Value-Based Care Leads to Higher Prices for Surgical Complexities

A study discloses that as a result of value-based care payment reforms, surgical complications now lead to increased prices for both hospitals and 3^rd-party payers.

As a result of recent attempts to bring value-based care to the reimbursement cycle, it is now more significant for both providers and payers to gain an understanding about the link between costs and surgical complications, in accordance to a recent study in The Journal of the American Medical Association.

Surgical complications are growingly leading to financial penalties and poor performance on quality metrics tied to payments, which are raising prices for both hospitals and third-party payers. As an outcome, both groups are now financially supported to promote surgical quality improvement, claimed a research team from the University of Michigan Ann Arbor.

“Perhaps the best representation of the financial burden absorbed by hospitals is profit margin,” the team wrote. After conducting a study, researchers analyzed that overall hospital profit margins shrank from 5.8% for patients without complications to 0.1% for patients with complications.

AMA extending its tech incubator partnerships

The AMA is teaming with IDEA Labs, a technology incubator, to work with students at 5 universities who are establishing new technologies for physicians that take into account how practices really operate.

In various ways, technology has not made healthcare simpler because the technology is clunky and was not designed to support physician practice workflows, says James Madara, MD, CEO and executive vice president of the American Medical Association. Electronic health records are a prime instance, he adds, noting that unlike other industries, “healthcare is not a linear manufacturing process; it is more of a systems engineering issue.”

Another issue with technology development is monolithic—the belief that a product will work throughout a delivery system when it is not flexible enough to do so, Madara notes. “There are institutions that establish their own innovation labs, but while the products are helpful within their walls, they aren’t scalable elsewhere.”

Are you Still Confused to Choose a right EHR for you?

Introduction

If you're still weighing the pros and cons of an electronic health record (EHR) purchase, consider this: Forget about going to an EHR because the government may or may not force you to comply. Think of improving your practice and perhaps your quality of life with the benefits of an EHR. Your coding compliance will increase. You'll have access to data about your practice and patients that would be impossible with a paper chart. An EHR will have a major impact on your practice and the way that you currently triage patients in the office. Here are common scenarios in offices without an EHR: A paper chart is expensive to produce and you can never seem to find it when you need it most. A chart audit will most likely confirm that your documentation does not add up to the code reported. In my chart reviews I find that physicians are either under coding or under documenting services performed and that approximately 30% of handwritten charts are not compliant. Although choosing the right EHR can be confusing, these 10 steps can help ensure that you'll be happy with your selection.

1. Take a closer look at ASP technology.

Application service provider (ASP) technology means that the EHR program and data are housed securely at a vendor's or institution's location; you don't need to have expensive servers and tech support in your office if you have high-speed Internet access. The ASP EHR model will range from about $350 to $650 per month, plus training. Billing software will be an additional cost. The other option is buying an EHR that requires an in-house server and software. Systems like this that I reviewed averaged between $40,000 and $60,000 depending on the amount of bells and whistles added. With ASP models, benefit changes and software improvements are continually updated on your site so that your practice is always using the most recent data and advanced software. You don't need proprietary hardware or additional servers. You do not need to house your own server, and many systems have a minimal cost up front. You also will be able to log in from home to view patient data and reports. The downside to ASP technology is that when the Internet is down, so are you. Make sure you have good, stable Internet service before considering this option.

2. Take your time and evaluate companies thoroughly.

Two good resources for starting your search are the KLAS reports and CCHIT- certified companies. The KLAS rating will show you detailed information from physicians about software performance and cost. CCHIT (Certification Commission for Health Information Technology) is an independent organization that performs certification criteria and inspections for EHRs. Products must significantly exceed minimum federal-standards requirements, are rated for usability, and are verified to be in use successfully at multiple sites, according to the CCHIT Website. You may consider hiring a consultant to help you review your practice's EHR needs. There are several places to locate a consultant with experience. Try your local chapter of the American Medical Association or the National Society of Certified Healthcare Business Consultants. The NSCHBC's Website (www.nschbc.org) lists consultants by state.

3. Check out your software vendor.

Ask for references in your specialty. Call practices that have worked with the vendor and ask about downtime, software support, and overall satisfaction with the software. Choosing a company is half the battle. What will you be married to after the salespeople leave? Once you have done your research, choose 2 or 3 top contenders and then compare what I call the "nuts and bolts," which is the daily interaction with the EHR company.

4. Evaluate the EHR company's daily support structure.

How does the company handle support calls? Some companies require you to send an email with the problem described. These emails may be handled outside of the United States and may be processed by a computer rather than a human being. You will get to speak to a real person only when the email consultation fails. Email is a frustrating medium when your software won't work. Make sure that you are comfortable with your vendor's support system.

5. Make sure the company interfaces with your laboratory.

Most companies can build an interface for lab data. Make sure you ask about the cost of the interface. Some companies will charge as much as $5,000 plus a monthly fee for an interface.

6. Scrutinize the medical notes preloaded in the EHR.

If you find that most of the data preloaded in the system will not fit within your scope of practice, pass up using that EHR. It has been my experience that it is too overwhelming to learn a new EHR and build templates at the same time. If you have to build it yourself, take a pass and find a company that suits your needs.

7. Research the billing package.

The EHR is only part of the purchase. Discuss the billing package of your new system in detail. Must-haves in billing software: CPT and ICD-9 codes updated yearly. You want a system that automates this process. Most cutting-edge billing software will automatically update codes every year with a download. Automated statements will save you time and money. Most vendors offer this service at a discounted rate compared with postage. You will get to take advantage of the bulk discount rate. Automated verification of benefits is a big plus for family practice or internal medicine groups. The patient benefits are downloaded into the system. Copays and deductibles are easily identified and save staff hours of time. Your copay can be as much as 30%-40% of your income on an exam, so this is a significant benefit to your practice. Rejected claim reports. Most vendors will tell you that they have a "claim-scrubbing process." The software scrubs the claims for several different factors, and therefore reduces error. This is true to some extent. Invalid CPT codes and ICD-9 codes without the fifth digit are screened by this process as are claims with other basic coding errors. The most important factor in billing software is the ability to load LCD or CCI edits and specific carrier-required modifiers. An example of this is screening colonoscopy or well exams. Most carriers only cover a specific diagnosis for these procedures. Good billing software will warn you if you are not billing the service with a covered diagnosis. This tool is a major benefit for billing staff. Electronic posting of payments. This service is a real time-saver. A 20-page EOB from Medicare can be downloaded in seconds. The software posts all payments, adjustments, and rejections. You receive a report of all postings for review. EDI transmission reports are extremely important to your billing success. Investigate how the company reports provide you with a list of claims transmitted. Carrier errors and rejections should be easy to access. You will also want proof of timely filing to be at your fingertips.

Hints for Introducing an EHR to Your Practice

8. Add the scheduling and billing module first before bringing on the EHR.

If you are adding a new billing system and EHR at the same time, I highly recommend that you add the scheduling and billing system first. This will give you time to populate that patient demographics and allow staff the time to train and become efficient with the scheduling software.

9. Set aside enough time to train.

Regardless of how great the EHR performs, you will not be able to enjoy its full benefits if your staff is not fully trained. Lighten your workload on the first few days of training. Don't schedule meetings or take outside calls if they are not completely necessary. Devote your time allowed for training to the trainer. I have seen an office spend several thousand dollars for training and not get the full benefit because the patient load was too heavy or other activities were planned at the same time. When the trainer leaves, you will be lost if your staff aren't fully trained. I recommend that you schedule 3-5 full training days with a follow-up of 2 more days in a couple of weeks. You can absorb only so much information in a single session. I also advise clients to request a seasoned trainer. EHR sales have sparked in the last 2 years and companies are hiring new trainers. Make sure that if you have a new trainer, the company will send an experienced representative to assist.

10. Prepare yourself and your staff for change.

Even with the best EHR system, you will experience confusion, frustration, and tears. Why? Because everything changes and the prized paper chart is gone. You will forget about your beloved paper after a few weeks of using the EHR, however. Educate your staff about the transition. Prepare them for confusion in the first couple of weeks. I recommend against using a dual system of paper charts and EHR. Make the break from paper and suffer through the transition. You made the purchase in order to get rid of the paper. In the end you will have devoted a great deal of time and some financial resources that will pay off for your practice. You will reap the benefits of change. You will wonder why you waited so long, and your beloved paper chart will be all but a bad memory.

Spirometry Billing (A Reimbursement Guide)

Who should have Spirometry Testing? In earlier times there was no any real concept that how to get reimbursement against the spirometry. Afterwards, in 1994, the American Thoracic Society published an official statement of “Standardization of Spirometry.” In this statement there was seen a potential indications for Spirometry, some of which may not be covered by Medicare or other payors:

• To assess therapeutic interventions (e.g., bronchodilator therapy, steroid treatment, management of CHF, etc.)


• To assess preoperative risk


• To screen individuals at risk of having pulmonary diseases (e.g., smokers, occupational exposures)*


• To assess health status before enrollment in strenuous physical activity programs*


• To assess patients as part of a rehabilitation program*


• To assess risks as part of an insurance evaluation*


• To assess individuals for legal reasons (e.g., Social Security. personal injury lawsuits)*

*These Indications are generally not covered by Medicare. What Codes describe spirometry procedures? What are the associated payment rates? The current Procedural Terminology (CPT) codes defined below are the most common codes used to describe spirometry procedures performed. The simplicity Spirometer does not perform a respiratory flow volume loop (CPT code 94375). Note: According to the Centers for Medicare and Medicaid Service (CMS) Correct Coding Initiative, none of the procedures described by the CPT codes listed below may be billed together on the same date of service. Please consult the latest version of the National Correct Coding Policy Manual to identify rebundling combinations. Edits may be reviewed at www.cms.hhs.gov/physicians/cciedits/default.asp

CPT Code **	Description	Unadjusted 2005 Medicare Allowable***
94010 (may not be billed with 94060 or 94375 on same DOS)	Breathing capacity test	$33
94060 (may not be billed with 94010 or 94375 on same DOS)	Evaluation of wheezing (pre-and post-bronchodilator)	$55
94375 (may not be billed with 94060 or 94375 on same DOS)	Respiratory flow volume loop	$36

** Most commonly used CPT codes for spirometry. Additional codes may be found in the Current Procedural Terminology (CPT) Manual published by the American Medical Association. All spirometers may not perform all procedures identified by CPT codes. The existence of CPT codes does not guarantee coverage of payment for any device by any insurance carrier of Medicare. Medical necessity must be established by the patient’s physician in accordance with specific coverage policy guidelines. *** Medicare allowable amounts vary by geographic region. What documentation is needed to support payment for spirometry procedures? Many Medicare Part B carriers have published Local Medical Review Policies (LMRP) that describe specific coverage guidelines for spirometry procedures. For example Upstate Medicare in New York offers the following list of ICD-9 codes, which may help support the medical necessity for spirometry testing. These codes may not be applicable in other regions of the country. For definitive coverage and payment information contact your local Part B carrier. What are general coverage guidelines for spirometry under the Medicare Program? · Local Medical Review Policies have been written by many Part B carriers, and copies may be requested through customer’s local Medicare Part B Carrier. · The appropriate combination of tests may be coded if proper clinical indication exists. Consult local medical necessity policy for Correct Coding guidelines and unbundling information. · The Medicare Program specifically excludes coverage for screening tests, including;

• Spirometric assessment of an asymptomatic patient, with or without high risk of lung disease;


• Studies as part of a routine examination; and


• Studies as part of an epidemiologic survey.

Reference:

1. American Thoracic Society (1995). Standardization of spirometry, 1994 update. Am J Respir Crit Care Med. 1995;152:1107-1136.


2. American Medical Association. Current Procedural Terminology. Professional Edition.


3. Physician fee Schedule: payment policies and relative units. Federal Register Vol. 69, No. 219, November 15, 2004.


4. Local Medical Review Policy. Pulmonary Function Testing. 2003. Update Medicare Division, New York.


5. American Medical Association. International Classification of Diseases, ICD-9-CM.

HHS HealthBeat (December 17, 2010)

Weight training after breast cancer

From the U.S. Department of Health and Human Services, I’m Ira Dreyfuss with HHS HealthBeat.

Women who get breast cancer treatment may develop possibly painful swelling in the arm or side affected by treatment, such as removal of lymph nodes near the breast with cancer. These nodes ordinarily hold and drain fluid, and the fluid can then back up.

But a study finds that a program of slow but increasing weight training can cut the risk of the condition, which is called lymphedema. At the University of Pennsylvania School of Medicine, Dr. Kathryn Schmitz looked at data on 154 women. Half of the women lifted weights twice a week:

``Women who did the weight training were less likely to have increases in arm swelling than women who did not do the weight training.’’ (6 seconds)
The study in the Journal of the American Medical Association was supported by the National Institutes of Health.

Learn more at hhs.gov.

HHS HealthBeat is a production of the U.S. Department of Health and Human Services. I’m Ira Dreyfuss.
Last revised: December, 16 2010