Medicare Audits Update AAOS in Action: AAOS in Action: Medicare Audits and Coverage Determinations AAOS Fall Meeting October 20, 2012 Craig A. Butler, MD, MBA Chair, Health Care Systems Committee

AAOS Response Alert via AAHKS (Parsley, Halsey) Alert via AAHKS (Parsley, Halsey) Issue presented to AAOS Board of Directors Issue presented to AAOS Board of Directors BOD Coverage Determination Project Team (CDPT) created BOD Coverage Determination Project Team (CDPT) created Chair - David Templeman, MD Chair - David Templeman, MD 6 Members 6 Members

Project Team Charges 1. Advocate for the suspension of audit programs in all jurisdictions until coverage determination criteria can be reviewed by all concerned professionals. 2. Track, monitor and comment on Medicare Local Coverage Determinations (LCDs), as well as those of private payers and state Medicaid coverage boards 3. Communicate information about LCDs to our members 4. Educate members about Medicare Recovery Audit Contractors (RACs) and Medicare Administrative Contractors (MACs) and, closely monitor their activities. 5. Consider the pros and cons of advocating for Medicare national coverage determinations (NCDs) and make recommendations to the Board. 6. Develop model coverage determination documents to be used in advocacy efforts 7. Develop educational tools, such as documentation checklists, that convey existing documentation requirements to orthopaedic surgeons, recognizing that these documentation requirements may not be optimal 8. Engage, promote, facilitate and monitor the participation of orthopaedic surgeons serving on Contractor Advisory Committees (CACs). 9. Provide timely status reports to the Board.

CDPT/AAOS Actions Model LCD for TJA Procedures Model LCD for TJA Procedures Congressional Letter Congressional Letter Meetings with CMS Meetings with CMS MLN Matters Article MLN Matters Article Meetings with MACs Meetings with MACs Orthopaedic CAC Network Orthopaedic CAC Network Audit Reporting Tool Audit Reporting Tool Member Education Member Education Member Publications Member Publications Regulatory Comment Letters Regulatory Comment Letters

Model LCD Modeled after First Coast Service Options LCD in Florida (which was edited by AAOS/AAHKS/FOS) Modeled after First Coast Service Options LCD in Florida (which was edited by AAOS/AAHKS/FOS) Reviewed by AAHKS Reviewed by AAHKS Improved by CDPT and PL Improved by CDPT and PL Sent via postal mail and to ALL Contractor Medical Directors Sent via postal mail and to ALL Contractor Medical Directors Available at Available at

Congressional Letter Letter from Rep. Ruppersberger (D-MD) and Rep. Burgess (R-TX) - 43 co-signatories Letter from Rep. Ruppersberger (D-MD) and Rep. Burgess (R-TX) - 43 co-signatories Asked CMS to pressure MACs to halt audits until the MACs provide clear documentation guidance Asked CMS to pressure MACs to halt audits until the MACs provide clear documentation guidance OGR staff visited 70+ of the 87 Targeted Congressional offices OGR staff visited 70+ of the 87 Targeted Congressional offices Through grassroots action alerts, AAOS Fellows sent 80 s to Members of Congress asking for their sign-on Through grassroots action alerts, AAOS Fellows sent 80 s to Members of Congress asking for their sign-on Find the letter at Find the letter at Response – September 25, 2012 Response – September 25, 2012

Meetings with CMS OGR Staff first met with CMS 12/27/11 OGR Staff first met with CMS 12/27/11 This led to CMS participation in the Annual Meeting panel on Medicare Audits This led to CMS participation in the Annual Meeting panel on Medicare Audits OGR Staff again met with CMS 8/21/12 to discuss the Congressional letter OGR Staff again met with CMS 8/21/12 to discuss the Congressional letter CMS then published an MLN Matters article September 17, 2012 CMS then published an MLN Matters article September 17, 2012

MLN Matters Article AAOS first submitted a draft 3/2012 AAOS first submitted a draft 3/2012 CMS did not seem eager to publish it until the Congressional letter and AAOS meeting with CMS CMS did not seem eager to publish it until the Congressional letter and AAOS meeting with CMS AAOS resubmitted an updated draft in early September AAOS resubmitted an updated draft in early September CMS published MLN Matters article 9/17/2012 CMS published MLN Matters article 9/17/2012 AAOS has published this guidance widely AAOS has published this guidance widely

Meetings with MAC CMDs AAOS and AAHKS Members met with Contractor Medical Directors 6/14/2012 AAOS and AAHKS Members met with Contractor Medical Directors 6/14/2012 Resulted from relationship developed between Brian Parsley, MD and CMD Debra Patterson, MD after AAOS Annual Meeting Resulted from relationship developed between Brian Parsley, MD and CMD Debra Patterson, MD after AAOS Annual Meeting Led to communication of model LCD to all CMDs nationwide Led to communication of model LCD to all CMDs nationwide

Orthopaedic CAC Network Led by Fred Redfern, MD, AAOS has information on the Contractor Advisory Committee (CAC) representatives in 41 states Led by Fred Redfern, MD, AAOS has information on the Contractor Advisory Committee (CAC) representatives in 41 states 15 of those 41 CACs have vacancies for orthopaedic surgeons 15 of those 41 CACs have vacancies for orthopaedic surgeons Still missing information on CAC representatives in 10 states Still missing information on CAC representatives in 10 states 5 of 10 missing states are in J14 (New England) 5 of 10 missing states are in J14 (New England)

Next Steps for CAC Network Who will lead the Orthopaedic CAC Network? Who will lead the Orthopaedic CAC Network? What information should be shared with the Orthopaedic CAC Network? What information should be shared with the Orthopaedic CAC Network? How should information be shared? How should information be shared? Will it have any review or decision-making authority? Or is it just a list-serv? Will it have any review or decision-making authority? Or is it just a list-serv? How will we maintain the most updated contact list? How will we maintain the most updated contact list?

Audit Reporting Tool AAOS Fellows can report audit activity to the AAOS AAOS Fellows can report audit activity to the AAOS Distributed via Advocacy Now, state orthopaedic societies, the BOC list-serv, and AAOE Distributed via Advocacy Now, state orthopaedic societies, the BOC list-serv, and AAOE Find it at Find it at

Member Education 2012 Annual Meeting symposium on Medicare Audits 2012 Annual Meeting symposium on Medicare Audits 2012 Fall Meeting symposium on Medicare Audits (today!) 2012 Fall Meeting symposium on Medicare Audits (today!) Webinar Series Webinar Series To follow the content of Fall Meeting symposium To follow the content of Fall Meeting symposium

Member Publications

Regulatory Comment Letters AAOS/AAHKS/FOS collaborated on comments on proposed LCD for TJA (J9) in summer 2011 AAOS/AAHKS/FOS collaborated on comments on proposed LCD for TJA (J9) in summer 2011 Most requested amendments were made Most requested amendments were made AAOS/AAHKS/AAPM&R collaborated on opposition to proposed LCD denying IRF admission for a class of patients after single joint replacement procedures (J10) AAOS/AAHKS/AAPM&R collaborated on opposition to proposed LCD denying IRF admission for a class of patients after single joint replacement procedures (J10) Letter submitted 9/10/12 Letter submitted 9/10/12 Proposed LCD rescinded 9/13/12 Proposed LCD rescinded 9/13/12

Stormy Seas Ahead Clawbacks based upon FL LCD Clawbacks based upon FL LCD LCD for Ultrasound guided joint aspirations LCD for Ultrasound guided joint aspirations High intensity E & M coding High intensity E & M coding

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