Orthopedic Coding Alert

CMS pulls back on some proposed changes.

With ICD-10 and CPT^® code changes on the radar, you don’t want to miss other healthcare news that may affect your reimbursement starting in the new year. Review some of the general policy updates to keep your practice’s reimbursement flowing in 2016.

Rejoice Over Stalled Incident-To Changes

According to experts, despite previous indications, incident-to rules remain unchanged for 2016, in that a physician who initiates a patient’s care at an initial visit may be in the office when a non-physician practitioner (NPP) or a mid-level provider (MLP) sees his patient during another separate encounter. The practice can then bill the service “incident to” the physician, under the physician’s national provider identifier (NPI), for 100 percent reimbursement. To bill incident-to, the physician supervising the incident-to service does not have to be the same one who originally saw the patient, but does have to be part of the same practice and associated with that NPP/MLP.

Important: This reverses a rule change that would have gone into effect on Jan. 1, 2016, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook. “This reversal of the rule change means more NPPs can bill incident-to services directly to Medicare at 100 percent reimbursement when any physician is in the office suite,” he adds.

Ferragamo points to Health Law Update’s (Baker Hostetler) recent article “ Proposed Rule Aims to Reduce Stark Regulations and Clarify ‘Incident To,’” which states “... we are aware of communication from CMS after the proposed rule was published indicating that the revisions were intended to clarify that the ordering and supervising physician/NPP do not need to be the same person. Stakeholders are encouraged to submit comments on this issue to ensure that the regulations accurately capture CMS’s intended policy.”

Background: In the July 15 proposed Medicare Physician Fee Schedule (MPFS), CMS suggested deleting a portion of the incident-to regulations that stated that the physician “supervising the auxiliary personnel need not be the same physician [or NPP] upon whose professional service the incident to service is based.” This change confused coders and experts alike, and many worried that the change meant the ordering physician must also be the supervising physician, and thus the billing provider.

Still relevant: CMS also proposed that the person providing the incident-to service does so in accordance with state law and is licensed to do it. The incident-to provider also cannot have been excluded from any federal health care program or have had their enrollment revoked for any reason. In other words, just because the service is billed under a supervising doctor’s number doesn’t mean the performing NPP can be excluded from Medicare. These guidelines will still apply, even though the supervision changes did not go through.

More details: You can read the article from Health Law Update at www.bakerhealthlawupdate.com/2015/07/proposed-rule-aims-to-refine-stark-regulations-and-clarify-incident-to.

Don’t Write Off Global Periods

At the end of 2014, CMS put forth a proposal in the Federal Register that shocked many coding professionals. Under the plan, the current 10-day global codes would transition to 0-day in 2017, and the 90-day global codes will change to 0-day in 2018. “This certainly would have resulted in a pay cut for surgeons,” Ferragamo says.

Update: The Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) reversed the decision of CMS to eliminate bundled payments for 10- and 90-day global surgical procedures.

“It’s hard to say definitively if the removal of global period would be good or bad for physicians as I think there are good and bad aspects,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with Peace Health in Vancouver, Wash. “Certainly the potential is there for surgeons to [provide better treatment and more attention] for patients who are very sick and require more follow-up or for patients who develop complications. At this time, Medicare bundles all of that.” On the other hand, Bucknam says surgeons would need to change their thinking and their documentation, improving the details they include, for post-operative visits or face drastic reductions in reimbursement.

Change may still come: “Unfortunately, we will likely see this pay cut in global payments in the near future,” Ferragamo says.

Bucknam agrees: “I do think that CMS will eventually eliminate global periods one way or the other,” she says. “Consider the proposals to bundle payments for hospital care. Hospitals do not have a global period for surgery. That is particularly for physicians. If payments are bundled I think it is likely the global period concept will not apply. There are also some other new payment methodologies that are being tossed about that would work much better if a global period wasn’t part of the equation.”

Observation Care Will Require Notice to Patients

Observation care can be confusing from a billing standpoint, but it is even more puzzling for patients who think they were admitted to the hospital as inpatients, when in actuality they were simply in the observation unit. That confusion will soon end, however, thanks to a new bill that President Obama signed into law on August 7.

The Notice of Observation, Treatment and Implication for Care Eligibility Act (NOTICE Act) requires hospitals to inform Medicare beneficiaries in observation care that they are outpatients — and not inpatients — and whether they will face cost-sharing implications as a result of that outpatient status. In addition, the notice has to inform patients that they will not be eligible for post-discharge skilled nursing facility (SNF) services since SNF coverage requires a three-day inpatient stay in the hospital.

Although patients cannot typically change to inpatient status after receiving the notice, they can at least make an informed decision of whether or not to pursue post-discharge skilled nursing care, which will cost more due to the lack of an inpatient stay.