Payment Strategies
Were You Fooled on April Fools’ Day? Kathleen D. Schaum, MS
If you are like this author, you are on ‘‘high alert’’ from the moment you awaken in the morning until you fall asleep on the night of April 1st. Those of us whose friends and family like to play practical jokes are especially susceptible on April 1st. However, we rarely expect the US government and the Centers for Medicare & Medicaid Services (CMS) to play jokes on us on April Fools’ Day. Luckily, this year none of my family and friends played a joke on me, but I spent the entire day trying to assimilate all the reimbursement changes that became effective on April 1st. In fact, when I read about one of the changes, I actually thought it was an April Fools’ joke: I expected the announcement to end with ‘‘April Fools,’’ but it didn’t!
Were You Fooled by the ‘‘Patch’’ to the Medicare Physician Fee Schedule? Qualified healthcare professionals (QHPs), for example, physicians, podiatrists, nurse practitioners, physician assistants, and so on, were hoping that all members of Congress would work together to create a new Medicare payment system. Unfortunately, the best Congress could do was to extend the ‘‘patch,’’ which was supposed to end on March 31, 2014, through December 31, 2014. The bad news is that the ‘‘doc fix patch’’ signed on April 1st leaves QHPs with an antiquated Medicare payment system. The good news is that the ‘‘doc fix patch’’ provided a 0.5% update to the physician fee schedule conversion factor. The patch also prevented the 24% fee schedule reductions that should have taken place on January 1, 2014. Therapists also received some good news from the ‘‘doc fix patch.’’ It prevented the expiration of the therapy exception process and extends the program for another year. The CMS reminded providers of outpatient therapy services to submit the KX modifier on their therapy claims when an exception to the cap is requested for medically necessary services furnished through March 31, 2015.
Were You Fooled by the Postponement of the Implementation of International Classification of Diseases, 10th Revision (ICD-10)? Then the unthinkable happened! Congress slipped another item into the ‘‘doc fix patch’’ legislation: They delayed implementation of the ICD-10 code set that was supposed to start
on October 1, 2014. The new April 1st law says that the deadline for implementation of the ICD-10 will not be earlier than October 1, 2015. As of today, April 17, 2014, CMS has not announced a new ICD-10 deadline. Some wound care providers may welcome this delay, but many (who have prepared well and who understand the value that ICD-10 codes will bring to value-based wound care) are very disappointed with the delay. Prior to the delay announcement, CMS had set an April 10, 2014, deadline for all Medicare Administrative Contractors (MACs) to convert their existing Local Coverage Determinations (LCDs) and articles that referenced International Classification of Diseases, Ninth Revision, Clinical Modification codes, to ICD-10 codes. All other LCDs and articles (ie, those LCDs and articles that do not contain ICD-10 information or articles not attached to an LCD) were required to be published on the Medicare Coverage Database website no later than September 4, 2014. All except 1 MAC accomplished the ICD-10 LCD mapping assignment by the April 10th deadline. Wound care providers can view their future effective LCDs with ICD-10 diagnosis codes by visiting the CMS coverage database: http://www.cms.gov/medicare-coverage-database/ overview-and-quick-search.aspx. Because providers should continue preparing for the conversion to ICD-10, the MACs’ future effective LCDs and articles should provide great examples of some ICD-10 codes and their descriptions that are relevant to wound care. Wound care providers should continue to refine their documentation specificity to align with these specific new codes. Wound care providers should not cease their ICD-10 training and should not discard their ICD-10 implementation plans. Instead, forward-thinking wound care providers will increase the details covered in their ICD-10 training programs so that the transition to ICD-10 will run flawlessly on the future implementation date. Wound care QHPs should make the most of this time to improve their clinical documentation: This improvement will better explain the medical necessity of their work today and will better show their outcomes in the value-based wound care of the future. Caution: If your computer software has been configured to automatically switch to ICD-10 codes on October 1, 2014, be sure to ask your software vendor to change that date and to
Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms Schaum can be reached for questions and consultations by calling 561-964-2470 or through her e-mail address: [email protected]. Submit your questions for Payment Strategies by mail to: Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467. Information regarding payment is provided as a courtesy to our readers, but does not guarantee that payment will be received. Providers are responsible for caseby-case documentation and justification of medical necessity. WWW.WOUNDCAREJOURNAL.COM
251
ADVANCES IN SKIN & WOUND CARE & JUNE 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Payment Strategies
keep it open-ended until CMS announces the final implementation date.
Were You Fooled by the Implementation of the New CMS-1500 Claim Form? In the November 2013 issue of Advances in Skin & Wound Care, this author shared the information about the upcoming implementation of the new CMS-1500 claim form 02/12. It seems that many wound care professionals did not get the message and continued to use the old CMS-1500 claim form 08/05. Because the ICD-10 implementation was put ‘‘on hold,’’ many practitioners likely believed that the implementation of the new CMS-1500 claim form was also put ‘‘on hold.’’ When their old claim forms were rejected on April 1st, it was not an April Fools’ joke. Following are a few important reminders: The new CMS-1500 claim form was effective April 1, 2014, and is mandatory. The new version expands the number of possible diagnosis codes to 12. ) Box 21 for diagnosis codes is now lettered A to L, and the letters read left to right. The diagnosis code box on the old form was numbered 1 to 4 and read up and down. Wound care professionals should be sure to place the primary and secondary diagnosis(es) in the correct order from left to right. ) Box 24E for the diagnosis pointers must correlate with the letter of the appropriate diagnosis codes. The new CMS-1500 claim form version includes a place (to the left of the dotted vertical line on item 17) for qualifiers to identify ordering, referring, or supervising provider roles: ) DN V referring provider ) DK V ordering provider ) DQ V supervising provider The official instructions, from the National Uniform Claim Committee, for how to complete the new CMS-1500 claim can be found at http://www.nucc.org/images/stories/PDF/1500_ claim_form_instruction_manual_2012_02.pdf.
Were You Fooled by the April 1st Outpatient Prospective Payment System (OPPS) Changes to Some Cellular and/or Tissue-Based Products for Wounds (CTPs) (Old Term ‘‘Skin Substitute’’)? Even though wound care providers know that CMS makes updates to drugs and biologics on a quarterly basis, they were a little bit surprised to see changes to the CTPs just after the 2014 OPPS Final Rule made so many changes. The expected quarterly updates to the average sales prices for the separately payable CTPs that are purchased by QHPs and applied in their offices were updated on April 1, 2014, and can be found at http://www.cms.gov/Medicare/Medicare-Feefor-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/ 2014ASPFiles.html. ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 6
In addition, CMS updated the payment rate for Q4127 Talymed, per square centimeter to $13.78 for the following quarters: April 2013 through June 31, 2013; July 1, 2013, through September 30, 2013; and October 1, 2013, through December 31, 2013. Providers who think they may have received an incorrect Q4127 payment for these time periods may request contractor adjustment of the previously processed claims. The April Fools’ Day surprises pertained to the use of CTPs in hospital-based outpatient wound care departments (HOPDs) and ambulatory surgical centers: CMS reassigned some CTPs, which were new for CY 2014, from the ‘‘low cost’’ group to the ‘‘high cost’’ group. As you probably recall, CMS mapped CTPs to the ‘‘low cost’’ and ‘‘high cost’’ groups based on its threshold of $32 per square centimeter. Any new CTPs without pricing information were assigned to the ‘‘low cost’’ category until pricing information becomes available. There were actually 9 new CTPs that were effective January 1, 2014, and that were assigned to the ‘‘low cost’’ payment group because pricing information was not available for them at the time of the January 2014 update. Before the April 1, 2014, update, CMS received pricing for 3 of the 9 products. Therefore, 1 product, Q4143 Repriza, per square centimeter remained in the ‘‘low cost’’ group. Two products (Q4147 Architect Extracellular Matrix, per square centimeter, and Q4148 Neo 1k, per square centimeter) were reassigned to the ‘‘high cost’’ group. CMS changed the payment status indicator, for Q4121 Theraskin, per square centimeter, from ‘‘items and services packaged into Ambulatory Payment Classification rates’’ to ‘‘pass-through drugs and biological.’’
Were You Fooled by the Publication of Each Physician’s Medicare Payment? Our April Fools’ Day surprises actually continued through April 9th! To continue making our healthcare system more transparent, affordable, and accountable, the Health and Human Services (HHS) released privacy-protected data on services and procedures provided to Medicare beneficiaries by physicians and other healthcare professionals. The data also show payment and submitted charges, or bills, for services and procedures by each provider. The CMS said that the ‘‘data will offer insight into the Medicare portion of a physician’s practice.’’ The data include information for more than 880,000 distinct healthcare providers who collectively received $77 billion in Medicare payments in 2012 under the Medicare Part B Fee-for-Service program. Interested parties can now conduct a wide range of analyses that compare 6000 different types of services and procedures that were provided, as well as payments received by individual healthcare providers. In addition, the information allows comparisons by physician, specialty, location, the types of medical
252
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Payment Strategies
service and procedures delivered, Medicare payment, and submitted charges. Wound care providers can now compare their data with data from their peers throughout the country. You may remember last May when CMS released hospital charge data that allowed consumers and healthcare providers to compare what hospitals charge for common inpatient and outpatient services across the country. Hospital outpatient wound care departments were able to compare their charges with the charges of other HOPDs throughout the country. To view the inpatient charge data, visit http://www.cms.gov/ Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/Medicare-Provider-Charge-Data/Inpatient.html. To view the outpatient charge data, visit http://www. cms.gov/Research-Statistics-Data-and-Systems/Statistics-
WWW.WOUNDCAREJOURNAL.COM
Trends-and-Reports/Medicare-Provider-Charge-Data/ Outpatient.html. Now consumers and healthcare providers can compare physicians’ charges and payments. To view the new physician data, visit http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/Medicare-ProviderCharge-Data/Physician-and-Other-Supplier.html.
Summary Now that you have read about April Fools’ Day 2014 and the following April 9th, I wouldn’t blame you for encouraging my family and friends to play practical jokes on me next year. No more Congress, CMS, or HHS April Fools’ Day surprises!
253
&
ADVANCES IN SKIN & WOUND CARE & JUNE 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Were You Fooled on April Fools’ Day? Kathleen D. Schaum, MS
If you are like this author, you are on ‘‘high alert’’ from the moment you awaken in the morning until you fall asleep on the night of April 1st. Those of us whose friends and family like to play practical jokes are especially susceptible on April 1st. However, we rarely expect the US government and the Centers for Medicare & Medicaid Services (CMS) to play jokes on us on April Fools’ Day. Luckily, this year none of my family and friends played a joke on me, but I spent the entire day trying to assimilate all the reimbursement changes that became effective on April 1st. In fact, when I read about one of the changes, I actually thought it was an April Fools’ joke: I expected the announcement to end with ‘‘April Fools,’’ but it didn’t!
Were You Fooled by the ‘‘Patch’’ to the Medicare Physician Fee Schedule? Qualified healthcare professionals (QHPs), for example, physicians, podiatrists, nurse practitioners, physician assistants, and so on, were hoping that all members of Congress would work together to create a new Medicare payment system. Unfortunately, the best Congress could do was to extend the ‘‘patch,’’ which was supposed to end on March 31, 2014, through December 31, 2014. The bad news is that the ‘‘doc fix patch’’ signed on April 1st leaves QHPs with an antiquated Medicare payment system. The good news is that the ‘‘doc fix patch’’ provided a 0.5% update to the physician fee schedule conversion factor. The patch also prevented the 24% fee schedule reductions that should have taken place on January 1, 2014. Therapists also received some good news from the ‘‘doc fix patch.’’ It prevented the expiration of the therapy exception process and extends the program for another year. The CMS reminded providers of outpatient therapy services to submit the KX modifier on their therapy claims when an exception to the cap is requested for medically necessary services furnished through March 31, 2015.
Were You Fooled by the Postponement of the Implementation of International Classification of Diseases, 10th Revision (ICD-10)? Then the unthinkable happened! Congress slipped another item into the ‘‘doc fix patch’’ legislation: They delayed implementation of the ICD-10 code set that was supposed to start
on October 1, 2014. The new April 1st law says that the deadline for implementation of the ICD-10 will not be earlier than October 1, 2015. As of today, April 17, 2014, CMS has not announced a new ICD-10 deadline. Some wound care providers may welcome this delay, but many (who have prepared well and who understand the value that ICD-10 codes will bring to value-based wound care) are very disappointed with the delay. Prior to the delay announcement, CMS had set an April 10, 2014, deadline for all Medicare Administrative Contractors (MACs) to convert their existing Local Coverage Determinations (LCDs) and articles that referenced International Classification of Diseases, Ninth Revision, Clinical Modification codes, to ICD-10 codes. All other LCDs and articles (ie, those LCDs and articles that do not contain ICD-10 information or articles not attached to an LCD) were required to be published on the Medicare Coverage Database website no later than September 4, 2014. All except 1 MAC accomplished the ICD-10 LCD mapping assignment by the April 10th deadline. Wound care providers can view their future effective LCDs with ICD-10 diagnosis codes by visiting the CMS coverage database: http://www.cms.gov/medicare-coverage-database/ overview-and-quick-search.aspx. Because providers should continue preparing for the conversion to ICD-10, the MACs’ future effective LCDs and articles should provide great examples of some ICD-10 codes and their descriptions that are relevant to wound care. Wound care providers should continue to refine their documentation specificity to align with these specific new codes. Wound care providers should not cease their ICD-10 training and should not discard their ICD-10 implementation plans. Instead, forward-thinking wound care providers will increase the details covered in their ICD-10 training programs so that the transition to ICD-10 will run flawlessly on the future implementation date. Wound care QHPs should make the most of this time to improve their clinical documentation: This improvement will better explain the medical necessity of their work today and will better show their outcomes in the value-based wound care of the future. Caution: If your computer software has been configured to automatically switch to ICD-10 codes on October 1, 2014, be sure to ask your software vendor to change that date and to
Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc, Lake Worth, Florida. Ms Schaum can be reached for questions and consultations by calling 561-964-2470 or through her e-mail address: [email protected]. Submit your questions for Payment Strategies by mail to: Kathleen D. Schaum, MS, 6491 Rock Creek Dr, Lake Worth, FL 33467. Information regarding payment is provided as a courtesy to our readers, but does not guarantee that payment will be received. Providers are responsible for caseby-case documentation and justification of medical necessity. WWW.WOUNDCAREJOURNAL.COM
251
ADVANCES IN SKIN & WOUND CARE & JUNE 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Payment Strategies
keep it open-ended until CMS announces the final implementation date.
Were You Fooled by the Implementation of the New CMS-1500 Claim Form? In the November 2013 issue of Advances in Skin & Wound Care, this author shared the information about the upcoming implementation of the new CMS-1500 claim form 02/12. It seems that many wound care professionals did not get the message and continued to use the old CMS-1500 claim form 08/05. Because the ICD-10 implementation was put ‘‘on hold,’’ many practitioners likely believed that the implementation of the new CMS-1500 claim form was also put ‘‘on hold.’’ When their old claim forms were rejected on April 1st, it was not an April Fools’ joke. Following are a few important reminders: The new CMS-1500 claim form was effective April 1, 2014, and is mandatory. The new version expands the number of possible diagnosis codes to 12. ) Box 21 for diagnosis codes is now lettered A to L, and the letters read left to right. The diagnosis code box on the old form was numbered 1 to 4 and read up and down. Wound care professionals should be sure to place the primary and secondary diagnosis(es) in the correct order from left to right. ) Box 24E for the diagnosis pointers must correlate with the letter of the appropriate diagnosis codes. The new CMS-1500 claim form version includes a place (to the left of the dotted vertical line on item 17) for qualifiers to identify ordering, referring, or supervising provider roles: ) DN V referring provider ) DK V ordering provider ) DQ V supervising provider The official instructions, from the National Uniform Claim Committee, for how to complete the new CMS-1500 claim can be found at http://www.nucc.org/images/stories/PDF/1500_ claim_form_instruction_manual_2012_02.pdf.
Were You Fooled by the April 1st Outpatient Prospective Payment System (OPPS) Changes to Some Cellular and/or Tissue-Based Products for Wounds (CTPs) (Old Term ‘‘Skin Substitute’’)? Even though wound care providers know that CMS makes updates to drugs and biologics on a quarterly basis, they were a little bit surprised to see changes to the CTPs just after the 2014 OPPS Final Rule made so many changes. The expected quarterly updates to the average sales prices for the separately payable CTPs that are purchased by QHPs and applied in their offices were updated on April 1, 2014, and can be found at http://www.cms.gov/Medicare/Medicare-Feefor-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/ 2014ASPFiles.html. ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 6
In addition, CMS updated the payment rate for Q4127 Talymed, per square centimeter to $13.78 for the following quarters: April 2013 through June 31, 2013; July 1, 2013, through September 30, 2013; and October 1, 2013, through December 31, 2013. Providers who think they may have received an incorrect Q4127 payment for these time periods may request contractor adjustment of the previously processed claims. The April Fools’ Day surprises pertained to the use of CTPs in hospital-based outpatient wound care departments (HOPDs) and ambulatory surgical centers: CMS reassigned some CTPs, which were new for CY 2014, from the ‘‘low cost’’ group to the ‘‘high cost’’ group. As you probably recall, CMS mapped CTPs to the ‘‘low cost’’ and ‘‘high cost’’ groups based on its threshold of $32 per square centimeter. Any new CTPs without pricing information were assigned to the ‘‘low cost’’ category until pricing information becomes available. There were actually 9 new CTPs that were effective January 1, 2014, and that were assigned to the ‘‘low cost’’ payment group because pricing information was not available for them at the time of the January 2014 update. Before the April 1, 2014, update, CMS received pricing for 3 of the 9 products. Therefore, 1 product, Q4143 Repriza, per square centimeter remained in the ‘‘low cost’’ group. Two products (Q4147 Architect Extracellular Matrix, per square centimeter, and Q4148 Neo 1k, per square centimeter) were reassigned to the ‘‘high cost’’ group. CMS changed the payment status indicator, for Q4121 Theraskin, per square centimeter, from ‘‘items and services packaged into Ambulatory Payment Classification rates’’ to ‘‘pass-through drugs and biological.’’
Were You Fooled by the Publication of Each Physician’s Medicare Payment? Our April Fools’ Day surprises actually continued through April 9th! To continue making our healthcare system more transparent, affordable, and accountable, the Health and Human Services (HHS) released privacy-protected data on services and procedures provided to Medicare beneficiaries by physicians and other healthcare professionals. The data also show payment and submitted charges, or bills, for services and procedures by each provider. The CMS said that the ‘‘data will offer insight into the Medicare portion of a physician’s practice.’’ The data include information for more than 880,000 distinct healthcare providers who collectively received $77 billion in Medicare payments in 2012 under the Medicare Part B Fee-for-Service program. Interested parties can now conduct a wide range of analyses that compare 6000 different types of services and procedures that were provided, as well as payments received by individual healthcare providers. In addition, the information allows comparisons by physician, specialty, location, the types of medical
252
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Payment Strategies
service and procedures delivered, Medicare payment, and submitted charges. Wound care providers can now compare their data with data from their peers throughout the country. You may remember last May when CMS released hospital charge data that allowed consumers and healthcare providers to compare what hospitals charge for common inpatient and outpatient services across the country. Hospital outpatient wound care departments were able to compare their charges with the charges of other HOPDs throughout the country. To view the inpatient charge data, visit http://www.cms.gov/ Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/Medicare-Provider-Charge-Data/Inpatient.html. To view the outpatient charge data, visit http://www. cms.gov/Research-Statistics-Data-and-Systems/Statistics-
WWW.WOUNDCAREJOURNAL.COM
Trends-and-Reports/Medicare-Provider-Charge-Data/ Outpatient.html. Now consumers and healthcare providers can compare physicians’ charges and payments. To view the new physician data, visit http://www.cms.gov/Research-Statistics-Data-andSystems/Statistics-Trends-and-Reports/Medicare-ProviderCharge-Data/Physician-and-Other-Supplier.html.
Summary Now that you have read about April Fools’ Day 2014 and the following April 9th, I wouldn’t blame you for encouraging my family and friends to play practical jokes on me next year. No more Congress, CMS, or HHS April Fools’ Day surprises!
253
&
ADVANCES IN SKIN & WOUND CARE & JUNE 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
