Highmark Medicare Services MAC Jurisdiction-12 Contractor Advisory Committee (CAC) Meetings February 11-13, 2009

Highmark Medicare Services


MAC Jurisdiction-12 MAC Jurisdiction-12 Contractor Advisory Contractor Advisory

Committee (CAC) Committee (CAC) MeetingsMeetings

February 11-13, 2009February 11-13, 2009


AGENDAAGENDA

Welcome and IntroductionsWelcome and Introductions J-12 Contractor Update J-12 Contractor Update Medical Affairs ReviewMedical Affairs Review Contractor Advisory CommitteeContractor Advisory Committee

Roles, Composition, Survey, ScheduleRoles, Composition, Survey, Schedule Discussion of Draft LCDsDiscussion of Draft LCDs Old Business / New BusinessOld Business / New Business Q & AQ & A


Andrew Bloschichak, MD, MBAAndrew Bloschichak, MD, MBAVP Clinical Affairs VP Clinical Affairs 717-302-4198 (office)717-302-4198 (office)717-302-4165 (fax)717-302-4165 (fax)

[email protected]@highmarkmedicareservices.comhighmarkmedicareservices.com

Contact InformationContact Information


Paula Bonino, MD, MPEPaula Bonino, MD, MPEContractor Medical DirectorContractor Medical Director

412-544-1931 (office)412-544-1931 (office)412-544-1971 (fax)412-544-1971 (fax)




Eileen M. Moynihan, M.D., FACR, FACPEileen M. Moynihan, M.D., FACR, FACPContractor Medical DirectorContractor Medical Director

856-857-5257 (office)856-857-5257 (office)717-302-4165 (fax)717-302-4165 (fax)




Highmark Medicare ServicesHighmark Medicare Services

J-12 J-12

Contractor UpdateContractor Update


Transition Transition UpdateUpdate

All transitions completed as of 12-12-08All transitions completed as of 12-12-08 Largest Jurisdiction in countryLargest Jurisdiction in country

Approximately 4.2 M Medicare beneficiariesApproximately 4.2 M Medicare beneficiaries 137,350 physicians and healthcare professionals137,350 physicians and healthcare professionals 433 Hospitals 433 Hospitals 131 Million claims per year (11% of Nat’l volume)131 Million claims per year (11% of Nat’l volume) $31.5 Billion/year in healthcare payments$31.5 Billion/year in healthcare payments

Current Operational Metrics: Current Operational Metrics:


Claims Processing – Part A

98.6%

98.8%

99.0%

99.2%

99.4%

99.6%

99.8%

100.0%

PA MD DC NJ DE

November

December

January

CPT %CMS Standard: 95%


Claims Processing – Part B

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

PA MD DCMA NJ DE

November

December

January

CPT %CMS Standard: 95%


Provider Contact Center – Part A Call Completion Rate

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

97.0%

98.0%

PA MD DC NJ DE

November

December

January

% of Completion

CMS Standard: 80% Call Completion Rate


Provider Contact Center – Part B Call Completion Rate

87.0%

88.0%

89.0%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

PA MD DC NJ DE

November

December

January

% of Completion

CMS Standard: 80% Call Completion Rate


Provider Contact Center – Part A ASA

0

5

10

15

20

25

30

35

40

45

50

PA MD DC NJ DE

November

December

January

Seconds/CallCMS Standard: 60 seconds/call


Provider Contact Center – Part B ASA

0

10

20

30

40

50

60

PA MD DCMA NJ DE

November

December

January

Seconds/CallCMS Standard: 60 seconds/call


Redeterminations

75%

80%

85%

90%

95%

100%

July-Sept Oct-Dec Jan

Part A

Part B

% within 60 days


Enrollment – Part A (January 2009)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PA MD DC NJ DE

Enrollment

Maintenance

Timeliness %

CMS Standard 80%


Enrollment – Part B (January 2009)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

PA MD DCMA NJ DE

Enrollment

Maintenance

Timeliness %

CMS Standard 80%


Highmark Medicare ServicesHighmark Medicare Services

J-12 J-12

Medical Affairs UpdateMedical Affairs Update


Local Coverage Local Coverage DecisionsDecisions

Local Coverage Decisions implement the SSA Local Coverage Decisions implement the SSA 1862(a)(1)(A) requirement of Reasonable and 1862(a)(1)(A) requirement of Reasonable and Necessary through:Necessary through:• Analysis of scientific evidenceAnalysis of scientific evidence• Refinement and input from a diverse body of Refinement and input from a diverse body of

clinicians (CAC)clinicians (CAC)• Use of ‘Community Standard of Practice’ via Use of ‘Community Standard of Practice’ via

clinicians and dataclinicians and data• Application to individual claim determinations Application to individual claim determinations


LCD Development LCD Development ProcessProcess

LCDs will be developed, in keeping with CMS directives: LCDs will be developed, in keeping with CMS directives: • A validated widespread problem; A validated widespread problem; • a significant risk to the Medicare trust fund (high dollar a significant risk to the Medicare trust fund (high dollar

and/or high volume services);and/or high volume services);• Assuring beneficiary access to care;Assuring beneficiary access to care;• Frequent denials issued or anticipated;Frequent denials issued or anticipated;• Multi-state contractor creating uniform LCDs across its Multi-state contractor creating uniform LCDs across its

jurisdiction;jurisdiction;• CERT findings CERT findings


Local Coverage Decisions Local Coverage Decisions

LCDs set coverage for LCDs set coverage for ALL Medicare ALL Medicare programs in the stateprograms in the state

PLUS Medicare used as template by many PLUS Medicare used as template by many other payorsother payors

All LCDs (and drafts) on contractor Web SiteAll LCDs (and drafts) on contractor Web Site Can comment on web, via CAC, to CMDs Can comment on web, via CAC, to CMDs

directly, at “Open session”directly, at “Open session”


Local Coverage Decisions Local Coverage Decisions (LCDs)(LCDs)

Draft LCDs sent out to CAC and posted on website to Draft LCDs sent out to CAC and posted on website to allow 45 days for commentallow 45 days for comment

Interested parties can comment directly, through Interested parties can comment directly, through website, at “Open Session”.website, at “Open Session”.

After final policy published, allow 45 days notification After final policy published, allow 45 days notification until implementationuntil implementation

Draft policy comments and responses posted on Draft policy comments and responses posted on websitewebsite

All then posted on CMS national LCD database All then posted on CMS national LCD database (www.cms.hhs.gov/coverage)(www.cms.hhs.gov/coverage)


C0ntractor Advisory C0ntractor Advisory CommitteeCommittee

One CAC per stateOne CAC per state Meets 3-4 times per year, no more than 4 months Meets 3-4 times per year, no more than 4 months

apart apart Purpose:Purpose:

• Formal mechanism for participation in Formal mechanism for participation in development of ALL LCDs in advisory development of ALL LCDs in advisory capacitycapacity

• Mechanism to discuss administrative Mechanism to discuss administrative policies policies

• Forum for information exchangeForum for information exchange


C A CC A C

CAC is not a forum for peer review, discussion CAC is not a forum for peer review, discussion of individual cases, or individual providersof individual cases, or individual providers

Not a forum for specific billing issues or Not a forum for specific billing issues or individual interestsindividual interests

Reviews and comments on ALL drafts, but Reviews and comments on ALL drafts, but final implementation rests with CMDfinal implementation rests with CMD


MAC LCDs and CACMAC LCDs and CAC

Local Coverage Determinations (Medical Policies)Local Coverage Determinations (Medical Policies)• 57 Policies for MAC start• Had full comment period prior to finalization• LCDs, Comments & Responses Posted on our Website• Date of Service Sensitive by Segment Cutover Date• In the absence of an NCD/LCD services must be “R&N” per SSA

National Coverage DeterminationsNational Coverage Determinations• Coding Articles - PET Scans; BMM; Immunizations

Jurisdiction Advisory Committee / Contractor Advisory CommitteeJurisdiction Advisory Committee / Contractor Advisory Committee• Statewide Membership; A/B Combined; 3/year• Survey recently sent to members of record• Updated rosters and contact information


CAC SurveysCAC Surveys

231 Responses received ! Prefer 3 meetings/year; Feb – June – Oct cycle for all

locales Maintain state specific membership and meetings (but

almost 2/3 in favor of at least 1 CAC/yr as combined) Meeting times:

PA Weekday mornings NJ Weekday morning (afternoon close 2nd) Del Weekday evening MD Weekday evening DCMA Weekday morning (evening close 2nd)


CAC SurveysCAC Surveys

Prefer option to attend any CAC of choice if schedule demands

In favor of CAC meetings via teleconference: YES 58% NO 41%

Many comments in favor of one teleconference/year, however not all CACs via teleconference as find face-to-face meetings important


Upcoming CAC Upcoming CAC MeetingsMeetings

Second Thursday of Feb-June-Oct as Second Thursday of Feb-June-Oct as anchoranchor

Separate Meetings for each Locale Week Separate Meetings for each Locale Week of June 10-12of June 10-12

Planning for combined meeting for all J-Planning for combined meeting for all J-12 October 9/1012 October 9/10


COMPREHENSIVE ERROR COMPREHENSIVE ERROR RATE TESTING RATE TESTING

(CERT) (CERT)

PROGRAMPROGRAM


Comprehensive Error Rate Testing (CERT) Program

GPRA established in mid 90’sGPRA established in mid 90’s Managed by CMS with outside contractor, Managed by CMS with outside contractor,

Advance MedAdvance Med Data obtained by specialty, procedures, localeData obtained by specialty, procedures, locale Major driver of Major driver of

Medical ReviewMedical Review LCD DevelopmentLCD Development Physician/Provider Outreach and Physician/Provider Outreach and

EducationEducation


Comprehensive Error Rate Testing Comprehensive Error Rate Testing (CERT) Program(CERT) Program

CERT Documentation Office requests records from billing provider of CERT Documentation Office requests records from billing provider of recordrecord

AdvanceMed performs complex medical review using NCDs, CMS AdvanceMed performs complex medical review using NCDs, CMS coding policies, each contractor’s LCDs and articlescoding policies, each contractor’s LCDs and articles

Contractors must recover “overpayments” and pay “underpayments” Contractors must recover “overpayments” and pay “underpayments” on claims with errors determined by AdvanceMedon claims with errors determined by AdvanceMed

Physicians / providers can appeal such findingsPhysicians / providers can appeal such findings Contractors are tasked with implementing various interventions to Contractors are tasked with implementing various interventions to

reduce the Error ratereduce the Error rate Highmark Medicare Services and CMS website quite extensive in Highmark Medicare Services and CMS website quite extensive in

CERT information (www.cms.hhs.gov/cert)CERT information (www.cms.hhs.gov/cert)


Table 3b: National Error Rates by Year

YearTotal Dollars

Paid

Overpayments Underpayments Overpayments + Underpayments

Payment Rate Payment RateImproper

Payments Rate

1996 $168.1 B $23.5B 14.00% $0.3 B 0.20% $23.8 B 14.20%

1997 $177.9 B $20.6B 11.60% $0.3 B 0.20% $20.9 B 11.80%

1998 $177.0 B $13.8B 7.80% $1.2 B 0.60% $14.9 B 8.40%

1999 $168.9 B $14.0B 8.30% $0.5 B 0.30% $14.5 B 8.60%

2000 $174.6 B $14.1B 8.10% $2.3 B 1.30% $16.4 B 9.40%

2001 $191.3 B $14.4B 7.50% $2.4 B 1.30% $16.8 B 8.80%

2002 $212.8 B $15.2B 7.10% $1.9 B 0.90% $17.1 B 8.00%

2003 $199.1 B $20.5B 10.30% $0.9 B 0.50% $12.7 B 6.40%

2004 $213.5 B $20.8B 9.70% $0.9 B 0.40% $21.7 B 10.10%

2005 $234.1 B $11.2 B 4.80% $0.9 B 0.40% $12.1 B 5.20%

2006 $246.8 B $9.8 B 4.00% $1.0 B 0.40% $10.8 B 4.40%

Error Rates by SpecialtyError Rates by Specialty Error Rate Projected Improper Payment Amount

General Practice 22.20%22.20% $212,369,460 $212,369,460

Pulmonary Disease 19.30%19.30% $291,337,094 $291,337,094

Chiropractic 15.30%15.30% $92,309,814 $92,309,814

Geriatric Medicine 11.80%11.80% $9,822,684 $9,822,684

Emergency Medicine 10.70%10.70% $180,887,379 $180,887,379

Psychiatry 10.70%10.70% $81,500,712 $81,500,712

Physical Med and Rehab 8.90%8.90% $53,141,230 $53,141,230

Internal Medicine 7.60%7.60% $601,424,011 $601,424,011

Gastroenterology 7.30%7.30% $98,157,283 $98,157,283

General Surgery 6.60%6.60% $115,182,292 $115,182,292

Family Practice 6.40%6.40% $253,401,309 $253,401,309

Cardiology 5.10%5.10% $325,652,570 $325,652,570

All Specialties/providers 5.00%5.00% $3,678,057,770 $3,678,057,770

Error Rates by Specialty Error Rates by Specialty (cont.)(cont.)

All Specialties/providers 5.00% $3,678,057,770

Orthopedic Surgery 4.40% $114,135,388

Vascular Surgery 4.40% $19,939,498

Urology 4.20% $72,463,458

Nurse Practitioner 4.00% $20,061,954

Pain Management 3.80% $5,493,295

Allergy/Immunology 2.80% $4,726,848

Hematology/Oncology 2.40% $92,340,993

Anesthesiology 2.10% $27,066,376

Ophthalmology 1.80% $65,405,586

Diagnostic Radiology 1.40% $59,245,685

Radiation Oncology 0.70% $7,834,567

Ambulatory Surgical Center 0.20% $3,582,286


CMS May ’07 CERT Report CMS May ’07 CERT Report Part BPart B


J-12 Part B CERTJ-12 Part B CERT

May 2008 Error Rate

Projected Improper Payments

Dec 2007 Error Rate

Empire NJ 00805 7.30% $241,410,095 7.00%

Average= 4.50% 4.80%

Trailblazer MD/DE/DC/VA 00901/00902/00903/00904 4.30% $145,775,915 3.90%

HGSA PA 00865 3.80% $117,885,973 3.00%

Carrier

Paid Claims Error Rate


J-12 Part A CERTJ-12 Part A CERT

May 2008 Error Rate

Projected Improper Payments

Dec 2007 Error Rate

Highmark Medicare Services DC/MD 00366 1.80% $92,924,004 1.90%

Empire CT/DE/NY 00308 1.70% $76,451,956 0.90%

Average= 1.50% 1.50%

Riverbend NJ/TN 00390 1.20% $42,812,491 1.50%

Veritus PA 00363 0.90% $18,553,177 0.70%

FIs

Paid Claims Error Rate

Highmark Consolidated CERT Error Rate Trending- Part A

Claims Sampled 7/2007 - 6/2008

1.43

3.7

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

J UL07 AUG07 SEP 07 OCT07 NOV07 DEC07 J AN08 FEB08 MAR08 AP R08 MAY08 J UN08

Claim Sample Month

Gro

ss P

aid

Cla

ims

Err

or

Rat

e

Current Rate FY09 GP RA Goal (3.7%) GP RA Minus 5% GP RA Minus 10%

Part A MD CERT Error Rate TrendingClaims Sampled 7/2007 - 6/2008

1.56

3.7

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00


Claim Sample Month

Gro

ss P

aid

Cla

ims E

rro

r R

ate

Current Rate FY09 GPRA Goal (3.7%) GPRA Minus 5% GPRA Minus 10%

Part A NJ CERT Error Rate TrendingClaims Sampled 7/2007 - 6/2008

3.28

3.7

0.00

1.00

2.00

3.00

4.00

5.00

6.00


Claim Sample Month

Gro

ss P

aid

Cla

ims

Err

or

Rat

e

Current Rate FY09 GPRA Goal (3.7%) GPRA Minus 5% GPRA Minus 10%

Highmark Consolidated CERT Error Rate Trending- Part B

Claims Sampled 7/2007 - 6/2008

4.60

3.7

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00


Claim Sample Month

Gro

ss P

aid

Cla

ims

Err

or

Rat

e


Part B PA CERT Error Rate TrendingClaims Sampled 7/2007 - 6/2008

3.30

3.7

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50


Claim Sample Month

Gro

ss P

aid

Cla

ims

Err

or

Rat

e


Part B DE CERT Error Rate TrendingClaims Sampled 7/2007 - 6/2008

2.11

3.7

-0.50

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00


Claim Sample Month

Gro

ss P

aid

Cla

ims E

rro

r R

ate


Part B MD CERT Error Rate TrendingClaims Sampled 7/2007 - 6/2008

2.87

3.7

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

J UL07 AUG07 SEP07 OCT07 NOV07 DEC07 J AN08 FEB08 MAR08 APR08 MAY08 J UN08

Claim Sample Month

Gro

ss

Paid

Cla

ims

Err

or

Rate


Part B DC CERT Error Rate TrendingClaims Sampled 7/2007 - 6/2008

4.56

3.7

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00


Claim Sample Month

Gro

ss P

aid

Cla

ims

Err

or

Rat

e


Part B NJ CERT Error Rate TrendingClaims Sampled 7/2007 - 6/2008

6.51

3.7

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

J UL07 AUG07 SEP07 OCT07 NOV07 DEC07 J AN08 FEB08 MAR08 APR08 MAY08 J UN08

Claim Sample Month

Gro

ss P

aid

Cla

ims E

rro

r R

ate



Part B CERT DriversPart B CERT Drivers

Our Informatics and CERT Team is able to Our Informatics and CERT Team is able to determine CERT Drivers (within statistically determine CERT Drivers (within statistically significant groupings) for our Jurisdiction bysignificant groupings) for our Jurisdiction byCountyCountySpecialty / Provider TypeSpecialty / Provider TypeProcedure Codes and Betos GroupsProcedure Codes and Betos Groups

This information is utilized to focus our This information is utilized to focus our interventions and monitor effectivenessinterventions and monitor effectiveness


Part B CERT DriversPart B CERT Drivers Evaluation and Management ServicesEvaluation and Management Services

Consultations (esp. inpatient Level IV/V)Consultations (esp. inpatient Level IV/V)Subsequent Office Visits (esp. 99214)Subsequent Office Visits (esp. 99214)Hospital Visits , including Discharge (time separates Hospital Visits , including Discharge (time separates

99238-99239)99238-99239) Therapies Therapies

PT / OTPT / OTChiropractic ServicesChiropractic Services

Diagnostic Studies (-26) need “Interpretation and Diagnostic Studies (-26) need “Interpretation and Report”Report”

New Issue - Date of Service and Physician Orders!New Issue - Date of Service and Physician Orders!


MEDICAL REVIEWMEDICAL REVIEW Medical Review / Progressive Corrective Action (PCA) is Medical Review / Progressive Corrective Action (PCA) is

DATA DRIVEN (but not data determined)DATA DRIVEN (but not data determined) Data includes CERT, Medicare utilization in many Data includes CERT, Medicare utilization in many

statistical analysesstatistical analyses Notice of Medical Review:Notice of Medical Review:

Provider notified via “ADR” Additional Documentation Provider notified via “ADR” Additional Documentation RequestRequest

If based on comparative data, data is providedIf based on comparative data, data is provided Reviews can be Reviews can be provider-specific or service-provider-specific or service-

specificspecific (procedure code driven) (procedure code driven) Most common provider-specific reviews of recent Most common provider-specific reviews of recent

years are “Pre-pay Probes” which consists of 20-30 years are “Pre-pay Probes” which consists of 20-30 claim sample reviewed BEFORE payment madeclaim sample reviewed BEFORE payment made


MEDICAL REVIEWMEDICAL REVIEW Documentation is not only required, but is essential for Documentation is not only required, but is essential for

fair and accurate reviewfair and accurate review Providers have 30 days to respondProviders have 30 days to respond Service denied as not ‘R&N’ if no doc after 45 daysService denied as not ‘R&N’ if no doc after 45 days Unfortunately in many PCA efforts we do not receive Unfortunately in many PCA efforts we do not receive

any documentation 30 +% of the time!!any documentation 30 +% of the time!! Contractors have 60 days from receipt of records to Contractors have 60 days from receipt of records to

complete reviewcomplete review Depending on outcome of Probe and $ at risk, can Depending on outcome of Probe and $ at risk, can

lead to full Pre-Pay reviewlead to full Pre-Pay review





E&MsE&Ms Based on E&M Documentation Guidelines per AMA Based on E&M Documentation Guidelines per AMA

and CMS (1995/1997)and CMS (1995/1997)

E&M Scoresheet and dedicated webpage on webE&M Scoresheet and dedicated webpage on web

Computer-based modules with CME credit on websiteComputer-based modules with CME credit on website

HMS POE staff very able and willing to conduct HMS POE staff very able and willing to conduct learning workshopslearning workshops


ConsultationsConsultations

Effective January 1, 2006, per AMA CPT:Effective January 1, 2006, per AMA CPT:

99251 – 99255 Initial inpatient consultation for new or 99251 – 99255 Initial inpatient consultation for new or established patientestablished patient

99241 – 99245 Office (or other Outpatient) consultation for new 99241 – 99245 Office (or other Outpatient) consultation for new or established patientor established patient

Can use TIME if documentation meets time requirementsCan use TIME if documentation meets time requirements

Need:Need: Request – Reason - ReportRequest – Reason - Report LCD requirements (Expertise and/or specific patient knowledge)LCD requirements (Expertise and/or specific patient knowledge) Appropriate documentation for level of careAppropriate documentation for level of care

Requires all 3 components of History, Exam, and Medical Requires all 3 components of History, Exam, and Medical Decision MakingDecision Making


CONSULTATIONSCONSULTATIONS Need Need HistoryHistory; Exam; AND Medical Decision-; Exam; AND Medical Decision-

Making (or Time reporting requirements)Making (or Time reporting requirements) NPPs may Request or Perform Consults ( within NPPs may Request or Perform Consults ( within

scope of practice, expertise)scope of practice, expertise) Split-Sharing of Consults is NOT allowed as of Split-Sharing of Consults is NOT allowed as of

1-1-2006 per CMS instruction1-1-2006 per CMS instruction ‘‘Standing’ consults are not covered by MedicareStanding’ consults are not covered by Medicare For ongoing management, report as subsequent For ongoing management, report as subsequent

visitsvisits


Prevention GapPrevention Gap

Covered ServiceCovered Service Medicare Utilization Medicare Utilization

Pap Test and Pelvic ExamPap Test and Pelvic Exam 36%36%

Prostate Cancer ScreeningProstate Cancer Screening 54%54%

Screening MammogramsScreening Mammograms 54%54%

Pneumococcal ShotPneumococcal Shot 65%65%

Flu ShotsFlu Shots 68%68%

Cardiovascular screeningsCardiovascular screenings 82%82%



Medicare Part B Preventative Medicare Part B Preventative ServicesServices









REVIEW OF DRAFT LCDsREVIEW OF DRAFT LCDs


Conflict of InterestConflict of Interest

The opportunity to influence a The opportunity to influence a policy and/or decision, either policy and/or decision, either directly or indirectly, through one’s directly or indirectly, through one’s membership on the Committee, membership on the Committee, which allows for personal gain.which allows for personal gain.


Conflict of InterestConflict of Interest

CAC acknowledges that members CAC acknowledges that members represent their specific specialties represent their specific specialties and clinical practice, and will be and clinical practice, and will be speaking on behalf of that speaking on behalf of that specialty/practice. To that extent, specialty/practice. To that extent, any inherent benefit as such is not any inherent benefit as such is not considered a “conflict of interest.”considered a “conflict of interest.”


Conflict of Conflict of InterestInterest

CAC members are asked to divulge any CAC members are asked to divulge any “significant financial interest”, as defined “significant financial interest”, as defined as ownership interest of 5 % or more in as ownership interest of 5 % or more in companies (other than their clinical companies (other than their clinical practice), which stand to benefit from practice), which stand to benefit from Medicare policy decisions, prior to Medicare policy decisions, prior to providing comments regarding specific providing comments regarding specific policies. policies.


Draft Local Coverage Draft Local Coverage Determinations (LCDs)Determinations (LCDs)

DL 27499DL 27499Intraoperative Neurophysiological TestingIntraoperative Neurophysiological Testing

DL 27530DL 27530Sleep Disorders TestingSleep Disorders Testing

DL 29544DL 29544Posterior Tibial Nerve StimulationPosterior Tibial Nerve Stimulation

DL 29547DL 29547EMG and Nerve Conduction StudiesEMG and Nerve Conduction Studies


DL 27530 Sleep Disorders Testing

Updated LCD to address:Updated LCD to address: Repeat testing criteria for PSGRepeat testing criteria for PSG Coverage criteria for Home Sleep TestingCoverage criteria for Home Sleep Testing Clarify specific covered indications for PSG, HST Clarify specific covered indications for PSG, HST

for OSA and CPAPfor OSA and CPAP

HST emerging with CMS mandate for coverage HST emerging with CMS mandate for coverage of CPAP based on Dx of OSA by HST of CPAP based on Dx of OSA by HST



LCD updated in keeping with:LCD updated in keeping with:CMS HST instructionsCMS HST instructionsDMERC CPAP coverage GuidelinesDMERC CPAP coverage GuidelinesAmerican Academy of Sleep Medicine American Academy of Sleep Medicine

Clinical Guidelines for Use of Unattended Clinical Guidelines for Use of Unattended Portable Monitors in Dx of OSA Portable Monitors in Dx of OSA (specifically physician performing PC)(specifically physician performing PC)

Other contractor LCDsOther contractor LCDs



No change to documentation guidelinesNo change to documentation guidelines Significant updates to ICD-9 covered Significant updates to ICD-9 covered

indications to include:indications to include: Expansion of coverage for 95807-95810 Expansion of coverage for 95807-95810 Allowing limited coverage for 95806 and Allowing limited coverage for 95806 and

G0398-G0400G0398-G0400

CAC Comments….. CAC Comments….. **


Updated policy for emerging/expanding Updated policy for emerging/expanding service; initially distributed 04/01/08service; initially distributed 04/01/08

Data often showed monitoring of ten or Data often showed monitoring of ten or more cases at a timemore cases at a time

Many diagnoses did not seem to Many diagnoses did not seem to support medical necessitysupport medical necessity

Many inquiries about who could performMany inquiries about who could perform

LCD DL27499 LCD DL27499 IntraoperativeIntraoperativeNeurophysiological TestingNeurophysiological Testing


LCD DL27499 IntraoperativeLCD DL27499 IntraoperativeNeurophysiological TestingNeurophysiological Testing

Many inquiries and issues about Many inquiries and issues about location of the performing providerlocation of the performing provider

Many inquiries about type of equipment Many inquiries about type of equipment to be usedto be used

Needed to add ICD 9 CM codes to Needed to add ICD 9 CM codes to match the narrative diagnoses for ease match the narrative diagnoses for ease of processingof processing

CAC commentsCAC comments **


LCD DL29547LCD DL29547 Electromyography Electromyography (EMG)(EMG) and Nerve Conduction Studiesand Nerve Conduction Studies

Components of testing in segregated policies in Components of testing in segregated policies in the past. Difficult to pull all components the past. Difficult to pull all components together in one policy without JAC commentstogether in one policy without JAC comments

Clarify what constitutes valid studies under the Clarify what constitutes valid studies under the CPT codes of the policy.CPT codes of the policy.

Specify guidance for performance and billing of Specify guidance for performance and billing of nerve conduction studies due to previously high nerve conduction studies due to previously high utilizationutilization


LCD DL29547LCD DL29547 Electromyography Electromyography (EMG)(EMG) and Nerve Conduction Studiesand Nerve Conduction Studies

Followed AAEM guidelines regarding Followed AAEM guidelines regarding number of studiesnumber of studies

CAC Comments….CAC Comments….


DL29544 Posterior Tibial DL29544 Posterior Tibial Nerve Stimulation (PTNS)Nerve Stimulation (PTNS)

This procedure involves percutaneous (or This procedure involves percutaneous (or transcutaneous) peripheral stimulation of the transcutaneous) peripheral stimulation of the posterior tibial nerve. posterior tibial nerve.

It has been under study for the treatment of pelvic It has been under study for the treatment of pelvic floor dysfunction manifesting in a variety of clinical floor dysfunction manifesting in a variety of clinical problems such as: urinary frequency, urgency, problems such as: urinary frequency, urgency, incontinence or retention; bowel dysfunction; and/or incontinence or retention; bowel dysfunction; and/or pelvic pain.pelvic pain.

This procedure came to our attention through a This procedure came to our attention through a provider inquiry about proper coding; and through provider inquiry about proper coding; and through CMS Contractor Medical Director Workgroup CMS Contractor Medical Director Workgroup discussions.discussions.


Posterior Tibial Nerve Posterior Tibial Nerve Stimulation Procedure / Methods Stimulation Procedure / Methods

While studies vary in the protocols used, generally a While studies vary in the protocols used, generally a 34 gauge needle is placed percutaneously above the 34 gauge needle is placed percutaneously above the medial malleolus, into the tibial nerve, with a surface medial malleolus, into the tibial nerve, with a surface electrode on the foot. A stimulator delivers a low electrode on the foot. A stimulator delivers a low voltage electrical impulse. voltage electrical impulse.

Most papers report sessions of 30 minutes of Most papers report sessions of 30 minutes of treatment weekly for 10 to 12 weeks. Continuation treatment weekly for 10 to 12 weeks. Continuation beyond the initial treatment is highly variable, and beyond the initial treatment is highly variable, and little published experience is available. little published experience is available.

What is available shows a rapid loss of improvement What is available shows a rapid loss of improvement when treatment is stopped. Most use “for the when treatment is stopped. Most use “for the duration”, every 3 to 4 weeks. One small study duration”, every 3 to 4 weeks. One small study demonstrated about a 3 month window before loss of demonstrated about a 3 month window before loss of effect.effect.


Posterior Tibial Nerve Posterior Tibial Nerve Stimulation: Hypotheses Stimulation: Hypotheses

The mechanism of action is not known, but some of The mechanism of action is not known, but some of the hypothetical bases are as follows:the hypothetical bases are as follows:

The posterior tibial nerve is a mixed sensory-motor The posterior tibial nerve is a mixed sensory-motor nerve whose fibers originate from spinal roots L4 nerve whose fibers originate from spinal roots L4 through S3.through S3.

PTNS inhibits bladder activity by depolarizing somatic PTNS inhibits bladder activity by depolarizing somatic sacral and lumbar afferent fibers. Afferent stimulation sacral and lumbar afferent fibers. Afferent stimulation provides central inhibition of the preganglionic provides central inhibition of the preganglionic bladder motor neurons. Stimulation of the large bladder motor neurons. Stimulation of the large somatic fibers could modulate / inhibit the thinner somatic fibers could modulate / inhibit the thinner afferent A-delta or C fibres, decreasing the afferent A-delta or C fibres, decreasing the perception of urgency.perception of urgency.

Neurochemical changes and changes to blood flow Neurochemical changes and changes to blood flow have been hypothesized.have been hypothesized.


Posterior Tibial Nerve Posterior Tibial Nerve Stimulation: HypothesesStimulation: Hypotheses

Activation of endorphin pathways within the spinal Activation of endorphin pathways within the spinal cord could affect detrusor behaviorcord could affect detrusor behavior

Most of the discussion has focused on the role of Most of the discussion has focused on the role of neuromodulation of the sacral nervous outflow tract neuromodulation of the sacral nervous outflow tract

Neuromodulation helps restore the balance between Neuromodulation helps restore the balance between inhibitory and excitatory impulses that govern bladder inhibitory and excitatory impulses that govern bladder function function

The “minimally invasive” method for neuromodulation The “minimally invasive” method for neuromodulation may address drawbacks of implantation of sacral may address drawbacks of implantation of sacral neurostimulator, including the need for re-operation neurostimulator, including the need for re-operation (up to 30%); migration of neural leads, etc. (up to 30%); migration of neural leads, etc.


Posterior Tibial Nerve Stimulation: Clinical Posterior Tibial Nerve Stimulation: Clinical Considerations for Medicare Patients, Esp. Considerations for Medicare Patients, Esp.

Elderly Elderly

Urinary incontinence is a common and disabling problem Urinary incontinence is a common and disabling problem associated with isolation, embarrassment, other illnesses (e.g., associated with isolation, embarrassment, other illnesses (e.g., infection, decubiti), and loss of independent living – need more infection, decubiti), and loss of independent living – need more and better prevention and treatment optionsand better prevention and treatment options

Often multifactorial – drugs, drug interactions Often multifactorial – drugs, drug interactions

Consider practical realities of treatment delivery Consider practical realities of treatment delivery o Diabetes and other peripheral neuropathyDiabetes and other peripheral neuropathyo Peripheral edema, CHFPeripheral edema, CHFo Cardiovascular disease – patient on anticoagulationCardiovascular disease – patient on anticoagulationo Visual impairmentVisual impairmento Arthritis – hands, hips, etc. – positioning and performing, mobility Arthritis – hands, hips, etc. – positioning and performing, mobility o Cognitive impairment, dementiaCognitive impairment, dementiao BPH, prostate CABPH, prostate CA


Posterior Tibial Nerve Stimulation: Posterior Tibial Nerve Stimulation: Regulatory Considerations Regulatory Considerations

Related NCDs:Related NCDs: 160.2 Treatment of Motor Function Disorders with Electric 160.2 Treatment of Motor Function Disorders with Electric

Nerve Stimulation: Not covered, with some exceptions Nerve Stimulation: Not covered, with some exceptions 160.7 Electrical Nerve Stimulators: Peripheral and Central, for 160.7 Electrical Nerve Stimulators: Peripheral and Central, for

chronic intractable pain; criteria for coverage discussed chronic intractable pain; criteria for coverage discussed 160.7.1 Assessing Patients Suitability for Electrical Nerve 160.7.1 Assessing Patients Suitability for Electrical Nerve

Stimulation Therapy: for pain; TENS and PENS discussedStimulation Therapy: for pain; TENS and PENS discussed 230.8 Non-Implantable Pelvic Floor Electrical Stimulator: 230.8 Non-Implantable Pelvic Floor Electrical Stimulator:

covered for stress and/or urge urinary incontinence with specific covered for stress and/or urge urinary incontinence with specific criteria (usually delivered by vaginal or anal probes, external criteria (usually delivered by vaginal or anal probes, external pulse generator)pulse generator)


Posterior Tibial Nerve Stimulation: Posterior Tibial Nerve Stimulation: Regulatory Considerations, Data Regulatory Considerations, Data

230.15 Electrical Continence Aid: Not covered (device placed in 230.15 Electrical Continence Aid: Not covered (device placed in anal canal, portable generator stimulates anal musculature)anal canal, portable generator stimulates anal musculature)

230.16 Bladder Stimulators (Pacemakers): Not covered 230.16 Bladder Stimulators (Pacemakers): Not covered (implanted electrodes, current causes contractions) (implanted electrodes, current causes contractions)

230.18 Sacral Nerve Stimulation for Urinary Incontinence: 230.18 Sacral Nerve Stimulation for Urinary Incontinence: Covered for urinary urge incontinence, urgency-frequency Covered for urinary urge incontinence, urgency-frequency syndrome, and urinary retention. Test stimulation, then syndrome, and urinary retention. Test stimulation, then permanent implantation. Specific inclusion and exclusion permanent implantation. Specific inclusion and exclusion criteria discussed.criteria discussed.

Data on next slide – NOC code – claims review showed almost Data on next slide – NOC code – claims review showed almost all of the services were all of the services were notnot PTNS, but rather neurosurgical PTNS, but rather neurosurgical services: very little current use in J12 region per claims services: very little current use in J12 region per claims


HCPCS 64999Trend of Dollars Paid - Part B

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08

Month

$ P

aid

12102/12202 (DC/DE)

12302 (MD)

12402 (NJ)

12502 (PA)

Total


Posterior Tibial Nerve Posterior Tibial Nerve StimulationStimulation

Published Research Findings Published Research Findings

Small numbers; various etiologies and problems; Small numbers; various etiologies and problems; mixed prior history of treatment and length / type of mixed prior history of treatment and length / type of symptoms; symptoms;

No control groups, unable to assess placebo effect; No control groups, unable to assess placebo effect; methods vary in amount of current applied, frequency methods vary in amount of current applied, frequency and length of treatments (not directly comparable);and length of treatments (not directly comparable);

Almost all do not reflect the Medicare population, Almost all do not reflect the Medicare population, except perhaps the disabled;except perhaps the disabled;

No randomized controlled studies or studies of No randomized controlled studies or studies of sufficient sample size and power; sufficient sample size and power;

Some investigators receive support from the study Some investigators receive support from the study sponsorsponsor


Posterior Tibial Nerve Posterior Tibial Nerve StimulationStimulation

Published Research FindingsPublished Research Findings

Misattributed effects of urodynamic testing itself as Misattributed effects of urodynamic testing itself as evidence of success of procedureevidence of success of procedure

Some report an “intention-to-treat” analysis, others do Some report an “intention-to-treat” analysis, others do not evaluate dropouts. not evaluate dropouts.

Definitions of success or improvement also vary – not Definitions of success or improvement also vary – not directly comparabledirectly comparable

Modest statistical findings – clinical relevance? Modest statistical findings – clinical relevance? Other Medicare Contractors who have LCDs: Non-Other Medicare Contractors who have LCDs: Non-

coverage at this timecoverage at this time


Posterior Tibial Nerve Posterior Tibial Nerve Stimulation Stimulation

Alternatives are available, all with pros and cons: Alternatives are available, all with pros and cons: meds, surgical, behavioral, multiple interventions meds, surgical, behavioral, multiple interventions for multifactorial problem for multifactorial problem

““On the horizon”: implanted electrode in posterior On the horizon”: implanted electrode in posterior tibial nerve, externally placed radiofrequency tibial nerve, externally placed radiofrequency generator – self-administered.generator – self-administered.

““Promising work”, currently experimental / Promising work”, currently experimental / investigational for the Medicare population, investigational for the Medicare population, therefore not reasonable and necessary (non-therefore not reasonable and necessary (non-covered).covered).

DiscussionDiscussion



Upcoming CAC Upcoming CAC MeetingsMeetings

Second Thursday of Feb-June-Oct as Second Thursday of Feb-June-Oct as anchoranchor

Separate Meetings for each Locale Week Separate Meetings for each Locale Week of June 10-12of June 10-12

Planning for combined meeting for all J-Planning for combined meeting for all J-12 October 9/1012 October 9/10


CAC DISCUSSIONCAC DISCUSSION

OLD BUSINESS…OLD BUSINESS…

NEW BUSINESS…NEW BUSINESS…


““The Future Ain’t What It Used To The Future Ain’t What It Used To Be”Be”

YogiYogi


Documents

Highmark Medicare Services MAC Jurisdiction-12 Contractor Advisory Committee (CAC) Meetings February 11-13, 2009