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Mandatory Stark reporting: ...continued from page 51 New developments in payment and public reporting of quality of care ...continued from page 9 One conundrum that hospitals are likely to face is whether each contract with each physician for each portion of the two year period must be provided to CMS. If the hospital’s contracts are “uniform,” then only a sample must be provided. An agreement is uniform if “all of the elements present in the arrangements are materially the same.” Given the language in the certification, the stakes involved, and the nature of contracts between physicians and hospitals, contracts that are “uniform” may prove to be the exception rather than the norm. The names of approximately 290 hospitals that will receive the packet can be identified. Those hospitals are either physician-owned or competitors, who failed to respond to an earlier “voluntary” request for information. At the time this article goes to press, it is not possible to identify the remaining 110 hospitals. It seems likely, however, that at least one hospital in each state (and more likely, two) will be chosen. Hospital compliance officers are well-advised to show the Certification Statement and Worksheet 7 to the CEO and CFO, along with the form’s cover letter. 4 A candid discussion of whether the hospital could respond with the scope and quantity of information required and in the time allotted should ensue. The hospital may choose to play “Russian Roulette” and gamble that it is not one of the hospitals chosen, but woe to the compliance officer whose senior management is “surprised” at receiving CMS’s demand. n 1 56 Fed. Reg. 61374 2 The instructions state: “For any question pertaining to the financial relationship between a physician and the Hospital or entity or individual, “physician” shall include each immediate family member of the physician, as defined in 42 CFR §411.351.” 3 CMS sought public comment in Federal Register notices that published on May 18, 2007 (72 FR 28056), and September 14, 2007 (72 FR 52568). CMS began the process anew in the FY 2009 IPPS proposed rule (73 FR 23700). 4 The full packet is available at http://www.cms.hhs.gov/PaperworkReduc- tionActof1995/PRAL/itemdetail.asp?filterType=none&filterByDID=- 99&sortByDID=2&sortOrder=descending&itemID=CMS1218565&in tNumPerPage=10 include: retained foreign object after surgery, air embolism, blood incompatibility, stage III & IV pressure ulcers, falls and traumas such as electric shock and burns, and manifestations of poor glycemic control. Two recent developments signal CMS’ intent to expand this policy to professionals and to entities other than inpatient hospitals. First, in the OPPS Final Rule, CMS discussed in detail its intent to expand its Hospital- Acquired Conditions program to outpatient hospital and other settings. Coining the term “healthcare-associated conditions,” CMS signaled its intent to extend the IPPS policy to hospital outpatient departments, ambulatory surgical centers (ASCs), skilled nursing facilities (SNFs), home health, physician practices, and other settings where preventable conditions can arise. Although no definitive policy changes were adopted in the OPPS Final Rule, CMS made clear that it views the ongoing problem of preventable healthcare-associated conditions in outpatient settings as a key strategy in its attempt to use Medicare payments to drive quality of care. This issue likely will be included in the joint IPPS/OPPS listening session that CMS intends to schedule this winter. Second, CMS has taken its focus on “never” events in a different direction. Instead of including certain “never” events among the hospital-acquired conditions for which it currently denies payment if not present on admission, CMS has proposed three National Coverage Determinations (NCDs) eliminating payment for three serious medical errors: performing the wrong surgical or other invasive procedures on a patient; surgical or other invasive procedures performed on the wrong body part; and surgical or other invasive procedures performed on the wrong patient. The three NCDs were released on December 2, 2008, and CMS’ goal is to issue them in final form by March, 2009. By using the NCD approach, the payment denial policy will extend beyond inpatient hospital care, affecting payment to physicians, hospital outpatient departments, and all other health care providers or suppliers which may be involved. Conclusion As the foregoing developments indicate, CMS continues to aggressively pursue strategies to tie payment to quality. It is expanding the scope of its pay-for-reporting initiatives to new settings and types of providers as a transition to pay for quality (value-based purchasing), and continues to expand the number of measures used to monitor quality. All healthcare entities and professionals are well advised to stay abreast of these new developments and to participate in them if they can, as payment tied to demonstrated quality of care is the Congressional goal in the not too distant future. n 1 Tax Relief and Health Care Act of 2006, Pub. Law 109-432 (Dec. 20, 2006), adding subsection (k) to SSA § 1848 and 42 U.S.C. § 1395w-4. 2 The Medicare Improvements for Patients and Providers Act of 2008, Pub. Law 110-275 § 131(b) (July 15, 2008), amending SSA § 1848(k), (m) and 42 U.S.C. § 1395w-4(k), (m). 3 SSA § 1848(k)(3)(B); 42 U.S.C. § 1395ww-4(k)(3)(B). 4 Pub. Law 110-275 at § 131(d). 5 HHS, Development of a Plan to Transition to a Medicare Value-Based Purchasing Program for Physician and Other Professional Services (Nov. 26, 2008), available at http://www.cms.hhs.gov/PhysicianFeeSched/ downloads/PhysicianVBP-Plan-Issues-Paper.pdf. 6 Subsection (d) refers to SSA § 1886(d); 42 U.S.C. § 1395ww(d). Subsection (d) hospitals are hospitals in the 50 States, D.C., and Puerto Rico, except for psychiatric hospitals, rehabilitation hospitals, hospitals whose inpatients are predominantly under 18 years old, and hospitals whose average inpatient length of stay exceeds 25 days. 7 Deficit Reduction Act of 2005, Pub. Law 109-171 § 5001(a), (b) (Feb. 8, 2006). 8 The drafted legislation is currently titled the Medicare Hospital Quality Improvement Act of 2008 (not yet numbered). 9 CMS, Physician Quality Reporting Initiative: 2007 Reporting Experience (Dec. 3, 2008) available at http://www.cms.hhs.gov/PQRI/Downloads/PQRI2007ReportExperience.pdf. 10 Pub. Law. 110-275 § 131(b)(3), adding SSA § 1848(m)(5)(G); 42 U.S.C. § 1395w-4(m)(5)(G). 11 2009 Physician Fee Schedule Final Rule, 73 Fed. Reg. 69725, 69846-47 (Nov. 19, 2008). 12 Id. at 69845. 13 Medicare Prescription Drug Improvement and Modernization Act of 2003, Pub. Law 108-173 (Dec. 8, 2003), adding SSA § 1860D-4(e), 42 U.S.C. § 1395w-104(e). 14 CMS, Overview of E-Prescribing program, http://www.cms.hhs.gov/ eprescribing/. 15 2009 Physician Fee Schedule Final Rule, 73 Fed. Reg. 69725, 69848 (Nov. 19, 2008). 16 For specific codes, see CMS, Medicare’s Practical Guide to the E- prescribing Incentive Program (Nov. 2008), available at http://www. cms.hhs.gov/partnerships/downloads/11399.pdf. 17 Information about the qualified e-prescribing systems can be found at CMS, 2009 Electronic Prescribing Incentive Program – Adoption/Use of Medication Electronic Prescribing Measures, (Nov. 7, 2008) available at http://www.cms.hhs.gov/PQRI/Downloads/E-PrescribingMeasure- Specifications.pdf. 18 73 Fed. Reg. 68502, 68758 (Nov. 18, 2008) 19 Pub. Law. 109-432 Part B § 109 (Dec. 20, 2006), adding SSA § 1833(t) (17), 42 U.S.C. § 1395(l)(t)(17). 20 72 Fed. Reg. 66580, 66860 (Nov. 27, 2007). 21 Inpatient Prospective Payment System FY 2009, 73 Fed. Reg. 48434, 48471 (Aug. 19, 2008). March 2009 52 Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
Charge Description Master compliance assessments Editor’s note: Joel W. Lipin is Managing Director, Reimbursement Services with Sinaiko Healthcare Consulting, Inc. in Los Angeles. He may be reached by telephone at 310/551-5252. Years ago (not to reveal my age) the Charge Description Master (CDM) was an unknown entity. I remember numerous occasions in which I entered a CFO’s office and tried to convince the staff that they needed to pay attention to the data within their CDM. Many times I experienced reluctance during these visits. I now look back on those times and realize that CDM awareness has truly evolved to a point now where most healthcare-related magazines have an article about the CDM on some regular basis. The CDM is a critical component within the middle section of the revenue cycle that brings together charging, coding, and billing functions as the computerized warehouse for charge descriptions, coding, and pricing for all charges incurred within a hospital setting. Because there are two distinct sources of coding, from the CDM (hard-coded) and Health Information Management (HIM) (soft-coded), it is important to understand where the coding is derived for each of the various departments. Some examples are the laboratory, which usually is hard-coded from the CDM; the Surgical Services areas are usually soft-coded by HIM, based upon the medical record documentation. To ensure that your CDM maintains accurate information, it is mandatory to conduct CDM compliance assessments at least once a By Joel W. Lipin, MD, MPH year. With CPT/HCPCS codes being revised as each Centers for Medicare and Medicaid Services (CMS) memorandum is issued, it is even more important to review the accuracy of each line item within your CDM in accordance with federal, state, and third-party regulatory requirements. The basic assessment should include, at a minimum, an evaluation of appropriate CPT/HCPCS codes, UB-04 revenue codes, accurate and consistent descriptions, appropriate and consistent pricing of line items, as well as verification that services are accurately identified during the charge capture process. The project scope should include all line items within the CDM, because several procedures and services will occur across many departments. In most cases, these procedures and services are performed in a like manner and should be represented from a description, coding, and pricing perspective as the same. Not only is this a potential compliance risk if one department is charging a different price than another or charging the same for services that should be efficient by setting, but pricing transparency and defensible pricing issues are also at risk. More than ever, hospitals need to be cognizant of how their charges are established, whether they reflect prices above the highest fee schedule price, are greater than calculated costs, and are mindful of CPT/HCPCS coding hierarchy relationships. One example of the coding relationship includes the three CPT codes within radiology for magnetic resonance imaging of the brain, (i.e., CPT codes 70551, without contrast; CPT code 70052, with contrast; and CPT code 70553, Health Care Compliance Association • 888-580-8373 • www.hcca-info.org without followed by contrast). In this case, the price for the procedure without contrast should be lower than the procedure with contrast, which in turn should be lower than the procedure that includes both a study without contrast followed by the procedure with contrast. Too often a CDM becomes incongruent as a result of yearly percentage price increases without a concern for these relational hierarchy issues. The CDM assessment should also include detailed face-to-face meetings with each department and should include an analysis of existing processes surrounding charge capture, CDM maintenance, and updates. Discussions with the department directors should identify potential breakdowns within the middle section of the revenue cycle (where the CDM resides) and work towards developing recommendations to resolve any identified issues. The approach for the departmental meetings should include discussions toward: n Compliance, medical necessity, charge capture, current correct coding initiatives, and national and local coding decisions; n Procedures and services that are provided and not currently captured; n Procedural methodology confirmation; n Controls, reconciliation, and/or policies and procedures related to charge capture, CDM, and pricing; n Charge tickets or electronic order entry screens to the CDM for appropriate line item additions, deactivations, or variances; n Line-by-line review to determine accuracy of the charge description, CPT/HCPCS code(s), UB-04 revenue code(s) and the price; n Procedures that may or may not be appropriate for bundling or unbundling; n Inclusion of separate line-item billing for Medicare-reimbursable supplies and Continued on page 54 53 March 2009
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Page 25 and 26: ASK LEADERSHIP Compliance Today Nee
Page 27 and 28: YOUR INFORMATION FYIFOR Declining e
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