hospital Engagement Contractors.” These federal contractors will compete to receive the funds from the Department of Health and Human Services (HHS).

“Hospital Engagement Contractors” will take steps to reduce patient harm in hospitals and readmissions.  They will be responsible for designing intensive programs to teach and support hospitals in making care safer, training hospitals and care providers, providing technical assistance and establishing and implementing a system to track hospital progress in meeting quality improvement goals.

To apply for an opportunity to get one of these contracts, visit:

https://owa.hhs.gov/owa/redir.aspx?C=f698fd1bdf864392ab1770d8b5d21de6&URL=http%3a%2f%2fwww.fbo.gov

Christopher Myers

The Office of the Inspector General (OIG) conducted a study sampling 780 Medicare patients who had at least one hospital stay in October 2008. The study looked for serious events on the National Quality Forum’s (NQF’s) “adverse event” (or “never events”) list, the Medicare Hospital Acquired Conditions (HAC) list, and the four most severe categories of the National Coordinating Council for Medication Errors Reporting and Prevention (NCC MERP) Index for Categorizing Errors. The study then used a team of physicians to analyze which events were reasonably preventable.

The study found that 13.5 percent of patients experienced one or more of these adverse events during their hospital stay. Only 0.6 percent of those sampled experienced an event on the NQF list, and only 1.0 percent experienced an HAC. Another 13.1 percent experienced one of the four most serious events on the NCC MERP Index, with a 1.3 percent overlap (beneficiaries who experience adverse events in more than one category). An additional 13.5 percent of patients experienced temporary adverse events.

Of these adverse events, reviewing physicians determined that 44 percent were clearly or likely preventable. They determined that events related to surgery and other procedures were less likely to be preventable, while medication, patient care and infections were more likely to be preventable (only 17 percent of surgery events were determined to be preventable).

Counting only preventable events, the national incidence rate of adverse events was estimated to be at 7.4 percent. As a result, the OIG has made several recommendations to the Department of Health and Human Services (HHS). Because NQF Serious Reportable Events and Medicare HACs only represented a small portion of adverse events, OIG recommended that HHS expand its definitions to include a wider array of events that cause patients harm.

The full report is available at:
http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf

Using both Medicare and private sector claims data, the Centers for Medicare and Medicaid Services (CMS) have proposed a system for evaluating the cost of practices versus performance. This new rule is authorized under the Patient Protection and Affordable Care Act (PPACA) and intends to curb rising health care costs by providing greater transparency to the market.

The program would appoint “qualified entities” which would have the authority to monitor claims data while being responsible for possibly sensitive patient health information. The “qualified entities” would process claims data from both Medicare and private insurance providers in order to show what practices are charging (on average) for certain procedures. Using this data, the “qualified entities” would create reports comparing different prices to different outcomes for each provider, which would be made available to the public.

The public reports would not include any individual patient data, only averages and aggregate data. “Qualified entities” would have to apply for their status and be approved by CMS. CMS would be in charge of policing and monitoring these entities, and have the authority to impose sanctions and banish entities from the program. This intends to prevent breaches of sensitive information and other noncompliance.

The full, proposed rule is published in the June 8, 2011 issue of the Federal Register. CMS invites comments on the rule.

Tucked under the Syndrome section of the ICD-9 Alphabetical Index, you can find Antiphospholipid Antibody, code 289.81. Flipping over to the Diseases of the Blood and Blood—Forming Organs section, there it is: “Primary hypercoagulable state.” But it’s more than just a number; it is a disease that is often misunderstood.

Antiphospholipid Antibody Syndrome (APS) is an autoimmune disease where the body recognizes certain normal components of blood and/or cell membranes as foreign substances and produces antibodies against them. This results in increased blood clotting and other health issues, such as premature stroke, repeated miscarriages, phlebitis, venous thrombosis and pulmonary thromboembolism.

People often confuse APS with acquired immune deficiency syndrome (AIDS) or a form of cancer, according to the APS Foundation of America. APS is not contagious, and no specific gene has been tied to the disease thus far. Women are more likely to be affected than men. Many patients with APS also have Lupus.

According to the 2006 International consensus statement on an update of the classification criteria for definite APS, “identification of APS requires the presence of vascular thrombosis and/or pregnancy morbidity, along with at least 1 of the following antiphospholipid antibodies: lupus anticoagulant (LA) antibodies, cardiolipin IgG and IgM antibodies, and β2-glycoprotein I (β2-GPI) IgG and IgM antibodies.” There are many laboratory tests used to identify these antibodies, so be sure to check documentation for these tests when coding a new diagnosis of APS.

More information, support and references are available on the APS Foundation of America’s website: www.apsfa.org/

CMS officials say, providers no longer have to personally attest for meaningful use of their electronic health records (EHR) systems, however only one register or attest per provider at one time.

This means practice managers can now register or attest on behalf of the physicians, but only after the provider links their national provider identifier (NPI) to the Identity and Access (I&A) Management System account that the practice manager sets up for themselves.  As for practice staff and consultants, they can register/attest by proxy for providers in the same way.

Each provider can appoint up to four authorized users to attest on their behalf.  The individual who registers for EHR attestation does not have to be the same person who completes the process.

Currently, there is still no way to handle multiple providers at one time.  Having a non-provider use CMS’s website for EHR Registration and Attestation System on behalf of a doc can certainly ease the burden for many.  However, this poses a different set of problems for large practices.  Each provider has to create his or her own I&A account and associate their NPI with the proxy’s user account as explicit consent to act on his or her behalf.  So, if we take a 200-provider practice, each physician must follow this process.   CMS states, “there is no method for batch registrations or attestation for multiple EPs (eligible professionals) at the same time; the incentive payments are based on individual EPs instead of practices, there must be in individual registration and attestation for each EP”.

Don’t give up hope yet.  Though nothing has been set just yet, CMS is actively looking into a solution that can address the issue of large practices having to attest for providers one-at-a-time.

A drastic deviation from the pay-per-procedure model, the Hospital Value-Based Purchasing program will reward hospitals for quality care instead of just quantity. The program’s launch was announced by the Department of Health and Human Services (HHS) on April 29, 2011.

The program applies mainly to acute care services. Some of the measures that will determine payments include:

• Ensure that patients who may have had a heart attack receive care within 90 minutes
• Provide care within a 24-hour window to surgery patients to prevent blood clots
• Communicate discharge instructions to heart failure patients
• Ensure hospital facilities are clean and well maintained

This program seeks to reduce mortality and generally improve the quality of care that patients receive. National bodies of experts, including the National Quality Forum, have endorsed the measures for FY 2013.

A full list of the quality measures can be found at:

http://www.healthcare.gov/news/factsheets/valuebasedpurchasing04292011b.html