Keeping up with advances in medicine and changes in the delivery of care is critical to a physician’s continuing professional development. Most state medical boards require mandatory Continuing Medical Education (CME) for renewal of physician licenses. New York State currently does not have this requirement but that does not mean physicians practicing in New York State do not have other requirements they must abide by regarding CME.

Hospitals and some insurance plans require a physician to maintain CME credits in the appointment or credentialing cycle. For example, Kaleida Health requires a physician to provide a list of CME credits earned from the date of the last reappointment which is usually two years. Univera has a three year recredentialing cycle and requires a physician to complete 50 CME credits annualized (150 CME credits may be spread out over the three year period from the date the physician was last reappointed).

The reality is physicians often don’t think of these hospital and insurance plan CME requirements as important enough to result in action being taken against privileges or insurance plan participation. A physician can be sanctioned for non-compliance. Does this really happen and how often? Random audits of CME do occur. Once a physician has attested that he/she has met the CME requirements for insurance plan participation it is important to keep adequate records of all CME credits within the renewal cycle in case you are selected for an audit.

Today, there are so many ways to obtain CME in an already hectic schedule. The American Medical Association has a combination of online classes, live events and courses that cover a broad range of professional interests. Journal CME is another option. Physicians can earn CME credits by reading timely, peer-reviewed articles in the JAMA & Archives Journals, and then passing a short online quiz on the relevant subject.

Lastly, if your malpractice carrier is MLMIC (other carriers may provide the same) a risk management course is available to you that provides up to 6 CME credits as well as a two year 5% premium credit.

Take the time now to get your CME credits up to date and maintain adequate records.
Repercussions for not maintaining CME could have a financial impact on your practice.

New York’s Wage Theft Prevention Act (which was passed on 04/09/2011) imposes new recordkeeping and notice obligations on New York employers and creates new penalties.

The act requires employers to provide employees with annual written pay notices starting in 2012. The notices must include rates of pay, basis for pay, regular pay day, name of employer, address of employer, and employer phone number. These statements must be given to employees in the month of January each year. The consequences for failing to provide the required notices can be substantial. As a result, compliance is necessary.

Employers must give this wage information statement (before February 1st) to each employee to review and sign. A copy of the signed statement should be given to the employee and the original is to be keep by the employer for a period of six years.

If you are a management/payroll client of HCSWNY, these notices were completed by HCSWNY and forwarded to your practice. It is the employer’s responsibility to make sure the forms are signed by the employee.

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has begun to notify covered entities that they have been selected for the first Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security audits under the Health Information Technology for Economic and Clinical Health (HITECH) Act. The selected entities represent a cross sample of the health care industry composed of billion-dollar health care systems to small physician practices. The audit will entail a comprehensive review of privacy and security policies and procedures, documentation and operations.

There is an anticipated 150 entities to undergo an audit, starting mid-January. The first 20 entities have been selected and notified. HHS has indicated that it hopes to continue with proactive audits in the future and expects to become more aggressive in its enforcement of complaints. Accordingly, now is a good time to ensure that:
> Policies and procedures, and documentation comprehensively address all privacy and security requirements;
> Privacy and security training has been completed and documented:
> Actions taken as part of the HIPAA compliance program have been documented, such as complaints and any resulting investigations, findings, and mitigation; and
> Your security risk assessment and documentation of your risk management decision-making process are up to date.

The Unlucky Winners
HHS divided the covered entity population into four levels and various types of covered entities:

Level 1 – Large providers/payors with more than $1 billion in revenue and/or assets
Level 2 – Large regional hospital systems/Regional payor with between $300 million and $1 billion in revenue and/or assets
Level 3 – Community hospitals, ambulatory surgery centers, regional pharmacies (with between $50 million and $300 million in revenue and/or assets) and self-insured entities that do not adjudicate their claims
Level 4 – Small provider and community pharmacies with less than $50 million in revenue and/or assets

What Audited Entities Can Expect
It is anticipated that the selected covered entities will receive notification letter along with requests for documentation. These covered entities may have as little as ten business days to respond. The requested information may include policies and procedures, training materials and documentation, a security risk analysis and other documentation required by the HIPAA regulations.

The site visits, which likely will begin in January, will include a team of auditors spending between three and ten business days on site, interviewing leadership and inspecting the premises. The auditors may review administrative, physical, technical safeguards of written, oral and electronic protected health information.

How To Prepare
The audits represent a good opportunity to take stock of your privacy and security programs and make improvements. OCR has indicated that, after publication of final rules modifying the HIPAA regulation in accordance with the HITECH Act, they will more aggressively pursue complaints where there are indications of noncompliance due to willful neglect. Preparing for the current wave of HIPAA audits will help prepare your organization for the heightened enforcement.

A few steps that your organization can take to help prepare for the audits include:

1. Addressing the entire lifecycle of electronic and hard copy protected health information, identifying where such information is created throughout the organization, how it is maintained, and how it is disposed of;
2. Creating a compliance cycle that regularly modifies policies and training in response to recurring issues and emerging threats; and
3. Conducting a comprehensive review of policies, procedures, other documentation and training.

The NY State Palliative Care Information Act calls for primary care practitioners caring for patients diagnosed with a terminal illness or condition to offer information and counseling regarding palliative care. As providers know, this is NOT hospice counseling, but rather a discussion of the care options available to the patient who has a terminal illness or condition regardless of the expected life-span.

To clarify, CMS defines hospice as a service for people expected to live 6 months or less. Palliative care counseling is appropriate even in someone who may live for more than six months, or ever for year, despite increasing debility or loss of function. The goal is to have a plan in place for palliation in the face of disease progression.

This counseling is needed because palliative care is not a one-size-fits-all approach. Diseases vary in life expectancy, treatment options, and even the degree of impact the news of a terminal condition may have on each patient.

Some individuals vow to fight to their last breath, while others will give up entirely, and others may decide that they will assess their quality of life on an ongoing basis.

Even more may live long enough to see research result in their prognosis being altered. A prime example of this would be in cases of CF. Not too long ago patients with Cystic Fibrosis did not live into late adolescence, and now they live well into adulthood. It is examples like this that indicate it may be appropriate to approach palliative care counseling yearly or more often with patients as their disease progresses.

In providing this counseling, the primary care physician may also recommend or refer to a team of professionals, again determined by the patient’s need and the disease state or condition. The professionals may consist of social workers, nutritionists, mental health counselors, and even geneticists where appropriate. The goal is to provide care options appropriate to the patient, to prevent or relieve pain and suffering and to enhance the patient’s quality of life.

Because we at Healthcare Solutions WNY believe that quality care, including appropriate types of counseling is important to our client’s patients and to the clients themselves, we asked our coding team to research how this palliative counseling may be documented and coded. Further, we asked our billing specialists what types of reimbursement may exist for the codes found.

Our coding specialists state that “for commercial payors, counseling for palliative care would require the use of code S0257 used in conjunction with the appropriate E&M service for that date”. The S0257 code is for “Counseling and discussion regarding advance directives or end of life care planning and decisions, with patient and/or surrogate”.

Our billers found that the current commercial payor rate for counseling code S0257 is $40.00. Unfortunately, Medicare and Medicaid do not cover palliative care counseling as of this date.

Medicare does pay for one-time Hospice counseling but as we noted, the counseling required under the PCIA is for people who do not meet the definition of “Hospice qualified”. Our coding specialist states that in the case of the need for palliative counseling in a Medicare patient, “E&M codes may be used for counseling with time as the deciding factor for leveling if correctly documented”.

As always, it is the documentation of the type and nature of the counseling being performed, as well as the start and stop times (for prolonged E&M visits under Medicare) that will support the coding chosen.

NOTE ALSO: If the patient affected by terminal disease has family members who are also patients in your practice, or if there are patients in your practice that have family members affected by a terminal disease, there are codes for depression counseling in addition to the E&M codes with time as the deciding factor.

As always, our coding and billing staff will be happy to help with any questions. Please call us at 716-206-1580 for more information.

Abstract
PURPOSE:
The aim of this study was to assess potential physician work efficiencies when more than one diagnostic imaging study is interpreted by the same provider during the same session.

METHODS:
Medicare Physician Fee Schedule data from the American Medical Association Resource-Based Relative Value Scale Data Manager for 2011 were analyzed to quantify relative contributions of preservice, intraservice, and postservice physician work to the total work of rendering diagnostic imaging services. An expert panel review identified potential duplications in preservice and postservice work when multiple examinations are performed on the same patient during the same session. Maximum potential percentage work duplication for various diagnostic imaging modalities was calculated and compared to US Government Accountability Office estimates.

RESULTS:
The relative contributions of preservice and postservice work to total work varied by modality, ranging from 20% [computed tomography (CT)] to 33% (ultrasound). The maximum percentage of potentially duplicated preservice and postservice activity ranged from 19% (nuclear medicine) to 24% (ultrasound). Maximum mean potentially duplicated work relative value units ranged from 0.0212 for radiography to 0.0953 for magnetic resonance imaging (MRI). Maximum percentage work reduction ranged from 4.32% for CT to 8.15% for ultrasound. This corresponds to maximum professional Physician Fee Schedule reductions of only 2.96% (CT) to 5.45% (ultrasound), approximating an order of magnitude less than the Government Accountability Office’s recommendations.

CONCLUSION:
Although potential efficiencies in physician work occur when multiple services are provided to the same patient during the same session, these are highly variable and considerably less than previously estimated.

Copyright © 2011 American College of Radiology. Published by Elsevier Inc. All rights reserved. PMID: 21719354

The Centers for Medicare and Medicaid Services (CMS) recently announced that Medicare’s recovery audit contractors (RACs) will no longer issue demand letters to providers as of January 3, 2012.

CMS is transferring the responsibility to Medicare administrative contractors (MACs), who will perform the adjustments based on the RAC’s review and issue an automated demand letter. MACs will then be responsible for fielding any administrative concerns providers may have such as timeframes for payment recovery and the appeals process. However, MACs will include the name of the initiating RAC and his/her contact information in the related demand letter.

You will have to know how to appeal these adjustments. If you are a billing client of HCSWNY, contact our billing department for more information. If you are not a client but would like more information, contact HCSWNY at 716-206-1580, or dichristinae@hcswny.com, or you can go to CMS’ Web site.

For any practice that is a cash basis taxpaying entity, you should be working with your bookkeeper and accountant to plan the best method of running down your cash balances. If you are one of our clients for management services, we will be providing your accountant with any information needed to facilitate your tax planning process.

As your tax preparer can further explain, the benefits to keeping your year-end cash balances low include: having more expenses paid this year to offset practice revenue and partner tax considerations (anyone who is going to be taxed on income should have the option of actually having that income in hand). Work with your accountant to see if you should be distributing additional payments to partners as those added draws need to be paid by the last payroll of the year. Also, consider paying January 2012 invoices before year-end to further pay down cash, and transfer expenses to the 2011 tax year.

In addition to tax planning, your practice should be working to ensure that all year-end staff bonuses are in the pipeline for processing in a timely fashion, and that all voluntary retirement contributions are communicated to your payroll and benefits administration vendors for processing prior to year-end.

Your human resource, accounting and payroll vendors should be able to provide you with maximum contribution tables for 401Ks, Simple IRAs, and Health Savings Accounts. If you are a management client of HCSWNY you will be receiving all applicable information by letter this week.

Remember that holidays can affect processing time for any requests, so be sure you know what days your vendors will be open to process your cash offsets, additional draws, invoice payments and retirement plans and contributions. The sooner you notify them, the more likely nothing will be missed by year-end.

If you have any questions and are not a current client, please contact 716-206-1580 or dichristinae@hcswny.com for more information or to see if we can make next year easier for you. If you are a current client, you may contact us directly as you have in the past.

Earlier in October, the HHS OIG Work Plan for Fiscal Year 2012 was unveiled. As always, the work plan revealed many areas of focus for physicians. Specifically, the RAC auditors will be looking at your compliance with billing assignment rules, “Incident-To” services, surgical global periods and E & M services including E & M trends and E & M documentation.

FOR OUR NOVEMBER NEWSLETTER FOCUS, we want you to be aware of potentially inappropriate payments for E & M services as a result of what appears to be “cut and paste” type documentation. Specifically, it has been noted by Medicare that many providers have shown an increase in the frequency of medical records with identical documentation across services.

They plan to review E & M services to assess whether the providers selected the code for service based upon the content of the service and that they have the documentation to support the level of service reported. Be very careful about “cookie cutter” or “cut and paste” notes in EMR documentation. Medicare feels that while chief complaints, HPI and PFSH may differ in most notes, the ROS and exams look identical from patient to patient.

Often the ROS and exams make no mention of the chief complaint or findings that relate to the assessment or plan for the patient.

This is likely to trigger increased audits and demands for repayment.

We encourage anyone, whether a current or prospective client to contact us at 716-206-1580 or dichristinae@hcswny.com if you would like us to take a look at your EMR templates and/or random encounters to see if you are at any risk from this specific aspect of RAC auditing.

REMEMBER ALSO THAT THE NYS OFFICE OF THE MEDICAID INSPECTOR GENERAL IS ALSO LOOKING AT PHYSICIANS – this focus is on finding any practice providing Medicaid Services that does NOT have an “effective” compliance plan. Feel free to contact us for more detail on what constitutes effective compliance planning and actions.