Statistical Uncertainty in the Medicare Shared Savings Program

Title: Statistical Uncertainty in the Medicare Shared Savings Program

First Author: DeLia, Derek

Date of Article: 2012 Q4

Full Title: Statistical Uncertainty in the Medicare Shared Savings Program

Other Authors: Donald Hoover,  Joel C. Cantor

Volume: 2012

Issue: Q4

Summary: According to analysis reported in “Statistical Uncertainty in the Medicare Shared Savings Program” published in Volume 2, Issue 4 of the Medicare & Medicaid Research Review, the role of random fluctuations in year-to-year healthcare spending may play a larger role in savings measurement than previously anticipated. Although CMS is fairly well protected from the chance that an Accountable Care Organization (ACO) would be rewarded inappropriately for savings that did not truly occur, ACOs are much less protected from the analogous chance that they are inappropriately denied rewards for savings that do occur. Smaller ACOs are especially vulnerable to the chance of being inappropriately denied credit for achieved savings. The article concludes with a discussion of strategies that can be used to anticipate and minimize the role of chance variation in ACO savings measurement.

Keywords: Medicare, Econometrics, Health Care Organizations and Systems, Health Economics, Health Policy / Politics / Law / Regulation, Incentives in Health Care, Payment Systems: FFS / Capitation / RBRVS / DRGs / Risk Adjusted Payments etc., Health Care Costs, Health Care Financing / Insurance / Premiums

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Denise Buenning from CMS Answers the Industry's Top Questions about the Version 5010 Upgrade

Upgrading to Version 5010 involves significant planning and preparation. The Version 5010/4010A electronic standards upgrade deadline was January 1, 2012. However, CMS enacted an enforcement discretion period through June 30, 2012 for all HIPAA-covered entities. It you haven't upgraded to Version 5010, it is important to begin testing now.

Denise Buenning, MsM, Acting Deputy Director, Office of E-health Standards & Services (OESS) recently took time to answer some of the industry's top questions on the Version 5010 upgrade.

1. Is the industry up to date with the Version 5010 upgrade and taking steps to prepare for the ICD-10 transition? Yes, we are hearing that the industry is progressing with Version 5010 implementation. We also continue to see from the Medicare Fee-For-service (FFS) group consistent increases across the board for 5010 transaction volumes and number of 5010 submitters.
   
   
   We are also hearing that the industry is continuing to take steps to prepare for ICD-10. ICD-10 is a major undertaking for providers, payers, and vendors. It will drive business and systems changes throughout the health care industry, from large national health plans to smaller provider offices, laboratories, hospitals, and more. The updates will go much more smoothly for organizations that plan ahead and prepare now. A successful upgrade to Version 5010 now and transition to ICD-10 later will be vital to transforming our nation's health care system.
   
   
2. What steps should I take if I am behind in the upgrade to Version 5010? There are a number of things that HIPAA-covered entities should do now. Communication among plans, providers, clearinghouses, and vendors, as well as other trading partners, is critical. Below outlines three steps providers can take now: 
   
   
   Reach out to clearinghouses for assistance and/or take advantage of any free or low cost software that may be available from payers.
   
   
   Check with payers now to see what plans they will have in place to handle incoming claims, and what interim alternatives are available.
   
   
   Consider contacting financial institutions to establish lines of credit to get through any possible temporary interruptions in claims reimbursement as a result of not being Version 5010 compliant.
   
   
   CMS has developed a fact sheet for health care providers, which discusses the risk mitigation steps in more detail.
   
   
3. How is CMS helping the industry prepare? The Workgroup for Electronic Data Interchange (WEDI) and CMS are holding a webinar on ASCX12 5010 implementation and problem solving on May 23, 2012 from 1:00-2:30 pm ET. Registration is free. These online presentations are designed to gather feedback, track challenges and provide guidance to correcting ASC X12 5010 implementation-related issues.
   
   
   WEDI and CMS previously held a webinar on ASCX12 5010 implementation, and  a replay of the webinar with the slides presented is located online.
   
   
   Additionally, the CMS website has official resources to help the industry prepare for Version 5010 and ICD-10. CMS will continue to add new tools and information to the site throughout the course of the transition.
   
   
   Sign up for ICD-10 Email Updates and follow @CMSgov on Twitter for the latest news and resources.

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Note from the Instructor: CMS Issues Recurring Update Notification Highlighting Important CY2013 OPPS Changes

On Friday, CMS released its annual recurring update notification reflecting the claims processing-related changes implemented in the CY 2013 OPPS final rule. Hospitals and CAHs are encouraged to review the transmittal more thoroughly to assure that they are prepared to implement these changes for services provided on and after January 1, 2013.

Hospitals and CAHs are also encouraged to be on the lookout for a similar transmittal (which has not yet been released) designed to reflect benefit-related changes included in the CY 2013 OPPS final rule. CMS also noted that the January 2013 integrated outpatient code editor (I/OCE) and OPPS pricer will reflect the healthcare common procedure coding system (HCPCS), ambulatory payment classification (APC), HCPCS modifier, and revenue code additions, changes, and deletions identified in this transmittal.

Highlights

CMS identified the following key changes for CY 2013:

• Changes to device, radiolabeled product and procedure edits for January 2013. The most current list of device edits can be found at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ .Failure to pass these edits will result in the claim being returned to the provider.
• Intracoronary stent placement procedure codes. The deletion of two CPT codes (92980 and 92981) that describe the placement of non-drug-eluting intracoronary stents and two existing HCPCS G-codes that describe the placement of drug-eluting intracoronary stents, along with the creation of nine new HCPCS C-codes in order to maintain the existing OPPS policy of differentiating payment for intracoronary stent placement procedures involving non-drug?eluting and drug-eluting stents for CY 2013.
• Outpatient payment for composite APC 8000. Modification of the intracardiac catheter ablation codes that may qualify a cardiac electrophysiologic evaluation and ablation service for composite payment under composite APC 8000 for services provided on and after 1/1/13. CMS’ action follows the AMA CPT editorial panel’s deletion of CPT codes 93651 and 93652 (intracardiac catheter ablation codes), effective 1/1/2013 and creation of new CPT codes 93653, 93654, and 93656, effective 1/1/2013.
• New 'sometimes therapy' services that may be paid as non-therapy services for hospital outpatients, Effective January 1, 2013 the addition of two HCPCS codes (G0456 and G0457) to the list of PT/SLP/OT “sometimes therapy” services that may be paid under certain circumstances to a facility under the OPPS. The limited set of sometimes therapy services are paid under the OPPS when they are not furnished as therapy, that is, when they are not furnished under a certified therapy plan of care.
• Coding changes for partial hospitalization psychiatric (PHP) services. Following the AMA’s CPT editorial panel deletion of 28 psychiatric CPT codes, including those related to PHP services, and replacing them with 12 new CPT codes (effective for services provided on and after 1/1/13),CMS’ implementation of corresponding changes to the PHP code set that is used for billing and documenting PHP services.
• Certain changes to drugs, biologicals, and radiopharmaceuticals:
  • Effective for services provided on and after 1/1/13, the creation of several new HCPCS codes to identify those drugs, etc. for which no specific code had previously been created. The new codes are set out in Table 1 of Attachment A to the transmittal;
  • Effective for services provided on and after 1/1/13, changes to the HCPCS/CPT or long descriptor, or both, of certain drugs, etc. These changes are set out in Table 2 of Attachment A to the transmittal. Hospitals are once again admonished to pay close attention to accurate billing for units of service consistent with the dosages contained in the long descriptors of the active CY 2013 HCPCS and CPT codes;
  • For CY 2013, payment for nonpass-through drugs, biologicals and therapeutic radiopharmaceuticals is made at a single rate of ASP + 6%, which provides payment for both the acquisition and pharmacy overhead costs associated with the drug, biological or therapeutic radiopharmaceutical. In CY 2013, a single payment of ASP + 6% will also be made (providing payment for both associated acquisition and pharmacy overhead costs for these pass-through drugs, biologicals and radiopharmaceuticals);
  • Any changes in the payment rates effective for services provided on and after 1/1/13, based on sales price submissions from the third quarter of CY 2012, will be incorporated into the January 2013 release of the OPPS Pricer.
• CY 2013 OPPS payment adjustment for certain cancer hospitals. CMS’ updating of the “target payment to cost ratio (PCR)” for CY 2013, for purposes of the cancer hospital payment adjustment, to 0.91 for outpatient services furnished on or after January 1, 2013 through December 31, 2013. Under the Affordable Care Act (ACA),beginning in CY 2012, CMS is to provide additional payments to each of the 11 cancer hospitals so that each cancer hospital’s final payment to cost ratio (PCR) for services provided in a given calendar year is equal to the weighted average PCR (which CMS refers to as the “target PCR”) for other hospitals paid under the OPPS.
• Changes to OPPS pricer logic:
  • Rural sole community hospitals (SCHs) and essential access community hospitals (EACHs) will continue to receive a 7.1% payment increase for most services (excluding drugs, biologicals, items and services paid at charges reduced to cost, and items paid under the pass-through payment policy) in CY 2013;
  • New OPPS payment rates and copayment amounts will be effective January 1, 2013. All copayment amounts will be limited to a maximum of 40% of the APC payment rate. Copayment amounts for each individual service cannot exceed the CY 2013 inpatient deductible;
  • For hospital outlier payments under OPPS, there will be no change in the multiple threshold of 1.75, which will continue to apply for 2013;
  • In addition, for hospital outlier payments under the OPPS, there will be no change in the fixed-dollar threshold of $2,025, which will continue to apply for CY 2013. The estimated cost of a service must be greater than the APC payment amount plus $2,025 in order to qualify for outlier payments;
  • For outliers for community mental health centers (bill type 76x), there will be no change in the multiple threshold of 3.4, which will continue to apply for 2013;
  • Effective January 1, 2013, 3 devices are eligible for pass-through payment (pass-through payment generally equals charges reduced to cost, sometimes subject to an offset amount) in the OPPS Pricer logic. Category C1830 (Powered bone marrow biopsy needle), has an offset amount of $0, because CMS is not able to identify portions of the APC payment amounts for the related procedure that were associated with the cost of a predecessor device. Category C1840 (Lens, intraocular (implantable)) and C1886 (Catheter, extravascular tissue ablation, any modality (insertable)) have offset amounts included in the Pricer for CY 2013, because CMS was able to identify portions of the APC payment amounts for the related procedures that were associated with the cost of certain predecessor devices. Pass-through offset amounts are adjusted annually;
  • Effective January 1, 2013, there will be one diagnostic radiopharmaceutical receiving pass-through payment in the OPPS Pricer logic. For APCs containing nuclear medicine procedures, Pricer will reduce the amount of the pass-through diagnostic radiopharmaceutical payment by the wage-adjusted offset for the APC with the highest offset amount when the radiopharmaceutical with pass-through appears on a claim with a nuclear procedure. The offset will cease to apply when the diagnostic radiopharmaceutical expires from pass-through status. The offset amounts for diagnostic radiopharmaceuticals are the “policy-packaged” portions of the CY 2013 APC payments for nuclear medicine procedures and may be found on the CMS website;
  • Effective January 1, 2013, the OPPS Pricer will continue to apply a reduced update ratio of 0.980 to the payment and copayment for hospitals that fail to meet their hospital outpatient quality data reporting requirements or that fails to meet CMS validation edits. The reduced payment amount will be used to calculate outlier payments, if any;
  • Pricer will continue to update the payment rates for drugs, biologicals, therapeutic radiopharmaceuticals, and diagnostic radiopharmaceuticals with pass-through status when those payment rates are based on ASP, on a quarterly basis.

Again, hospitals and CAHs are encouraged to review this transmittal closely to assure that they are prepared to comply with these changes effective for applicable services provided on and after 1/1/13.

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Benefits of Acquiring a Specialization during the Holidays!

Medical billing and coding for a specialist though similar to general billing and coding, involves usage of codes used only for a particular medical specialty - with the holiday season offering comparatively free time to medical billers and coders could be the best time to acquire a specialization of your choice to further your career.

A medical coder may question that generally more knowledge is more advantageous than having more of limited knowledge, so why acquire certification in a specialized field? --- Acquiring a certification & specialization can considerably improve your remuneration which is a must in today’s competitive environment.

These Industry facts further validate the above:

• Medical coders with a  specialization in areas like cancer registry earn better salaries than their counterparts without a specialization
• High-earning groups in the medical billing and coding profession are not only experienced but also possess some sort of specialization 
• There is a huge opportunity for medical coders with certification & a specialty area to earn an additional USD 10,000 per year
• 2012 - The Average Salary of a Medical Coding Specialist is at a comfortable USD 42,000 per year and can easily reach USD 50,000
• Medical billers & coders in entry level jobs typically earn around USD 13 per hour and with specialization and experience can increase to anywhere between USD 30 to USD 40 per hour

Benefits

Along with higher remuneration there are several other benefits to seeking a specialist certification:

Specialist doctors are more likely to hire those with specialized training - as specialized training helps deal with the particular codes used by specialists, ensuring the physician gets optimized service.

Improved job performance – acquiring medical coding certification in your chosen field will help in quick and accurate coding increasing your employer’s revenue in turn making you a valuable employee.

Increased knowledge in your field of expertise – which will improve exposure, help in acquiring required information of the specialized area and how the treatment of your chosen specialty works.

Specialization helps acquire new jobs - medical billing and coding specialization can help expand your work skills and seek opportunities in a new environment with new challenges.

Certain specializations important to the medical field – though all areas are vital, specialization like - cancer doctors, heart specialists, geriatric doctors - makes you a part of an important team that helps those who desperately need medical care.

Specialists help make your job more defined - limited to relatively few specialized procedures helps you focus your attention on a smaller number of codes and learn to manipulate them more precisely.

Assisting your employer to manage the high costs of specialist health care - Specialist doctors have incredibly high overheads, a good specialist biller can help in literally doubling the income of a practice.

These benefits will definitely help further your career, and medical billers and coders can immensely profit by making optimum use of the holiday season being extremely busy throughout the year and commence the necessary steps in acquiring a specialization.

Specializing includes two things: a specialized training program and certification in a specialist field. The American Association of Professional Coders (AAPC) offers specialist certification in nearly 20 areas- to medical billers and coders to choose.

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2013 Pain Management Coding Updates

Learn What Is On The 2013 Coding Horizon For Pain Management.

Your practice won’t receive the reimbursement it deserves if you don't have a complete and thorough understanding of the coding changes in store for 2013. Don’t risk denied payments by being out of the loop on the upcoming CPT’s Pain Management code changes for 2013!

Get your whole staff up to speed in just 60 minutes with all of the new, revised and deleted codes for Pain Management services with this information-packed audio conference.

Pain Management reimbursement expert Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, is here to tell you all you need to know to keep your practice thriving in 2013. In just 60-minutes, she opens your eyes to new reimbursement opportunities -- plus all the new pitfalls you'll have to avoid.

Here is what you'll learn:

• Don’t be caught without the facts -  Find out all the essentials on the CPT coding changes for pain management services coming in 2013.
• Get the scoop on the status of ICD-10?  Is it coming in 2013 or has it been delayed?  Do you know if there are new ICD-9 codes that you need to report for 2013 dates of service?
• Check out potential HCPCS code changes that may effect your pain management office practice in 2013
• Be proactive – What’s on the 2013 OIG Work plan that you should check into before you receive a payer request for records?
• Take a look at the potential PQRI measures for 2013 for pain management.  Are your pain management providers planning to report PQRI in 2013 or will they be subject to the Medicare penalty?
• Are your providers using E-prescribing?  What changes are coming in 2013 to the E-Rx incentive program. 

For More information regarding Pain Management Coding Updates: Click here

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CMS Warns Reviewers to Check EMR Templates

The Centers for Medicare and Medicaid Services released revised instructions for review contractors admonishing them to review all medical record entries signed by physicians, even ones created using the Limited Space Templates from electronic medical records.

According to the guidelines, contractors are to keep in mind that progress notes alone from EMR templates are not acceptable documentation for medical examinations, according to the instructions.

While CMS does not prohibit or endorse templates, the organization discourages use of templates with limited options or check boxes as they made it hard for providers to meet all coding requirements. 

More Articles on Coding, Billing and Collections:
CMS Corrects List of Payable Procedures for Surgery Centers
Future of Bush-Era Tax Cuts Uncertain; Negotiations Reach Critical Stage as Providers Consider Budgets for 2013
Study: Opioids Increase Replication of Cancer Cells

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Implementing a Safe Surgery Checklist to Meet CMS & Regulatory Standards: Advice From Surgical Care Affiliates

In a Dec. 6 webinar hosted by Becker's Healthcare, Linda Lansing, senior vice president of clinical services, and Kelly Bemis, director of clinical services at Surgical Care Affiliates, discussed implementing a safe surgery checklist at a surgery center.

History & justification for checklists

Ms. Lansing began the webinar with an overview of the history of the surgical checklist. "If you look at the literature, you'll see that the development of checklists from a professional point of view ties back to the aviation industry — and, most significantly, to the aviation industry during the 1930s and 40s," she said. During that time, airplanes were gaining more sophisticated technology in the cockpit, causing problems for pilots who had previously operated more simple machines. Though the technology was intended to improve safety, it was widely considered "too complicated" for a pilot to manage. The number of crashes during this time period attested to the high error rate.

In examining the behavior of pilots in these new planes, experts found that the pilots with the most flying experience were not always the ones with the best results. "We usually think that time and grade in a profession will go ahead and give us competence, and competence will drive … safety and good quality results," Ms. Lansing said. But the human brain is flawed, and even the best training does not prevent a pilot from forgetting a crucial task for take-off.

"They really began to consider: How do you deal with extreme complexity?" Ms. Lansing said. "How do you ensure you complete every step in the process, particularly when that process is done very frequently?" Interestingly, the more frequent and routine a process was, the more likely errors were to occur. As it turns out, when you've performed the same task a hundred times, you fall into a certain sense of complacency about double-checking your work.

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