Welcome to North Carolina Rheumatology Association

Medicare Carrier Advisory Committee Meeting
February 14, 2008
Part B North Carolina

Notes courtesy of North Carolina Rheumatology Association representative Greg Schimizzi, MD

National Provider Identifier (NPI)
NPI deadline has been moved back
Effective March 1, you must report an NPI number on every Medicare claim
You may report your UPIN/legacy pair and the NPI until May 23, 2008
You may not report only a legacy PIN; the claim will be rejected
Effective May 23, 2008 you must report only an NPI
Claims with anything else will be rejected after May 23
Only NPIs will be sent out on Remittance Advisory and cross-over claims after that date

Fee Schedule
Current conversion factor is $38.0780
The conversion factor went up by 0.5%
Does not equal all fees going up by 0.5%
Formula for 2008 non-facility pricing amount=
[((work rvu*Budget neutrality adjustor (0.8806) (round product to two decimal places)*Work GPCI + (Transitioned Non-Facility PI RVU*PE GPCI) + MP RVU*MPGPCI)]* Conversion Factor

GPCI = Geographic Price C index
North Carolina has one GPCI
Factors or variables that affect the Conversion factor:
Percentage change in physician fees for services
Percentage change in number of beneficiaries
Percentage change of per capita GNP
Percentages of changes in costs

Medicare Participation
Date for signing / opting out of Medicare extended (Feb 15, 2008)
Date for signing up for CAP (Medicare Competitive Acquisition Program) extended (Feb 15, 2008)

Physician Quality Reporting Initiative (PQRI), aka, Pay for Performance
1st 6 months of PQRI ended - no data yet… Perhaps by May 2008
74 measures
2nd phase has just begun.
110 measures in 2008-02-14
More specialties included

Medicare Part D Drug plan
Has been successful
Cost has been less than expected

Part B Durable Medical Equipment (DME) Workshop
March 11, 2008 Charlotte
Can sign up on the CGS website
Various workshops and seminars, 'webinars' over the next few months-can see calendar of events on CGS website
Approximately 4-5 months behind schedule
Conference calls with Carriers are announced on website

Fraud and Abuse reporting Benefit Integrity - Program Safeguard Contractors (BI-PSC) Update
No cases discovered
No cases resolved
Focus -
Use of 25 & 59 modifier
Nursing facility visits

Medicare Local Coverage Determinations (LCDs)
No new LCDs
Recent revisions
ESA (RPO/Darbo)
Botox
Rituximab liberalized to include SLE

Medicare Comprehensive Error Rate Testing (CERT) CGS finished 2007 with rate of 3.5& overall
NC as state went up to 4.7%
Because of two claims with high $$ value. Had the two claims been better documented the ruling could have been overturned
For May 08 mid year report now looking good (projected to be around 4.0%)
Please spread message to document well, submit documentation when requested
Knowledge of the CERT program in provider's offices around state appears spotty
Please help inform our specialties about the program and stress importance of cooperation.

Medical Review Data
Nothing very exciting to show
All look pretty good in aggregate (More or less normal distribution)
Outliers tend to be on individual basis
Areas of focus for CERT and MR review still pretty much the same - EM codes(consults, new pt visits, high level of complex/hosp visits) use of -25 modifier, Chiro
Disturbing trends:
Strange looking patterns from Nursing facilities (NFs)
High use of -25 -59 -22 modifiers (change in descriptors of several modifiers)
Still see high levels of service by NPPs
(Physician substitutes vs extenders??, exceeding scope of practice??)
NC has some of the highest number of physician extenders in the country

I asked about the specific function and lack of oversight controls on the RACs. The answer from Dr. Honeycutt and the Part A Medicare Medical Director was less than comforting. There is no oversight of the RACs built into the contracts. The Medical Directors confirmed our fears that the RACs will be essentially working separately and will respond only to complaints from CMS and only after MDs file complaints. They have broad powers to review and demand repayment based on their own interpretations of the Fee Schedule and Medicare statutes. (See example below) The major problems with the RACs are confirmed by the Medical Directors:
1. They receive a percentage of all funds that they recover as non-refundible commission. The RACs are allowed to retain these commissions whether they are erroneous or not THE DO NOT HAVE TO REFUND ANY OF THEIR COMMISIONS IF THEY ARE IN ERROR!
2. There is no oversight built into the contracts by CMS. Appeals are taken by CMS from physicians and acted upon after review of each individual complaint (set).
I voiced my opinion that the RACs are not dissimilar to audit attack dog teams without leash, fence or control. This assessment was not argued or contradicted by the Medical Directors.

This has already caused a great deal of difficulty in Florida. RAC demanded repayment from practioners who performed facet block injections without using fluoroscopy. CMS ruled that beginning in fall of 2007 these would only be reimbursed if fluoroscopy was used during the procedure. The policy formation followed a Federal Register recommendation made several years earlier. The RAC demanded recovery payments for all procedures dating back to the Federal Register recommendation and not to the start date set by CMS. It took many letters and involvement of organized societies to overturn the action by the RAC. The RAC only stopped this recovery after CMS finally gave a "cease and desist" order to the RAC.

Next meeting: June 12, 2008

Abbreviations
PSC=Program Safeguard Contractors
PQRI= Physicans Quality Reporting Initiative
CAP = Competitive Acquisitions Program
CGS = CIGNA Government Services
LCDs = Local Carrier Determinations
NCD=National Carrier Determination
CERT = Comprehensive Error Rate Testing program
RAC = Recovery A Contractors
CO = Contractural Obligations

Notes courtesy of North Carolina Rheumatology Association representative Greg Schimizzi, MD

North Carolina MDs should be using NPI numbers and these numbers should be accurate and complete.
The NPI Deadline has been moved back. Claims rejections will occur October 15, 2008.
No end date to contingency plan at this time for Part B.

Physician Quality Reporting Initiative (PQRI), aka, Pay for Performance

PQRI started on July 1 and ends December 31, 2007.
Program will continue into 2008. Some new measures will be available for 2008, and some old measures will be discontinued.
Final 2007 data not available until March.
Sizable number of MDs reporting.
No interim report on data available.

The CAP Program continues to be available.
October 1-15 is enrollment period.
Not many changes planned.

More successful than predicted.
Still some hitches but overall satisfaction is high among beneficiaries.
Drug prices have been driven down by the program.

The Medicare Contractor program is presently undergoing reorganization.
Regions III, IV and V have been awarded so far:
IV is Trailblazer
V awarded to Wisconsin Administrative Services

Top 100 billers in each state must complete process.
Letters have already gone out. If you are one of these you should know by now.

New ICD-9 codes updates for 2008 are complete.
CPT updates should be complete by Jan 1, 2008.
CGS DME-MAC (Cigna Government Services, Durable Medical Equipment, Medicare Administrative Contractors) in operation since early summer for region C (Southeast USA).
Surveys are going out for service satisfaction. Please fill out the surveys. Our region is lower than other regions. (If we do not respond or if responses are overly negative, a new contractor may be assigned to this region.)

Fraud and Abuse reporting Benefit Integrity - Program Safeguard Contractors (BI-PSC) Update

No new cases have been reported.
A few cases have been referred to the FBI for egregious fraudulent behavior.
If MDs are advised to change their billing behavior, they are reported to PSC if coding continues to be erroneous.

No new LCDs for this meeting
Two revisions have occurred:
1. Telemetric capsular imaging for small bowel tumors, celiac sprue and malabsorption
Codes available on website
Effective 12/1/2007
2. ESAs/Erythropoietin Analogs (EPO/DARBO)
Revised to conform to the new NCD (National Carrier Determination) published 7/31/2007
Slightly changed wording regarding dosing, initial levels
Maintained in the LCD the same coverage as before that are not addressed in the NCD
No National guidance has been given on some codes so CIGNA has been continuing to cover services that were not mentioned in the NCD.

Medicare Comprehensive Error Rate Testing (CERT)

Projected CERT final rate for November 2007 report will be approximately 4.3%
Up a bit from last year's report of 3.5 %
Primarily because of two claims for 1200 and 800 each. These two claims raised the error rate by approximately 0.5%.

Cigna Government Services (CGS) overall rate for all three states will be around 3.2 %
Final numbers available in early December 2007
Emphasize again the importance of submitting documentation when requested and maintaining good documentation in medical records. A toll free number is available for reporting.

Data review still indicates that high error codes for E&M codes:
Hospital admissions
Hospital shared visits vs consultation
Still seeing a lot of consults that appear to be shared visits - can't tell who did work
Beneficiaries being billed for services denied with a "CO##" denial
This indicates contractual obligation and the service cannot be billed to the beneficiary
Some billing services just continue to bill and don't read the Remittance Advice
This is Illegal and the provider - NOT the billing service is held responsible
Clarify with your billing services that this is not happening

Medicare Part D complaint form is available for complaints regarding erroneous enrollments in Med Advantage or allegations of illegalities or irregularities.

More information and helpful forms available on the North Carolina Department of Insurance Website (www.ncdoi.com or www.ncshiip.com) or by contacting Jeanie G. Schepisi, CMA at jschepis@ncdoi.net.

In cases of 'error', a special dis-enrollment period is allowed after erroneous enrollment.

Subcontractors have been engaged to recover erroneous reimbursements; not in NC yet but will be coming. Currently most effort is concentrated on hospital care overpayments.

CAC Meeting Notes June 2007

Medicare Carrier Advisory Committee Meeting
June 2007
Part B North Carolina

Notes courtesy of North Carolina Rheumatology Association representative Greg Schimizzi, MD

Centers for Medicare and Medicaid Services (CMS) Update

New director: Kerry Weems
From office of budget and finance

The new director from the office of budget and finance can be expected to be very hands-on with respect for budgetary constraints. Expect him to look carefully and advise Congress and administration on methods to reduce costs for Medicare.

Medicare Contractor Reform

The Medicare Contractor program is presently undergoing reorganization.
Competitive bidding for new regions; first phase nearing completion.

North Carolina's present Medicare contractor is Cigna. CIGNA has been one of the easier Medicare Contractors to work with, and has historically been sensitive to the interests of the NCRA.

We will not know the results of all of the bidding until sometime in 2008. Medicare Contractors will be fewer in number with wider areas of coverage/responsibility.

Medicare Recovery Audit Contractors (RACS)

As you may or may not be aware, a program currently is underway under which private companies contracted with the Centers for Medicare and Medicaid Services (CMS) are reviewing old Medicare claims to discover overpayments and demand their repayment from providers.

RACs demonstration project in place now
     4 regions slated to start in 2008
     1 state per region will be phased in every quarter
     States with larger Medicare penetration will be added first
     NC is the 10th largest Medicare region in the country
     Expect NC to be added early
     Private contractors who investigate claims

RACs will begin investigating claims for overcharges. The incentives for each independent contractor will encourage careful scrutiny of Medicare claims. This will likely result in more appeals filed regarding reviewed Medicare claims. The states selected for initial review will be additive until all states are initiated into the review process by 2009.

Medicare Durable Medical Equipment (DME) Contract

Operational June 14, 2007
Contractor reform has caused some contractors to network with other contractors

Medicare Competitive Acquisition Program (CAP)

Section 303 (d) of the Medicare Modernization Act requires the implementation of a competitive acquisition program (CAP) for Medicare Part B drugs and biologicals not paid on a cost or prospective payment system basis. The CAP is an alternative to the ASP (buy and bill) methodology for acquiring certain Part B drugs which are administered incident to a physician's services.

There is a big push to get MD participation
Not many MDs have signed up for this program
Depends on practice type. Some MDs like it, others want no part.

Complaints about the CAP program include increased work for very little savings, difficulty with paperwork, cumbersome system. Advantages voiced by the participants include one stop ordering, decreased financial risk for certain practices.

National Provider Identifier (NPI) - provider enrollment issues

The deadline has come and past.
There has not been 100% completion
CMS has put an extension for enrollment into place
CIGNA has hired extra personnel to help clear the backlog

There will be fewer claims allowed without the new NPI number , i.e. expect a gradual but continuous rise in rejections to occur for those who are still using the old Medicare ID numbers and are not utilizing the new NPI.

Medicare Benefit Integrity (BI) / Program Safeguard Contractor (PSC) Update

Cases referred involved
     Physically impossible services (Time and Volume)
     Nursing home visits for number of patients
     Billing for work when not in office, out of town
     Telephone supervision of extender billing while out of town
     Recalcitrance with previous infractions

Areas of interest for upcoming year
     Home visits - excessive visits, convenience
     Expensive diagnostic testing
     Ambulance = various providers "certifying" non-emergent trips, convenience trips
     Seeing a lot of excess documentation for the medical necessity, more "upcoding" (effect of adding EMR templates to documentation, Other??)

OIG will be called in to investigate any item / isue if and when discovered. The above list contains the hot button / red flag issues that are being targeted.

Medicare Local Coverage Determinations (LCDs)

No new draft LCDs

Old LCDs
Revised the LH-RH analog policy
Split into two policies

Least costly alternative policy for the two tiers was tried but was rejected. When there were only few to choose from, the differential was not great. With the advent of multiple different preparations and a wide variance in cost, the products were split into two groups. ( sic: long acting implants vs injectibles???)

Revised the Skin Substitutes policy
Allow coverage for some substances not previously covered
Some were taken off of the market

Revised the Erythropoeitin Analog policy
Removed approval for one ICD-9 code (no coverage for the anemia of malignancy)

Medicare Comprehensive Error Rate Testing (CERT)

As mentioned NC CERT rate for 2006 was 3.1%
Mid year rate for NC was 3.9% (5/07)
Overall US avg was 4.2% (equates to $10 Billion)
Problems: High error rate codes remain largely the same
     E/M codes are the highest error rates
     Hospital visits both initial and subsequent
     Office visits new & established
     Consults and follow up consults
     Chiropractic

Physician Quality Reporting Initiative (PQRI), aka, Pay for Performance

Final list of 74 quality measure statements, descriptions, and detailed specifications now posted at: www.cms.hhs.gov/PQRI

The reporting period is July 1 - December 31, 2007
Claims - based reporting using CPT Category II quality codes

Bonus payment calculation set by statute
Participating eligible professionals who successfully report may earn a 1.5% bonus subject to cap
1.5% bonus calculation is based on total allowed charges during the reporting period for covered professional services billed under the Physician Fee Schedule.

Bonus payments will be made to the holder of the Taxpayer Identifier number (TIN) in a lump sum in mid 2008

Website at www.cms.hhs.gov?PQRI contains all publicly available information
Medicare Carrier / Medicare Administrative Contractor (MAC) inquiry management
Join the CMS provider lists serves to receive notification

Cap calculation for PQRI bonus payments formula already devised =
Individual instances of reporting quality data x (Z) x National Average per measure payment amount
In this formula the currently proposed constant Z = 300%

National average per measure payment amount = National total charges associated with quality measures / national total instances of reporting

Congress has set aside $1.4 billion for 2008-9 payments. This equates to $450M for each 6 month period.

Average Primary care MD should see $1,500 - 2,000
Average specialist could possibly expect $6,000 bonus.

Where do we get more info? Info available at the website
     Common questions
          Do I have to register? No, just start reporting
          Is NPI required for bonus payment? Yes, an NPI is required
          Do MDs have to be Medicare participating? You do not have to be participating just a registered provider.
          Can CPT Cat II codes be submitted separately for claims for payment?
                 NO! Quality codes must be submitted on the same claim as the ICD 9 and CPT Category I codes because   the analysis of satisfactory reporting requires that both the numerator and the denominator codes be present.

Reporting Quality Data
The measure specifications contain instructions for Identifying opportunities to report ie. denominator ICD-9 and CPT category 1 codes

Choosing quality data codes
     Using exclusion modifiers 1P 2P 3P
     Using action not performed modifier i.e. 8P
     Aditional reporting instructions are under development
     An Implementation manual ca be found at the website which is extremely helpful
Contains a list of CPT/HCPCS and ICD-9 codes that can be billed for each quality parameter and has worksheets that can be helpful in determining what quality codes can be billed under what circumstances, frequency, etc

Question Answer Section

During the question and answer sessions some excellent topics came up:

For patients whose Medicare coverage has come into question due to changes in insurance caused by glitches in system or due to commercial substitutions (example patients are signed up for Medicare HMO coverage when it was their understanding that they were signing up for Part D plan supplement only).
     MDs can call 1-866-655-7996 for difficulty with problems with Medicare recipients losing insurance coverage / Medicare HMO problems.
     Beneficiaries should call 1-800-Medicare to report these problems.
     Most times the coverage will be reversed and investigated

For patients denied Part A coverage for infused medications such as those sent to hospital infusion centers as an alternative to MD office infusion for off label use. (Remember that Part B coverage is handled by CIGNA Medicare i.e. Boyd Honeycutt, M.D. and Part A coverage questions/ approvals are handled by Palmetto GBA.) Non-indicated or off label use will likely be rejected but MDs will need to call CMS directly to appeal the decision. The Palmetto GBA medical director (present at this meeting) offered her assistance (directing MDs to the proper channels in getting the service covered).

Next meeting on October 11, 2007.

The North Carolina Rheumatology Association and the American College of Rheumatology are proud to announce the initiation of a North Carolina Rheumatology Listserve.

This Listserve will allow you to communicate with your rheumatology colleagues across the state. You may ask questions and make comments pertaining to rheumatology issues, and all those who have joined may respond as they desire. The NCRA and the ACR will monitor and contribute as well. Please note that your responses are viewed by many persons, and you should choose your words wisely in this regard.

The major items of concern for Rheumatology professionals included an update from CMS on coding changes, announcement of Program safeguard contractor CIGNA updates particularly on coding reviews and LCDs (Local Coverage Determination) changes. Dr. Honeycutt gave a review of the Comprehensive error rate review testing for the calendar year 2004 which was just completed.

There was also information on the PDP (Part D Pharmacy) benefit at the end of the meeting given in the question and answer period. The information from the NCMS should be especially helpful and should be noted by all Rheumatologists.

§ The Follow Up Consult codes 99261-99263 (inclusive) have been completely deleted. DO NOT USE THESE CODES!

§ The Confirmatory Consult codes 99271-99275 inclusive have been completely deleted. DO NOT USE THESE CODES!

§ The Nursing facility codes 99301-99303 and 99311-99313 (inclusive) have all been deleted and are replaced with 99304-99306 and 99307-99310, respectively. Please do not use the old codes for nursing facility care. USE THESE NEW CODES.

Dr. Honeycutt reported that there have been no cases of medical fraud reported in North Carolina in the last full reported year (2004). There have been 2 cases that have been closed: An ambulance case for dialysis where there was no medical necessity and a second case in Tennessee involving an oncologist administering on half of the chemo drug doses (while billing for full amount of drug).

Dr. Honeycutt reported that the OIG (Office of Inspector General) will be on the look out in 2005 and 2006 data for:
§ inappropriate use of excessive use of modifier -25 and -29 and
§ excessive unwarranted home visits

[It is my understanding that many rheumatologists have started to use the modifier -25 more frequently now than in the past. PLEASE BE AWARE THAT THE OIG WILL BE ON THE LOOK OUT FOR THIS. It is not inappropriate to use these modifiers for example in infusion patients so long as there is a medical necessity for the E & M service and the documentation is placed in the medical chart. CMS clearly told us (CSRO and ACR) last year that they will be more lenient in their review but this has not apparently deterred the OIG to be on the look out for excessive use of these modifiers.]

CIGNA Government services will begin having Public Relations Spring sessions coming up in 9 locations around the state. There will be nominal fees to cover the cost of materials. Information can be found on the CIGNA website under Education. CIGNA will collaborate with NCMS and other specialty societies and organizations to co-publish educational information.

Dr. Honeycutt or his staff will be available for educational talks to specialty groups as his schedule allows. (I think that we are very fortunate to have Dr. Honeycutt in this role. He has been most helpful cooperative and user friendly.)

LCD 21665 dealt with Erythropoietin analogs for non-ESRD (end stage renal disease) use. The new policy combines two previous policies into one and removes the reference to ESRD use entirely (this is well covered in the CMS Manual). The update centers on initial and continued use. There is no real change in coverage or indications. It just combined the two old policies into one. Two other inclusions were commented on in the open comment period on this. One comment was to include EPO use in stages I and II CRD and the other was to expand indications for EPO pre op use in surgeries other than the already approved pre-op ortho procedures.

NC LCD 9942 deals with Bone mineral density measurement revision that was mandated by law. Coverage was expanded three years ago at a previous review although the data was not entirely appropriate. This current LCD conforms to the coverage mandated by law. There are still many denials for coverage due to several factors:
§ 3rd party coverage
§ Insufficient documentation
§ Timing (CIGNA-Medicare will allows one DEXA scan every 23 months unless there is documentation that it is necessary earlier than that.)
§ Ignorance of criteria

There was another LCD on skin substitutes that does not affect us and I did not fully understand it anyway. It seems that some plastic surgeons and other surgeons are utilizing these manufactured skin analogues to be used as closures for large wound areas instead of conventional dressings. CIGNA Medicare says No! No! No!

IN the question and answer period, there were questions regarding the new consult rules (deleted codes, etc.). All additional care after a consult should be billed as subsequent medical care of an established patient and not as follow up consult. If a consultant assumes care after a consultation, the billing should be for subsequent care also. If the consultation was to transfer the care of the patient, the initial visit can be billed as a consult or a new patient hospital visit - your choice. But all subsequent care will be as above. Billing for multiple consults is possible when during one (likely prolonged) hospitalization, a consultant evaluates and assists in the management of one problem and signs off then is called back to address another problem later in the same admission.

Mandatory consultations will not be covered by CIGNA Medicare. Those consults that are mandated by 3rd parties or hospital decision for protocol are not necessarily covered by Medicare. Medicare payments are based on Medical necessity and not hospital or 3rd party policies.

One of the best parts of the meeting was an answer by NCMS regarding the problems that patients are having with the Part D Pharmacy benefit. The NCMS has set up a hotline /website (ncmdpartd.org) to assist patients in selecting a Part D Plan. The personnel seem to be very capable and knowledgeable. They have several forms which I have attached here. These forms explain the program and include a questionnaire that can be mailed or faxed. A phone number is at the bottom of the form for those who do not have access to fax or internet.