1. 2010 CMS Update Coding for Stroke and Pay for Performance 2010 CMS Update Coding for Stroke and Pay for Performance © Copyright 2009 NeuStrategy All rights reserved.

2. 1. Coding for Stroke -Drip and Ship Code -Critical Care Codes -”Telehealth” (Telemedicine) Codes 2. Pay for Performance -Physician Quality Reporting Initiative -Hospital Quality Reporting Initiative -Premier Hospital Quality Incentive Demonstration © Copyright 2009 NeuStrategy All rights reserved.

3. A Primer Coding Conventions CMS Annual Update Cycle © Copyright 2009 NeuStrategy All rights reserved.

4. Standardized Coding Conventions ICD-9-CM Codes (1) Hospital billing codes ◦Diagnosis codes and procedure codes  Pertinent to a hospital admission  Used to classify inpatients into a MS-DRG used to determine payment ◦V-codes  Report factors that may influence present or future care  Usually listed as a secondary diagnosis  Supplemental tracking codes used to facilitate data collection (1) International Classification of Diseases, 9th Revision, Clinical Modification © Copyright 2009 NeuStrategy All rights reserved.

5. Standardized Coding Conventions CPT ® Codes (1) Physician, laboratory, radiology and other billing codes ◦CPT I (2)  Medical or procedural service  Assigned a relative value unit based on skill and time required  Modifiers used to indicate that a service or procedure has been altered but not changed in its definition  Used to determine payment ◦CPT II  Supplemental tracking codes used for performance measurement ◦CPT III  Temporary tracking codes used to facilitate data collection for emerging technology, services and procedures (1) Current Procedural Terminology (2) Same as HCPCS Level I codes © Copyright 2009 NeuStrategy All rights reserved.

6. Standardized Coding Conventions HCPCS Codes (1) Physician and supplier billing codes ◦Level I codes  Same as CPT I codes  Medical or procedural service  Used to determine payment ◦Level II codes  Drugs and biologics  Medical items or services billed by suppliers other than physicians ◦ Ambulance services, durable medical equipment  Used to determine payment ◦G-codes  Supplemental codes used to measure quality of services (1) Healthcare Common Procedure Coding System © Copyright 2009 NeuStrategy All rights reserved.

7. CMS Annual Update Cycle Hospital Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) October - September Proposed Update May 1, 2009 Comment Period June 30, 2009 Final Rule August 27, 2009 Effective Date October 1, 2009 (1) Medicare Physician Fee Schedule (MPFS) Oct Aug Nov Jan Jul (1) Unless otherwise indicated Fiscal Year (FY) January - December Proposed Update July 1, 2009 Comment Period August 31, 2009 Final Rule November 1, 2009 Effective Date January 1, 2010 (1) MayJunFebMarApr SeptDec © Copyright 2009 NeuStrategy All rights reserved.

8. Coding for Stroke - Hospitals Drip and Ship © Copyright 2009 NeuStrategy All rights reserved.

9. Effective October 1, 2008Effective October 1, 2008 Coded by Hospitals Receiving PatientsCoded by Hospitals Receiving Patients Requires a primary diagnosis code of strokeRequires a primary diagnosis code of stroke V-Code is secondary diagnosisV-Code is secondary diagnosis Used for tracking purposes onlyUsed for tracking purposes only Will provide data for future payment decisionsWill provide data for future payment decisions Hospital Coding Update – Drip and Ship Source: Federal Register / Vol. 73, No. 161, August, 19, 2008, Changes to the Hospital Inpatient Prospective Payment Systems © Copyright 2009 NeuStrategy All rights reserved. V45.88 Status post administration of tPA in a different facility within the last 24 hours prior to admission at current facility ICD-9-CM

10. No changes on October 1, 2009No changes on October 1, 2009 Commenter's to proposed rule for CMS FY 2009/2010 requested expedited review: “Is the code being used?”Commenter's to proposed rule for CMS FY 2009/2010 requested expedited review: “Is the code being used?” CMS declined to reviewCMS declined to review Hospital Coding Update – Drip and Ship Source: Federal Register / August, 27, 2009, Changes to the Hospital Inpatient Prospective Payment Systems © Copyright 2009 NeuStrategy All rights reserved. V45.88 Status post administration of tPA in a different facility within the last 24 hours prior to admission at current facility ICD-9-CM

11. Coding For Stroke – Physicians Critical Care Codes © Copyright 2009 NeuStrategy All rights reserved.

12. Physician Coding Update – Critical Care Codes Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9, 2008, and AAN website for additional details CPT Definition – Critical Care CPT Definition – Critical Care “Critical care is defined as the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.” © Copyright 2009 NeuStrategy All rights reserved.

13. Coded by Physicians Managing Critically Unstable PatientsCoded by Physicians Managing Critically Unstable Patients Often under-utilized in the ED for stroke patientsOften under-utilized in the ED for stroke patients Based on services performed, not physician specialtyBased on services performed, not physician specialty More than one physician can if one or more critical illness(es) or injur(ies) in whole or in partMore than one physician can if one or more critical illness(es) or injur(ies) in whole or in part Physician Coding Update – Critical Care Codes © Copyright 2009 NeuStrategy All rights reserved. 99291 Critical Care Services - First hour (30-74 minutes) 99292 Critical Care Services - Each additional 30 minutes CPT Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9, 2008, and AAN website for additional details

14. Suggests high level of medical decision-making, “real time access and capability” Key requirements which must be met for critical care Medical necessity/criticality and intervention(s) Cumulative time spent with patient during 1 day coordinating care counts - reviewing labs, images, speaking with family, seeking consults, etc. Certain procedures that may be billable are included Physician Coding Update – Critical Care Codes Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9, 2008, and AAN website for additional details © Copyright 2009 NeuStrategy All rights reserved.

15. Physician Coding Update – Critical Care Codes © Copyright 2009 NeuStrategy All rights reserved. 99243New OP Consult – 40 min$ 99.26 99244New OP Consult – 60 min$ 155.78 99245New OP Consult – 80 min$ 194.75 99255New IP Consult – 100 min$ 203.55 CodeDescription Medicare Allowable Amount (1) (1) Medicare Allowable FY09 Area 99 (Orlando, FL) 99291Critical Care - 30-74 min$ 214.98 99292Critical Care–Each add’l 30 min$ 107.63 Payment Rate Recognizes Complexity of Care Payment Rate for “Routine” Care

16. New CPT III Codes implemented in July 2008New CPT III Codes implemented in July 2008 Coded by Physicians Managing Critically Unstable Patients RemotelyCoded by Physicians Managing Critically Unstable Patients Remotely RVUs not assignedRVUs not assigned Payment based on individual payer policyPayment based on individual payer policy Not on CMS’s list of approved telehealth services Physician Coding Update – Remote Critical Care Codes Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9, 2008 © Copyright 2009 NeuStrategy All rights reserved. 0188T Remote real-time video-conferenced critical care First hour (30-74 minutes) Remote real-time video-conferenced critical care First hour (30-74 minutes) 0189T Each additional 30 minutes CPT

17. Physician Coding Update – Critical Care Codes © Copyright 2009 NeuStrategy All rights reserved. CodeDescription Medicare Allowable Amount (1) 0188TRemote Critical Care - 30-74 min$ 0 0189TRemote Critical Care–Each add’l 30 min $ 0 (1) Medicare Allowable FY 09 Area 99 (Orlando, FL) 99291Critical Care - 30-74 min$ 214.98 99292Critical Care–Each add’l 30 min$ 107.63 Payment Rate for Critical Care Not on CMS list of approved telehealth services

18. Coding Update “Telehealth” or Telemedicine Codes © Copyright 2009 NeuStrategy All rights reserved.

19. Terminology Used in Discussing Telemedicine/TelehealthTerminology Used in Discussing Telemedicine/Telehealth Telemedicine or “Telehealth” The use of medical information exchanged from one site to another via electronic communications to improve a patient's health Electronic communication T he use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site Coding Update – Telemedicine Codes © Copyright 2009 NeuStrategy All rights reserved.

20. Terminology Used in Discussing Telemedicine/TelehealthTerminology Used in Discussing Telemedicine/Telehealth MSA = Metropolitan Statistical Area RHPS = Rural Health Professional Shortage area Originating Site  Distant Site Coding Update – Telemedicine Codes © Copyright 2009 NeuStrategy All rights reserved. Spoke Hub Metropolitan Statistical Area - A geographic cluster of population defined by the United States Census Bureau. An MSA includes a city of at least 50,000 people or urbanized area of at least 100,000 people and the counties that include these areas. Hospital where patient is located Location of the physician delivering the medical service

21. Medicare telemedicine reimbursement is conditioned by:Medicare telemedicine reimbursement is conditioned by: Type of services provided *Type of services provided * Interactively with video/audio communications Communication must occur between patient and remote physician Professional services must be within a certain range of CPT codes Geographic locationGeographic location Originating site must be in a non-MSA county or RHPS area No limitation to the location of the physician delivering the medical service Type of institution delivering the services (originating site)Type of institution delivering the services (originating site) For stroke, must be a hospital (including critical access hospital) Type of providerType of provider For stroke, must be a physician Coding Update - Telemedicine Codes *Some exceptions exist for Federal telemedicine demonstration projects in Alaska and Hawaii © Copyright 2009 NeuStrategy All rights reserved.

22. Medicare Designated Telehealth ServicesMedicare “Designated Telehealth Services” The use of a telecommunication system may substitute for face-to-face, “hands on” encounter for designated telehealth services Effective January 1, 2008Effective January 1, 2008 Physician Coding Update – Telemedicine Codes © Copyright 2009 NeuStrategy All rights reserved. 99241- 99255 99241- 99255 IP/OP Consultations Minor to Severe Problem 15 min-110 min IP/OP Consultations Minor to Severe Problem 15 min-110 min 99201- 99215 99201- 99215 Office or OP Visits Minor to Severe Problem 5 min-60 min Office or OP Visits Minor to Severe Problem 5 min-60 min Refer to CMS Manual Pub 100-02, Transmittal 74, June 29, 2007 CPT

23. Coded by Physicians Performing Follow-up Inpatient Telehealth ConsultationsCoded by Physicians Performing Follow-up Inpatient Telehealth Consultations Effective January 1, 2009 Physician cannot be attending physician Services include related services before, during and after communicating with the patient via telehealth Conditions for payment are the same Physician Coding Update – Telemedicine Codes © Copyright 2009 NeuStrategy All rights reserved. G0406 Follow-up Inpatient Telehealth Consultation (Limited) G0407 Follow-up Inpatient Telehealth Consultation (Intermediate) G0408 Follow-up Inpatient Telehealth Consultation (Complex) Refer to CMS Manual Pub 100-04, Transmittal 1654, December 24, 2008 and MLN JA 6130, January 5, 2009 HCPCS

24. GT Modifier must be used to: designate interactive audio and video telecommunication systems certify that patient was present at an eligible originating site Physician reimbursed as if he/she was on-site Claims are submitted to carrier in physician’s service area Physician Coding Update – Telemedicine Codes © Copyright 2009 NeuStrategy All rights reserved. Refer to CMS Manual Pub 100-04, Transmittal 1654, December 24, 2008 and MLN JA 6130, January 5, 2009 99241-99255 99201-99215 G0406-G0408 IP/OP Consultation Follow-up inpatient Telehealth Office or OP Visits

25. Physician Coding Update – Telemedicine Codes © Copyright 2009 NeuStrategy All rights reserved. CodeDescription Medicare Allowable Amount (1) (1) Medicare Allowable FY 09 Area 99 (Orlando, FL) G0406F/U Inpatient Telehealth Consultation (15 min) $ 37.40 G0407F/U Inpatient Telehealth Consultation (25 min) $ 66.84 G0408F/U Inpatient Telehealth Consultation (<35 min) $ 95.85 99255New IP Consult – 100 min$ 203.55 Payment Rate for Initial Critical Care Payment Rate for Follow-up Care

26. Medicare Facility” Services for Spoke HospitalsMedicare “Facility” Services for Spoke Hospitals Additional payment billed separately to CMS Part B Conditions for payment are the same Payment rate updated annually 2009 rate is $23.72 “Are spoke hospitals billing for the facility fee?2009 rate is $23.72 “Are spoke hospitals billing for the facility fee? Variable – “not worth the effort to bill” Hospital Coding Update – Telemedicine Codes Refer to Federal Register / Vol. 73, No. 161, August, 19, 2008, Changes to the Hospital Inpatient Prospective Payment Systems © Copyright 2009 NeuStrategy All rights reserved. Q3014 Tel ehealth facility fee Originating Site HCPCS

27. H.R. 2068 Medicare Telehealth Enhancement Act Sponsored by Rep. Mike Thompson, D-CA Would eliminate geographic restrictions on reimbursement Would provide grants for development of telehealth networks House Ways and Means Committee Approved Components of H.R. 2068 for inclusion in H.R. 3200 Establishment of a Telehealth Advisory Committee to advice Secretary of HHS on CMS policies concerning telehealth Clarifies hospital credentialing requirements of telehealth providers Authorizes renal dialysis facilities to participate in telehealth Not included: Removal of geographic restrictionsRemoval of geographic restrictions Licensing of physicians to practice across boardersLicensing of physicians to practice across boarders Public Policy Efforts - Telehealth 1 Refer to Center for Telehealth and E-Health Law for more information © Copyright 2009 NeuStrategy All rights reserved.

28. 2. Pay for Performance -Physician Quality Reporting Initiative -Hospital Quality Reporting Initiative -Premier Hospital Quality Incentive Demonstration © Copyright 2009 NeuStrategy All rights reserved.

29. Pay for Performance Physician Quality Reporting Initiative © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/pqri/www.cms.hhs.gov/pqri/ www.qualitynet.org

30. 2006 – Physician Quality Reporting System established Financial incentive to report data on quality measures Voluntary for eligible professionals MD, DO NP, PA, Clinical Psychologist, Registered Dietitian, etc. PT/OT/SP Audiologists (added in 2009) 74 clinical quality measures74 clinical quality measures None specific to strokeNone specific to stroke Reporting occurred via claims submission (on same claim as associated professional services) Physician Quality Reporting Initiative (PQRI) © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/pqri/www.cms.hhs.gov/pqri/ www.qualitynet.org

31. Bonus payment available Must satisfactorily report of the 3 quality measures for at least 80% of cases in which chosen measure is reportable Provider is subject to validation by CMSProvider is subject to validation by CMS Bonus - 1.5% of TOTAL allowed charges for covered professional services Lump sum payable ~ July 2008Lump sum payable ~ July 2008 No public reporting Physician Quality Reporting Initiative (PQRI) © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/pqri/www.cms.hhs.gov/pqri/ www.qualitynet.org

32. 6,722,753 Measures Reported $3,600,000 Bonus Payments (1) 109,349 Attempted to Participate 56,722 Satisfactorily Reported $4,713 Average Bonus Earned 3.6 Average Measures Reported Physician Quality Reporting Initiative (PQRI) (1) Expected Source: www.cms.hhs.gov Fact Sheet “PQRI Makes Payments for the 2007 Reporting Periodwww.cms.hhs.gov CY 2007 Reported Experience © Copyright 2009 NeuStrategy All rights reserved.

33. CY 2009 – Physician Quality Reporting System is permanent Still voluntary Bonus payment – increased to 2% Measures expanded 153 clinical quality measures 153 clinical quality measures 8 measures relate to stroke care8 measures relate to stroke care Operates on a calendar year with variable reporting periods Nine (9) different options for reporting Claims submission or clinical registry Individual or group measures Physician Quality Reporting Initiative (PQRI) © Copyright 2009 NeuStrategy All rights reserved. Source: Federal Register, November 19, 2008 Section 01, MPFS

34. “Stroke Related” Measures 10. CT or MRI of brain within 24 hrs of hospital admission 11. Carotid Imaging Reports with reference to stenosis measurements 31. DVT prophylaxis received by end of hospital day two 32. Discharged on Antiplatelet Therapy 33. Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge 34. Tissue Plasminogen Activator (t-PA) Considered (<3 hrs) 35. Screening for Dysphagia 36. Consideration of rehabilitation services is documented 114. Inquiry Regarding Tobacco Use 115. Advising Smokers to Quit © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/pqri/www.cms.hhs.gov/pqri/ www.qualitynet.org Physician Quality Reporting Initiative (PQRI)

35. Outcome™ PQRI Partner Program CMS-qualified web-based registry Allow hospitals to leverage data already collected for physicians ~100 practices using it A few Get-With-The-Guidelines hospitals using it to provide physicians with their patient’s data Anticipate more neurologist will be interested Consider it as an alignment strategy with your neurologists Physician Quality Reporting Initiative (PQRI) © Copyright 2009 NeuStrategy All rights reserved. Refer to www.outcome.com/pqri.htm for more informationwww.outcome.com/pqri.htm

36. CY 2010 – New Elements Still voluntary Last year for Bonus Payment Group practices can qualify for incentive payment Names of physicians and groups satisfactorily reporting will be on CMS website A number of reporting options and report periods available Data captured through registries due in 2011 Adds an electronic medical record (EHR)-based reporting mechanism Physician Quality Reporting Initiative (PQRI) © Copyright 2009 NeuStrategy All rights reserved. Source: Federal Register July 13,, 2009 and August 5, 2009 Proposed Rule Section 02 MPFS Number of Measures Available 74 119 153 175 Proposed

37. Pay for Performance Hospital Quality Reporting Initiative © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/hospitalqualityinitwww.cms.hhs.gov/hospitalqualityinit www.qualitynet.org

38. 2004 – Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) established Financial incentive to report data on quality measures Voluntary but….must report designated quality measures to get full inflation-adjusted MS-DRG rates for the next year Non-reporting hospitals get 2% reduction in annual inflation adjustmentNon-reporting hospitals get 2% reduction in annual inflation adjustment Quality measures are publically reported www.hospitalcompare.hhs.gov 2009 – 99% of hospitals participated 97% received full inflation adjustment2009 – 99% of hospitals participated 97% received full inflation adjustment Hospital Quality Reporting Initiative (PQRI) © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/hospitalqualityinitwww.cms.hhs.gov/hospitalqualityinit www.qualitynet.org

39. Quality Measures - Inpatient Includes measures for 10 most common Medicare inpatient diagnoses Heart Attack Heart Failure Pneumonia Also includes Surgical (SCIP) Mortality Patient Experience Measures are be calculated using claims data and others from abstracted clinical data, survey data or individually reported Hospital Quality Reporting Initiative (HQI) © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/hospitalqualityinitwww.cms.hhs.gov/hospitalqualityinit www.qualitynet.org Number of Measures Required 10 69 Proposed 30 4346

40. Quality Measures – Outpatient 7 outpatient measures added in 20097 outpatient measures added in 2009 Includes 5 Emergency Department measures 2 Perioperative care measures Also includes 4 imaging efficiency measures Some measures will be calculated using claims data and others from abstracted clinical data Hospital Quality Reporting Initiative (HQI) © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/hospitalqualityinitwww.cms.hhs.gov/hospitalqualityinit www.qualitynet.org

41. CMS FY 2009 – Proposed Stroke Quality Measures STK-1 DVT Prophylaxis STK-2 Discharged on Antithrombotic Therapy STK-3 Patients with Afib Receiving Anticoagulation Therapy STK-5 Antithrombotic Medication by End of Day Two STK-7 Dysphagia Screening Included measures must be endorsed by National Quality Forum (NQF) stroke quality measures were not adoptedDue to lack of endorsement by NQF at the time of release of the final CMS inpatient rules, stroke quality measures were not adopted Hospital Quality Reporting Initiative (HQI) © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/hospitalqualityinitwww.cms.hhs.gov/hospitalqualityinit www.qualitynet.org

42. CMS FY 2010– Stroke “Measure” Adopted Participation in a systemic clinical data registry for stroke care Considered a “structural” measure Applicable to all hospitals Report once annually, submit via web-based tool (www.qualitynet.org) Effective 1/1/2010 Participation in a registry is not requiredParticipation in a registry is not required Report whether you participate If so, report, which registry AHA/ASA Get-With-The–Guidelines Registry is referenced Hospital Quality Reporting Initiative (HQI) © Copyright 2009 NeuStrategy All rights reserved. Source: Federal Register / August, 27, 2009, Changes to the Hospital Inpatient Prospective Payment Systems

43. CMS FY 2011– Future Outlook Eight (8) NQF endorsed stroke measures referenced A stroke mortality measure Anticipate EHR-based submission (piloting as early as 7/1/09) CMS FY 2012CMS FY 2012 Focus on improving reliability and quality of the process CMS will randomly select 800 hospitals annually and will validate 12 medical records on a quarterly basisCMS will randomly select 800 hospitals annually and will validate 12 medical records on a quarterly basis Hospital Quality Reporting Initiative (HQI) © Copyright 2009 NeuStrategy All rights reserved. Source: Federal Register / August, 27, 2009, Changes to the Hospital Inpatient Prospective Payment Systems

44. Pay for Performance Premier Hospital Quality Incentive Demonstration © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/hospitalqualityinitwww.cms.hhs.gov/hospitalqualityinit

45. CMS Hospital Quality Initiative - 3 Year Demonstration Project (beginning in 2006) Pay for “results” Selected hospitals paid a bonus for their performance on quality measures Heart attack, heart failure, pneumonia, CABG, hip and knee replacement Scored on quality measures related to each condition top 20%Hospitals in the top 20% will be recognized and given a financial bonus lower 20%By year 3 underperforming hospitals in lower 20% could receive lower payments Premier Hospital Quality Incentive Demonstration © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/hospitalqualityinetwww.cms.hhs.gov/hospitalqualityinet

46. Demonstration Project was extended through 2009 Purpose Test new payment models Test new ways to measure quality Test methods to provide information to support designing value-based purchasing modelsTest methods to provide information to support designing value-based purchasing models Premier Hospital Quality Incentive Demonstration © Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/hospitalqualityinitwww.cms.hhs.gov/hospitalqualityinit

47. Discussion Questions © Copyright 2009 NeuStrategy All rights reserved.

48. Presentation is available at www.neustrategy.com www.neustrategy.com Thank you © Copyright 2009 NeuStrategy All rights reserved. Please Note: Coding and reimbursement information provided is gathered from sources referenced on each slide and is presented for informative and illustrative purposes only. By making this information available, neither the author nor NeuStrategy, Inc. make representation or warranty regarding its completeness, accuracy, timeliness, or applicability for a particular patient case. This information does not constitute reimbursement or legal advice. Laws, regulations and payer policies concerning reimbursement are complex and change frequently. Providers are responsible for making appropriate decisions relating to coding and reimbursement submissions. Accordingly, the author and NeuStrategy, Inc. recommend that you consult with your payers, reimbursement specialist and/or legal counsel regarding coding, coverage and reimbursement matters.

49. NEUROLOGY AND STROKE CALL SURVEY RESULTS AVAILABLE Save-the-Date Webinar December 10, 2009 60 Minutes 2 pm ET / 1 pm CT 12 pm MT / 11 am PT