Robert Shesser M.D. MPHGeorge Washington University

Patient Care Services Reimbursement: 2011

Patient care services reimbursement

Revenue cycleDiagnosis codingProcedure codingCredentialingComplianceProductivity MonitoringReports

Revenue cycle I

Chart acquisitionCoding Data entry

Charge lag- interval between treatment and billingBilling

Primary and secondaryCharge posting, clean up, reportingAccounts receivable

everything that has been billed, but not collected Unit is “days” (total receivables/average charges/day)

Revenue cycle II

Benchmarking performance No data on charge lag Coding, Billing should cost 8% of collections GW MFA data

Charge lag EMR system: 5 days Charge lag paper charting: 8 days Chart acquisition, coding, data entry, charge correction,

registration updates $4.13/chart 3.6% collections

ICD (International Classification of Diseases) 1853-first International Statistical Congress-classification of

mortality 1893 - International List of Causes of Death- adopted by US 1898 1948 WHO took ILCD and developed ICD- included morbidity

coding application in US by National Center for Health Statistics

• branch of CDC developed ICD 9-CM (clinical modification) (1976)

official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States

National Center for Health Statistics pathologically based 5 digits E codes, V codes

Diagnosis Coding

ICD 10-CM (1989) Major change from ICD-9 6882 total codes in ICD-9, 12,420 total codes in ICD-10

Chapters (icd-10); Sections (icd-9) Letter followed by 4 numbers Codes reserved for provisional assignment of new diseases Country-specific clinical modifications- make certain

comparisons difficult ICD-10 CM in US; implementation date 10/1/13

Includes procedure codes

Diagnosis Coding

ICD-11 Process started in 2002 Attempting to decrease country-specific variations Web-based, function in an EHR environment Won’t be presented until 2014

SNOMED-CT (Systematized Nomenclature of Medicine Clinical Terms) Core of the electronic health record 311,000 active concepts with unique meanings formal logic-based definitions organized into hierarchies

Hierarchies have multiple levels of granularity International Health Terminology Standards Organization

(www.ithso.org)

Diagnosis Coding

Common Procedural Terminology (4th edition) developed and owned by AMA (1966)

Updated three times per year Three categories of codes

Category I-describe procedure or service 5 digits; series of 2 digit modifiers

used by all 3rd party payers to describe physician work

about 8000 codes E&M codes versus procedure code

Category II- supplemental tracking codes for performance measure reporting

Category III- tracking codes for new and emerging technologies

On AMA website Medicare fee schedules Complete RVU breakdown References describing commentaries on codes

Physician Billing

System to measure and compare physician work developed at Harvard University (Hsiao); 1989

commissioned by HCFA first employed by Medicare as payment basis in 1992

Medicare keys payment levels to RVU’s formula includes regional adjuster

three components physician work (52% of total value on average)

time technical skill risk

practice expense (44% on average) professional liability (4% on average)

Resource Based Relative Value Scale

Phase I vignettes of 25 services per specialty developed definition of time

pre-service, intra-service, post-service definition of intensity

physical effort/skill mental effort/judgment stress from iatrogenic risk

physician estimates national surveys small group processes

services in different specialties cross-linked by multiple regression

Development of RBRVS

Complex process of updating Social Security Act mandates review every 5 years AMA/Specialty society update committee

Relative Value Update Committee (RUC) receive input from specialty societies send recommendations to CMS CMS does final review and makes decisions

Resource Based Relative Value Scale

Emergency Medicine E and M codes

Process to verify physicians’ licensure, training and experience Licensure

State medical license Federal and state DEA numbers

Experience Residency training Board certification Hospital medical staff membership

Medicare Individual NPI number

Assigned directly by CMS Started by Medicare will replace all provider numbers for all payers

Group NPI number- provider group number

Physician Credentialing

Hospitals governed by JCACO processes (http://www.jcaho.org/)

Third party payers Medicare (http://www.cms.hhs.gov/)

Carriers (http://www.trailblazerhealth.com/) Medicaid (http://dchealth.dc.gov/information/maa_outline.shtm) Managed Care

NCQA (http://www.ncqa.org) Medical Groups

delegated credentialing

Physician Credentialing

Rigorous processes policies practitioners can review material and correct if inaccurate

Peer-review multidisciplinary committee Initial application

primary source verification license, training, education, board certification, work hx, liability hx

5 years of work history; gaps> 6 month need clarification National Practitioner Data Bank

Practitioner must attest to health status, history of loss, limitations of privileges

Elements of physician credentialing

Site visits managed care plans expected to visit physician offices

Recredentialing every 36 months primary source

licensure, board certification, NPDB

Ongoing monitoring between cycles

quality, complaints, sanctions

Elements of physician credentialing

Managed by HRSA (health resources and services administration of HHS)

National Practitioner Data Bank Created by act of Congress- 1986 alert system to “facilitate a comprehensive review of health care practitioners'

professional credentials” Includes:

adverse licensure actions by the States clinical privileges actions by Hospitals professional society membership actions paid medical malpractice judgments and settlements exclusions from participation in Medicare/Medicaid programs; r Adverse registration actions taken by the U.S. Drug Enforcement

Administration (DEA). Allied health practitioners added in 2010

Data Banks

Data Banks II

Healthcare Integrity and Protection Data Bank

Mandated in HIPPA (Health Insurance Portability Act-1996)

civil judgments against health care providers, suppliers, or practitioners related to the delivery of a health care item or service,

Federal or State criminal convictions against health care providers, suppliers, or practitioners related to the delivery of a health care item or service,

actions by Federal or State agencies responsible for the licensing and certification of health care providers, suppliers, or practitioners,

exclusions of health care providers, suppliers, or practitioners from participation in Federal or State health care programs,

any other adjudicated actions against health care providers, suppliers, or practitioners

System Performance Monitoring

Cash versus accrual Net Revenue = Gross Charges minus Contractual Allowances

Allowance- a contractually agreed upon discount Bad Debt- unpaid balance

Timely filing deadline Specified in most contracts Medicare is most forgiving (12 months) Many commercial plans are 90 or 120 days DC Medicaid is 180 days

Performance Monitoring

Useful Metrics Physicians

Patients per physician-hour worked RVU’s per physician-hour worked RVU’s per patient

Practice level Accounts with charges by year and by month Collected Dollars per closed case Collected dollars per billed RVU Total cash collected from the prior month