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1WSMOS – March 2014. Medicare Changes & Issues 2014 Richard W. Whitten, MD, FACP Contractor Medical Director - Medicare Vice-Chair, AMA/Specialty Society.

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Presentation on theme: "1WSMOS – March 2014. Medicare Changes & Issues 2014 Richard W. Whitten, MD, FACP Contractor Medical Director - Medicare Vice-Chair, AMA/Specialty Society."— Presentation transcript:

1 1WSMOS – March 2014

2 Medicare Changes & Issues 2014 Richard W. Whitten, MD, FACP Contractor Medical Director - Medicare Vice-Chair, AMA/Specialty Society RUC 2000-2006 Member, CPT ® Assistant Editorial Panel 2007-2010 dick.whitten@noridian.com

3 3WSMOS – March 2014

4 4 Disclosure of Financial Relationships Richard W. Whitten, MD Has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

5 5WSMOS – March 2014 IPPS; OPPS & “Observation” Other specific issues Where we’re headed… Q&A Issue Updates

6 6WSMOS – March 2014

7 7 IPPS; OPPS & “Observation” Other specific issues Where we’re headed… Q&A Issue Updates

8 8WSMOS – March 2014 “2-Midnight Rule”: count time from the initial outpatient clinical service If admission decision made after patient has passed midnight as outpatient and MD expects patient to require additional midnight, OK Unexpected transfer or death exceptions Treating MD must “certify” admission is appropriate Treating MD must write admission order Verbal order must be signed Observation vs. Admit

9 9WSMOS – March 2014 “…the physician should generally order an inpatient admission when he or she has determined either that the beneficiary requires care at the hospital that is expected to transcend at least 2 midnights or that it will involve a procedure designated by the OPPS as an inpatient- only procedure.” Observation vs. Admit 2

10 10WSMOS – March 2014 “…difficult to make a reasonable prediction, the physician should not admit the beneficiary…” “regulation is framed upon a reasonable and supportable expectation [of a 2-midnight stay], not the actual length of care” “We do not believe beneficiaries treated in an intensive care unit should be an exception to this standard, as our 2-midnight benchmark policy is not contingent on the level of care required.” Exception: New-onset mechanical ventilation Observation vs. Admit 3

11 11WSMOS – March 2014 “2 midnight presumption” Focus: “LOS crossing only 1 midnight” or less Monitor longer stays Admission must be medically necessary Documentation No social/convenience admits Billing time: starts after order and patient begins receiving inpatient services Observation vs. Admit 4

12 12WSMOS – March 2014 Reviews to ensure that the services provided were medically necessary Reviews to ensure that the stay at the hospital was medically necessary Reviews to validate provider coding and documentation as reflective of the medical evidence CERT Reviews under the Improper Payments Elimination and Recovery Improvement Act of 2012 (Pub. L. 112-248) Reviews directed by CMS or other authoritative governmental entity (including, but not limited to, the HHS Office of Inspector General and Government Accountability Office) 12 Medical Review Unaffected by 2-Midnight Rule

13 13WSMOS – March 2014 Expand the scope of telehealth originating sites to include all rural health clinics (RHCs) Add Transitional Care Management services codes: 99495 & 99496 and maintains 30 day timeframe “Chronic Care Management” CMS agrees with the logic, rationale & need - Stay tuned... Telehealth Services

14 14WSMOS – March 2014 Establish criteria for Category A IDE trials to conform to appropriate scientific and ethical standards Same requirements for Medicare coverage of Category B IDE device trials Voluntary centralized Medicare review process FDA-Approved Investigational Device Exemption Studies

15 15WSMOS – March 2014 “We solicited comments in the CY2014 proposed rule regarding the appropriateness of the billing of E/M services by chiropractors although we did not propose to pay chiropractors for E/M services in 2014” “very few commenters submitted comments that addressed all...” Chiropractors Billing E&M Services

16 16WSMOS – March 2014 https://itunes.apple.com/us/app/open-payments- mobile-for-physicians/id667567467?mt=8

17 17WSMOS – March 2014 Updated LCDs on website as of April 10 End-to-End Testing: July 21-25 Only 32 selected per MAC Volunteer forms are available on website Completed volunteer forms are due March 24 Front-end testing – available weekly ICD-10-CM

18 18WSMOS – March 2014 IPPS; OPPS & “Observation” Other specific issues Where we’re headed… Q&A Issue Updates

19 19WSMOS – March 2014 Medicare Functional Environment ZPICs OIG CERT US Attorneys

20 20WSMOS – March 2014

21 21WSMOS – March 2014

22 22WSMOS – March 2014 WELL… The Bee-Watcher Watcher watched the Bee- Watcher. He didn’t watch well. So another Hawtch- Hawtcher had to come in as a Watch-Watcher-Watcher.

23 23WSMOS – March 2014 …And today all the Hawtchers who live in Hawtch-Hawtch are watching on Watch-Watcher-Watchering- Watch, Watch-Watching the Watcher who’s watching that bee. You’re not a Hawtch-Hawtcher. You’re lucky you see. [credit and thanks to THEODORE GEISSEL (Dr. Suess) 1973]

24 24WSMOS – March 2014

25 25WSMOS – March 2014

26 26WSMOS – March 2014

27 27WSMOS – March 2014 A rose Is a Think of Gertrude Stein

28 28WSMOS – March 2014

29 29WSMOS – March 2014

30 30WSMOS – March 2014

31 31WSMOS – March 2014 A.Need to control capital expenditures 1.Property, “bricks and mortar” 2.Equipment 3.Infrastructure – communications, reporting and fiscal control B.Need to budget and then control all other expenditures 1.Dollars expended No Matter Whatever else happens…or what they call it -

32 32WSMOS – March 2014http://innovation.cms.gov/

33 33WSMOS – March 2014

34 34WSMOS – March 2014

35 35WSMOS – March 2014

36 36WSMOS – March 2014

37 37WSMOS – March 2014

38 38WSMOS – March 2014 Quality… Outcomes… What happens to:

39

40 40WSMOS – March 2014 Fewer Coverage & Analysis Group (CAG) Staff (both analysts & physicians) Conflict/controversy avoidance Estimate 5-6/year Emphasis on prevention & screening benefits National Coverage Decisions

41 41WSMOS – March 2014 A/B MACs

42 42WSMOS – March 2014 Example: FDG PET Scans Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors By NCD 8468: …cover 3 FDG PET scans …used to guide subsequent management of anti-tumor treatment strategy Coverage of any additional…determined by the local MAC

43 43WSMOS – March 2014 Thank you. Comments/questions welcome: Please remember to 1 st check both the Noridian website & Provider Call Center Dick Whitten, MD, FACP (206) 979-5007 dick.whitten@noridian.com

44 44WSMOS – March 2014


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