Dr. Joseph R. Maldonado
August 14, 2015
Volume 15, Number 31
At the 2015 House of Delegates of the Medical Society of the State of New York, Resolution 210 was passed calling for the creation of a Task Force on Independent Practice. The purpose of the taskforce is two-fold. First, the Taskforce would explore viable options for independent physicians to collaborate and create practice models to achieve the goals of “diversity of service, economy of scale and collective negotiations.” Second, consult experts and examine successful independent practice models in NY and elsewhere that will facilitate the preservation of independent practice in the State of New York. We need your help!
I am looking to assemble the MSSNY team to tackle this work. This calls for physicians who have developed innovative business models of private practice as well as those who have working knowledge of practice models that can accomplish the goals of the committee. This is NOT a committee for those who want to learn on the job. Rather, it is a team of individuals who have working experience both at the individual practice level establishing new medical business ventures as well as those who have expertise through academic, business and health policy endeavors.
Is your practice unique in what it offers? Have you created an IPA? Have you written a master’s thesis on collective negotiations and messenger model negotiations? Are you a physician offering concierge services or a telemedicine based practice? Are you a physician with a law degree or an MBA that has innovated healthcare delivery for your practice in a non-traditional manner or in an innovatively thriving traditional practice? This taskforce can use your skills.
Please contact Eunice Skelly at MSSNY (firstname.lastname@example.org) with a short bio and letter expressing your interest, expertise and what you intend to bring to the taskforce to advance the mission of the project. I will be looking for diversity of practice location as well as types of innovations that may contribute to a robust and comprehensive report and plan of action for preserving independent practice in New York.
Joseph Maldonado, M.D, MSc, MBA, DipEBHC
Please send your comments to email@example.com
MSSNY Survey Details Physician Concerns with Inadequate Health Insurance Coverage Faced By Patients
Legislators in New York and Washington D.C. must take action to assure that health insurance coverage truly provides patients with coverage for needed care, instead of a limited catastrophic benefit, according to survey results gathered by the Medical Society of the State of New York.
“The increased availability of subsidized health insurance coverage through New York’s Exchange has certainly been a positive development for our patients, but at the same time we find that more and more of our patients are underinsured due to the increasingly inadequate coverage and narrow networks offered by insurers,” said Dr. Joseph Maldonado, President of the Medical Society of the State of New York.
Many patients are surprised that the health insurance policies for which they have paid thousands of dollars per year will not cover many costs of care until they spend thousands of dollars out of pocket first. MSSNY’s survey found that significant numbers of patients are facing deductibles imposing huge out of pocket costs before health insurers begin to pay for care. MSSNY’s survey showed that nearly 21% of responding physicians indicated that one ¼ – ½ of their patients faced deductibles of $2,500-$5,000, and that 32% of responding physicians indicated that up to 10-25% of their patients faced deductibles of $2,500-$5,000. Moreover, nearly 25% of responding physicians indicated that 25 to 50 % of their patients faced deductibles of $1,000-$2,500, and 36% of responding physicians indicated that up to 25% of their patients had deductibles of $1,000-$2,500.
And many physicians report that the networks that insurers offer to patients are increasingly inadequate. Nearly 14% of responding physicians indicated that their participation contract with an insurer was not renewed in the last three years, while another 22% indicated that in the last three years they were not invited to participate in a product offering with an insurer despite participating in other products offered by that insurer. At the same, over 45% of responding physicians indicated that they were inappropriately listed as a participating physician on a health insurer’s website in the last year, which could mask an inadequate physician network.
Even as networks shrink, so do our patients’ ability to be treated by physicians outside the network. Over 33% of responding physicians indicated that the number of patients they treat with out of network coverage has gone down significantly in the last 3 years, while 42% noted that, for those patients who do have out of network coverage, the insurer covers a far less portion of medical portion of medical costs than they did 3 years ago. The recent enrollment report by the New York State of Health showed that out of network coverage benefits were only available in 11 counties in New York State, and none below the Bear Mountain Bridge, since insurers have refused to offer this coverage in most areas of the State.
MSSNY is urging policymakers to review these findings closely and to make necessary changes to federal and state laws and regulations to assure health insurers offer comprehensive health care coverage as well as comprehensive physician networks. A significant part of the problem is a provision of the ACA that enables insures to sell health insurance policies that foist up to 40% of the costs of care on patients. MSSNY also continues to strongly urge the Legislature to enact legislation (S.1846, Hannon/A.3734, Rosenthal) to assure that our patients have the ability to purchase coverage in New York’s Health Insurance Exchange that enables them to be treated by physicians outside the plan’s network.
“What many physicians find particularly difficult to understand is that, while health insurers continue to constrain the scope of their coverage as noted by the survey results, they also continue to request significant increases in the premiums they charge to consumers and businesses,” said Dr. Maldonado. “We urge that policymakers look closely at the policies being offered by these insurers and assure that these policies will actually provide coverage for the care needed by our patients.”
Two-Midnight Rule Enforcement Delayed Until 2016
CMS officials announced this week that it would continue to delay until the end of the year enforcement of the controversial “two midnight” rule governing short hospital stays so as to coincide with changes to the policy it recently proposed.
The two-midnight rule calls assumes a hospital admission is appropriate if the patient stays past two midnights. The rule was adopted in response to a spike in situations of patients going into “observation status.” Physician and hospital associations, however, have strongly opposed the rule, arguing that it undermines clinical judgment. Implementation of the rule has been delayed numerous times, including as part of the recent SGR repeal bill until September 30.
In July, CMS proposed that the rule be modified to allow physicians to exercise judgment to admit patients for shorter stays on a case-by-case basis. The proposal also put quality improvement organizations, or QIOs, in charge of initial reviews of the appropriateness of short inpatient hospital stays, rather than Medicare Administrative Contractors.
For more information, read here:
MSSNY Survey: EHR Usage Shows Continued Frustration with EHR Technology
As government increasingly seeks to condition physician payments on the achievement of hard to define cost efficiency and quality targets, it has decreed meaningful use of electronic health records an essential component of demonstrating quality care.
While this technology holds great promise to enhance care delivery, many physicians across New York and across the country have identified numerous obstacles to successfully incorporating EHR technology into their practice workflow, sometimes interfering with the delivery of patient care.
MSSNY’s HIT Committee has prepared a survey to elicit your thoughts on how EHR functionality could be improved including identifying areas on which additional educational programs would provide meaningful value for practicing physicians.
Please take a couple of minutes to provide your insight on these very important topics.
Please click here to take the survey.
Funding Opportunities Date Extended for Doctors Across New York
The New York State Department of Health, Office of Primary Care and Health Systems Management has made revisions to the Cycle IV Doctors Across New York (DANY) Physician Practice Support and Physician Loan Repayment Programs Funding Opportunity. The DANY application submission deadline has been extended to Monday, August 31, 2015. Applicants can, and are encouraged to, submit prior to the August 31st deadline. For other revisions, please refer to the New Program Changes (Supersedes all other document references) bullet on the website.
From Workers Compensation re September District Dialogue Sessions
Thank you to all who attended our Summer BPR Roadshows, which took place during our normal Summer District Dialogue Sessions. We are very fortunate for everyone’s participation and contribution, making our Summer BPR Roadshow a great success!
Please join us for our Fall 2015 District Dialogue Session. This will be the Board’s fifth District Dialogue Session since we began holding these sessions in September 2014. The Board plans to provide those who attend with:
- The latest update on BPR initiatives.
- Participant Dialogue Session – time for the Board to hear and discuss topics of interest to you.
We hope you join us at one of our District Offices. The locations, dates and times are as follows:
9/1/15, 12-1 PM
220 East Rabro Drive, Suite 100
Hauppauge, NY 11788
9/2/15, 12-1 PM
168-46 91st Ave
Jamaica, NY 11432
3rd Floor, Room 325
- White Plains
9/3/15, 12-1 PM
75 S Broadway
White Plains, NY 10601
9/8/15, 12-1 PM
Ellicott Square Building
295 Main Street
Buffalo, NY 14203
Suite 400, Room 438
9/9/15, 12-1 PM
130 Main Street West
Rochester, NY 14614
Basement Conference Room
9/15/15, 12-1 PM
Menands, NY 12204
Room 518A & 518B
9/16/15, 12-1 PM
935 James St
Syracuse, NY 13203
1st Floor-General Assembly
9/17/15, 12-1 PM
State Office Building
44 Hawley Street
Binghamton, NY 13901
18th Floor-Warren Anderson Community Room
9/22/15, 12-1 PM
111 Livingston Street
Brooklyn, NY 11201
22nd Floor, Room 1917
9/23/15, 12-1 PM
215 West 125th Street
New York, NY 10027
The Board has recently added a new email subscription topic for you called “District Dialogues”. Please subscribe to the District Dialogues topic in order to receive any information about past, present, or future District Dialogue sessions. (Click “Manage Preferences” at the bottom left of this email > sign in with your email > click “add subscriptions” > select “District Dialogues” under the General category.) Contact Notifications@wcb.ny.gov if you need assistance with subscribing.
Members Only: Your Patients Can Save Up to 75% on Prescription
With the rising cost of both generic and name brand medications, your patients could all use some help these days! The New York RX Card, MSSNY’s newest Member Benefit, is a 100% Free and 100% confidential point of sale prescription discount card that can save your patients up to 75% on your prescription medications! It is free to everyone with no minimum nor maximum uses, no age or income requirements, no enrollment or approval process and it is accepted at over 68,000 pharmacies, nationwide!
This card will provide you with Rx medication savings of up to 75% at more than 68,000 pharmacies across the country including CVS/pharmacy, Duane Reade, A&P, Hannaford, Kinney, Kmart, Pathmark, Stop and Shop, Target, Tops, Waldbaums, Walgreens, Walmart, Wegmans, and many more. You can create as many cards as you need. We encourage you to give cards to friends and family members. This card is pre-activated and can be used immediately!
The NYRX Card works on lowest price logic, to guarantee the best prices on medications. It won’t lower co-pays or replace existing insurance, but in some cases the New York Rx price is even lower than your patients’ co-pay! It can be used during the deductible periods in Health Savings Accounts and High Deductible Plans, lowering out-of pocket-expense on prescriptions. Medicare Part D recipients can use the card to discount their prescriptions not covered on their plan as well as receive discounts on medications not discounted when in the “donut hole.”
The NYRX Card is pre-activated and ready to go with no personal information taken or given. NYRX will mail as many cards you desire, directly to your office, with display stands. The cards typically are placed at the patient check out area…additionally, some doctors place them at the check in area too. Contact firstname.lastname@example.org for your cards!
The August 4th edition of The Daily included a Huffington Post blog by Paul Alexander (“Is New York’s Education Department Making the Doctor Shortage Worse?”) that reported erroneous information about the New York State Education Department (NYSED)’s policy regarding clerkships for international medical students. MSSNY spoke to Steve Boese, Executive Secretary of the Board for Medicine at the NYSED, who said the information in the Huffington Post blog is incorrect and that no prohibition on clerkships has been put in place.
When will the ICD-10 Ombudsman be in place?
The Ombudsman will be in place by October 1, 2015.
Does the Guidance mean there is a delay in ICD-10 implementation?
No. The CMS/AMA Guidance does not mean there is a delay in the implementation of the ICD-10 code set requirement for Medicare or any other organization. Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code. The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015, or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims.
What is a valid ICD-10 code? (Revised 7/31/15)
All claims with dates of service of October 1, 2015 or later must be submitted with a valid ICD-10 code; ICD-9 codes will no longer be accepted for these dates of service. ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family (see question 5) is submitted, Medicare will process and not audit valid ICD-10 codes unless such codes fall into the circumstances described in more detail in Questions 6 & 7.
An example is C81 (Hodgkin’s lymphoma) – which by itself is not a valid code. Examples of valid codes within category C81 contain 5 characters, such as:
C81.00 Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site
C81.03 Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes
C81.10 Nodular sclerosis classical Hodgkin lymphoma, unspecified site
C81.90 Hodgkin lymphoma, unspecified, unspecified site
During the 12 month after ICD-10 implementation, using any one of the valid codes for Hodgkin’s lymphoma (C81.00, C81.03, C81.10 or C81.90) would not be cause for an audit under the recently announced flexibilities.
In another example, a patient has a diagnosis of G43.711 (Chronic migraine without aura, intractable, with status migrainosus). Use of the valid codes G43.701 (Chronic migraine without aura) or G43.719 (Chronic migraine without aura, intractable without status migrainosus) instead of the correct code, G43.711, would not be cause for an audit under the audit flexibilities occurring for 12 months after ICD-10 implementation, since they are all in the same family of codes.
Many people use the terms “billable codes” and “valid codes” interchangeably. A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure as to whether an additional 4th, 5th, 6th or 7th character is needed. Using this free list of valid codes is straightforward. Providers can practice identifying and using valid codes as part of acknowledgement testing with Medicare, available through September 30, 2015. For more information about acknowledgement testing, contact your Medicare Administrative Contractor, and review the Medicare Learning Network articles on testing, such as SE1501.
Question 4: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code versus denied due to a lack of specificity required for a NCD or LCD or other claim edit?
Yes, submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims.
What is meant by a family of codes? (Revised 7/31/15)
“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.
Another example, K50 (Crohn’s disease) has codes within the category that require varying numbers of characters to be valid. The ICD-10-CM code book clearly provides information on valid codes within this, and other categories. And if in doubt, providers can check the list of valid 2016 ICD-10-CM codes to determine if all characters have been selected and reported. Examples of valid codes within category K50 include:
K50.00 Crohn’s disease of small intestine without complications
K50.012 Crohn’s disease of small intestine with intestinal obstruction
K50.90 Crohn’s disease, unspecified, without complications
To include the Crohn’s disease diagnosis on the claim, a valid code must be selected. If the paid claim were to be selected later for audit, the Guidance makes it clear that the claim would not be denied simply because the wrong code was included, so long as the code was in the same family. As long as the selected code was within the K50 family, then the audit flexibility applies.
Does the recent Guidance mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?
In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations. (See Question 7 for more information about this). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.
In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. The physician can resubmit the claims with a valid code.
National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) often indicate specific diagnosis codes are required. Does the recent Guidance mean the published NCDs and LCDs will be changed to include families of codes rather than specific codes?
No. As stated in the CMS’ Guidance, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family of codes. The Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.
As such, the recent Guidance does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10. It is important to note that these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9. LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side. The NCDs and LCDs are publicly available and can be found at http://www.cms.gov/medicare-coverage-database/.
Are technical component (TC) only and global claims included in this same CMS/AMA guidance because they are paid under the Part B physician fee schedule?
Yes, all services paid under the Medicare Fee-for-Service Part B physician fee schedule are covered by the guidance.
Do the ICD-10 audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?
No, the audit and quality program flexibilities only pertain to post payment reviews. ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests.
If a Medicare paid claim is crossed over to Medicaid for a dual-eligible beneficiary, is Medicaid required to pay the claim?
State Medicaid programs are required to process submitted claims that include ICD-10 codes for services furnished on or after October 1 in a timely manner. Claims processing verifies that the individual is eligible, the claimed service is covered, and that all administrative requirements for a Medicaid claim have been met. If these tests are met, payment can be made, taking into account the amount paid or payable by Medicare. Consistent with those processes, Medicaid can deny claims based on system edits that indicate that a diagnosis code is not valid.
Does this added ICD-10 flexibility regarding audits only apply to Medicare?
Answer 11: The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. This Guidance does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary.
Will CMS permit state Medicaid agencies to issue interim payments to providers unable to submit a claim using valid, billable ICD-10 codes?
Federal matching funding will not be available for provider payments that are not processed through a compliant MMIS and supported by valid, billable ICD-10 codes.
Will the commercial payers observe the one-year period of claims payment review leniency for ICD-10 codes that are from the appropriate family of codes?
The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. Each commercial payer will have to determine whether it will offer similar audit flexibilities.
CMS has recently agreed to hold listening sessions with physician organizations on two sections of the Medicare Access and CHIP Reauthorization Act (MACRA). The next session will address the alternative payment models provisions in MACRA, and will be held on August 19 from 10:30 am to noon Eastern. DC-based specialty staff will participate in person from the AMA’s Washington office but we are also arranging a call-in line for participation in both meetings by state medical society staff. A CMS slide deck laying out the MIPS section of the law along with a set of questions is attached. We expect to have questions to be addressed at the August 19 meeting soon and will send those out as well. In order to ensure that we have enough phone lines, we ask that if multiple people from the same state plan to participate in the call, they all gather at the same location and use a single phone line. The call-in line is 866-740-1260. The access number is 7897464.
Thursday, August 27; 2:30-4 pm ET
To Register: Visit MLN Connects Event Registration. Space may be limited, register early.
Don’t miss the August 27 MLN Connects Call — five weeks before ICD-10 implementation on October 1, 2015. CMS Acting Administrator Andy Slavitt will be opening the call with a national implementation update. Then, Sue Bowman from the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen from the American Hospital Association (AHA) will be joining us with coding guidance and tips, along with updates from CMS.
- National implementation update, CMS Acting Administrator Andy Slavitt
- Coding guidance, AHA and AHIMA
- How to get answers to coding questions
- Claims that span the implementation date
- Results from acknowledgement and end-to-end testing weeks
- Provider resources
Target Audience: Medical coders, physicians, physician office staff, nurses and other non-physician practitioners, provider billing staff, health records staff, vendors, educators, system maintainers, laboratories, skilled nursing facilities, home health agencies, and all Medicare providers.
Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.
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