Robert C. Fifer, Ph.D.
Mailman Center for Child Development, University of Miami

 Program evaluator for Duke University Medical
School and University of Texas Medical Branch
 Presenter at New Mexico Speech and Hearing
Association, North Carolina Academy of Hearing
Rehabilitation
 Member Genetics and Newborn Screening Advisory
Council, Florida Department of Health
 Consultant to Children’s Medical Services
Audiology Review Committee
 Member ASHA’s Health Care Economics
Committee

1997 Documentation Guide for E/M Coding
• History (Soap):
– Medical necessity for why the patient is there
• “Referred by” is not medical necessity
• Requires a history covering the following areas as appropriate
– Chief Complaint
– Duration of symptoms
– Family history
– Social / occupational history
– Prior medical history
– Relevant diagnoses
– This section justifies all that is done

 Actions and results (sOap)
 Describing what was done
 The test forms cannot stand on their own
 Most professionals don’t know what it is or what the raw results mean
 Description of procedures and observations
 Procedure description can be “canned”
 Description of what was found (results)

– Clinical Assessment (soAp)
• Must have a clear statement of practical and clinical significance
• Must flow logically from the history and the findings
– Recommendations (soaP)
• Logical conclusion to the matter.
• Based on these outcomes, the following recommendations are offered:…………
• Each recommendation must be supported by history, findings, and interpretation
• Do not list unsupported recommendation

 Medical Necessity
 All recommendations must be supported by the concept of “medical necessity”
 Recommendation should not be offered that is for the convenience of health care provider or patient
 Transfer to plan of care
 Use of report
 Separate document (Recommended)

• Signature
– If a paper report, must be an original signature
– Facsimile or stamped signature is not appropriate
– If electronic medical record (EMR), your login constitutes your signature
• Date
– Date of service must be specified and prominent in report
– Other dates may include date of review, date of
“signing”, date of dictation. These must be distinguished from date of service.

 ICD-10 allows greater specificity in diagnosis coding and will be even more so if functional scales are added
 Description of patient status in report will need to be more detailed in order to complement and justify the specific ICD-10 code selected
 Will affect descriptions of what was found and clinical assessment statement.
 BE CLEAR IN WHAT YOU WRITE!

 I saw your patient today, who is still under our car for physical therapy
 The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week."
 Patient has chest pain if she lies on her left side for over a year.
 Discharge status: Alive but without permission. Patient needs disposition; therefore we will get Dr. Blank to dispose of him
9

 The patient was to have a bowel resection.
However, he took a job as stockbroker instead.
 The patient is tearful and crying constantly. She also appears to be depressed.
 The patient refused an autopsy.
 The respiration tube was disconnected and the patient quickly expired.
10

 Consists of audiogram with some notes
 Ex: Referred by Dr. Razzelfratz for hearing test.
 Recommend hearing aids
 Fails to meet federal guidelines for minimum documentation standards for covered services
 Therapy notes incomplete or has sign-in sheets only

 October 1, 2014
 To International Classification of Diseases, 9th
Revision, Clinical Modification ICD-10-CM
 ICD-9-CM: Approximately 18,000 codes
 ICD-10-CM: Approximately 64,000 codes
 Provides more flexibility for adding new codes
12

 Medicare guidelines on code selection
 Not allowed to be “normal” within the ICD-9 or
ICD-10 coding system
 Code signs / symptoms that caused you to do the test
 Some recommend use of a V code for test encounter following (for example “Examination following a failed screening”

ICD-10-CM
 H90 Conductive and Sensorineural Hearing Loss
 Includes:
 Congenital deafness
 Excludes:
 Deaf mutism NEC ( H91.3
)
 Deafness NOS ( H91.9
)
 Hearing loss NOS ( H91.9
)
 Noise-induced ( H83.3
)
 Ototoxic ( H91.0
)
 Sudden (idiopathic) ( H91.2
)
14

ICD-10-CM
 H90.0 Conductive hearing loss, bilateral
 H90.1 Conductive hearing loss, unilateral with unrestricted hearing on the contralateral side
 H90.2 Conductive hearing loss, unspecified
 Conductive deafness NOS
 H90.3 Sensorineural hearing loss, bilateral
 H90.4 Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side
15

ICD-10-CM
 H90.5 Sensorineural hearing loss, unspecified
 Congenital deafness NOS
 Hearing loss:
 central } NOS
 neural } NOS
 perceptive } NOS
 sensory } NOS
 Sensorineural deafness NOS
16

 Congress is eager to do away with the therapy caps and the exceptions process and go to a simpler system.
 Now requires CMS to collect functional status and outcomes measurements
 Seven-level functional outcome system to be phased in this year for therapy services
 Similar to NOMS in structure
17

 International Classification of Functioning,
Disability and Health (ICF)
 Describes body functions, body structures, activities, and participation
 Useful for understanding and measuring outcomes
 ASHA has information available online
18

ICF Levels
0 No impairment means the person has no problem
1
2
3
Mild impairment means a problem is present less than 25% of the time, with an intensity a person can tolerate, and happened rarely over the last 30 days.
Moderate impairment means a problem is present less than 50% of the time, with an intensity that is interfering in the person’s day-to-day life, and happened occasionally over the last 30 days.
Severe impairment means a problem is present more than
50% of the time, with an intensity that is partially disrupting the person’s day-to-day life, and happened frequently over the last 30 days.
19

4
8
Complete impairment means a problem is present more than 95% of the time, with an intensity that is totally disrupting the person’s day-to-day life, and happened every day over the last 30 days.
Not specified means there is insufficient information to specify the severity of the impairment.
20

 Greatest problem in audits
 Often inadequate and over-simplified
 Often not clear
 Mismatch between CPT and diagnosis codes unsupported by documentation
21

 To protect the Medicare Trust Fund
 Medicare QIO (Quality Improvement Organization)
 CERT (Comprehensive Error Rate Test)
 RAC (Recovery Audit Contractor)
 ZPIC (Zone Program Integrity Contractor)
 MAC (Medicare Administrative Contractor)
 PSC (Program Safeguard Contractor)
 OIG (Office of Inspector General Audits)

 To protect Medicaid funds
 MIP (Medicaid Integrity Program)
 MFCU (Medicaid Fraud Control Unit)
 RAC (Recover Audit Contractor)
 IMRO (Independent Medical Review Organization

 QIO: Improve effectiveness, efficiency, economy, and quality of services provided to Medicare patients
 MAC Audits: Sampling of patient records to ensure quality of service delivery and completeness
 MIC reviews: Looking for overpayments and billing errors
 MIC Audits: Looking for fraud often with local law enforcement (can also be behind the scenes)

 ZPIC oversees the RACs and approves their CPT code selection for data-mined audits
 RAC searches the Medicare and Medicaid data bases for inappropriate billing patterns that violate principles of code reporting
 PSC obtains information from RACs regarding possible fraud and abuse

 RAC Pilot Project
 3 year demonstration
 6 states
 $1.3 billion recovered in overpayments
 Overpayments
 Medicare: $49.9 billion in 2013
 Medicaid: $14.4 billion in 2013
 Point of comparison
 Deficit reduction bill by Rep. Ryan cut $20 from budget

 Administrative and documentation errors
 Medically unnecessary services
 Diagnosis coding errors
 Inappropriate procedure code reporting

 KNOW THE RULES!!!!!
 Correct coding
 Types of codes
 Don’t go “code fishing”
 Be truthful in code selection
 Documentation
 “If it wasn’t documented, it never happened”
 The audiogram cannot stand alone, not even with notes
 Six elements of documentation – EVERY TIME
 Medical necessity – justify ALL procedures

 With rare exception, do not go outside of our family of codes for SLP and Aud services
 Do not code shop for what sounds good without understanding the procedure represented by that code
 If a procedure does not have a code, use the unspecified/unlisted code 92700
 Know the difference between a unit code, contact code, and timed code

 Contact code
 Untimed code reported once per date of service
 Will have no unit or timed designation in the descriptor
 Unit code
 Report the code up to a maximum number of times per date of service
 Designated by maximum number of units in descriptor
 Timed code
 Designated in descriptor by “1 st hour” or “each successive 15 minutes”

 Usually the report preparation is included in the intra-service time. It will be designated “with report” if that is true
 Be conservative when reporting the portion of time devoted to report writing
 Document in progress notes the start time and stop time for the face to face contact

 Medicare requires 100%, in the room supervision
 Medicare pays for the licensed professional’s time and not the student’s effort
 Decision-making must be by the professional
 Cannot be involved with care of a second patient
 Medicaid
 Supervision may vary from state to state
 Typically professional contact with family and student to ensure appropriate procedures, outcomes, and decision-making
 Depending on the student, may not require 100% supervision

 Depends on supervision level and medical necessity
 Practice patients / clients
 If supervision CAN be met and the decision is to see
Medicare patients, then must use an ABN if medical necessity is not met (more on ABNs momentarily)
 If decision is to NOT see Medicare patients, then a sign must be posted informing all patients / clients that Medicare is not accepted because level of student supervision cannot be done in accordance with Medicare regulations

38 years of per capita spending by country
Per Capita Spending for Health Care; Source: Kaiser Family Foundation
34

Health Care Costs for American Families
Source: Milliman Medical Index
35

Health Care Costs for American Families
Source: Milliman Medical Index

Health Care Costs for American Families
Source: Milliman Medical Index
 Miami most expensive at $24,965.00
 Phoenix least expensive at $18,365.00
 Primary utilization factors influencing out of pocket and overall expenses:
 Inpatient facility care
 Outpatient facility care
 Professional services
 Pharmacy
 Other

 Cost inflation
 Risen 78% since 2000 vs. 20% for salaries
 Average 9% per year with range of 7%-13%
 Defensive medicine (malpractice)
 Unnecessary procedure/treatment (fee for service)
 Ineffective treatment
 Inefficient service delivery models
 Pharmaceuticals
 End of life care

 Sustainable Growth Rate (SGR)
 PQRS
 New models of reimbursement
 Procedure reviews
 New Challenges

 Part of the 1997 Balanced Budget
Amendment to keep Medicare budget neutral
 Includes several factors to calculate the reimbursement of Medicare services
 Independent from RVU assignments from
AMA
 Annual budget allocation from Congress

 Intended to control the growth of Medicare costs
 Payments for services not withheld if SGR targets are exceeded
 If target expenditures exceed budget, the next year’s update is reduced
 If target expenditures are below budget, the next year’s update is increased

 The estimated percentage change in fees for physicians’ services.
 The estimated percentage change in the average number of Medicare fee-for-service beneficiaries.
 The estimated 10-year average annual percentage change in real gross domestic product (GDP) per capita. (from 2008 forward)
 The estimated percentage change in expenditures due to changes in law or regulations.

1990
1991
1992
1993
1994
1995
Year
9.1
7.3
10.0
10.0
7.5
1.8
% decrease
Year
1996
1997
1998
1999
2000
2001
2002
2003
7.3
4.5
8.3
7.3
% decrease
-0.3
3.2
4.2
6.9
Year
2004
2005
2006
2007
2008
2009
2010
2011
4.5
6.4
8.9
4.7
% decrease
6.6
4.2
1.5
3.5

 Immediate repeal of SGR
 Transition period with 0.5% increase annually for 5 years
 Merit Based Incentive Program
 PQRS
 Value Based Modifier
 Meaningful Use for Electronic Medical Records
 5% added incentive payment to physician payment under new Alternative Payment Models
 Increased funding for technical assistance to small physician practices (<15 physicians)
 Creation of a technical advisory panel to review and recommend Alternative Payment Models

 Consolidates quality programs (e.g., PQRS, Value
Based Modifier, Meaningful Use) into one.
 Payments based on achieving performance thresholds
 Introduces the concept of alternative payment models
 Incentivizes care coordination and shared responsibility of patient care
 Requires ongoing development of quality measures to evaluate performance

 Increases transparency of metrics and quality
 Physician Compare website
 Posts quality and utilization data for patients to make informed decisions about their care
 Allows qualified clinical data registries to purchase claims data for purposes of quality improvement and patient safety

 Congress passed a bill to delay to freeze the current situation for one year.
 Suspend 24% reduction in payments
 Extend the therapy caps exceptions until March
2015
 Delay implementation of ICD-10 for one year

 CMS Screens of billed codes looking for
 Codes frequently reported together
 Codes that have never been surveyed by the RUC or
HCPAC
 Codes believed to be overvalued based on utilization increases
 AMA Responses to CMS
 Overseeing survey process
 Facilitating potential methods of payment revision

 One of three performance based reimbursement factors affecting physicians – the primary performance based factor for audiologists at present
 Began as an enticement to physicians to abide quality of care standards
 Participation is now a requirement to maintain full
Medicare reimbursement
 Each health care discipline / specialty will develop performance standards

 Quality measures as evaluated by National
Quality Alliance, Physician Consortium for
Performance Improvement, and CMS
 Has moved to mandatory participation
 Penalty Adjustment: -1.5% in 2015; -2% in 2016 and beyond
 Most recent rule for 2014 requires reporting on 9 measures. Audiology and speech-language pathology exempted from that for now.
51

 Document or confirm the patient's current medications for 50% of the eligible patient visits for evaluation AND
 Indicate a referral to a physician for 50% of the patients who report or are diagnosed with dizziness

 Document or confirm the patient's current medications for 50% of the eligible patient visits for therapy

 PQRS applies to audiologists and SLPs in private practice, group practice, or
university clinics.
 At this time, PQRS does not apply to providers in facilities such as hospitals or skilled nursing facilities.
 Separate enrollment is not required.

 Under SGR repeal, each “society” will develop discipline-specific measures
 Audiology is represented in this effort by the
Audiology Quality Consortium (AQC)
 AQC is comprised of representatives of 10 audiology organizations (list on ASHA, AAA, and
ADA websites)
 At this moment, there are 5 proposed measures in development
55

56

 MedPAC: Move Away From Fee-for-Service
 Encourages increased utilization
 More services => more payment
 Questions of true medical necessity
 IOM and CMS: Move Away From Fee-for-Service
57

 Value-Based Purchasing
 Based on Medicare vision of “the right care for every person, every time”
 Aligns payment to efficiency and quality of care delivery
 Rewards providers for measured performance (read: outcomes)
58

 Promote evidence-based medicine
 Require clinical and financial accountability across all settings
 Focus on episodes of care
 Better coordination of care
 Payment based on outcomes, not number of sessions
(performance-based payment)
 Focus on effectiveness of treatment
59

Level Type of evidence (based on AHCPR 1992)
Ia Evidence obtained from meta-analysis of randomized controlled trial
Ib Evidence obtained from at least one randomized controlled trial
IIa Evidence obtained from at least one well-designed controlled study without randomization
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case control studies
IV Evidence obtained from case reports or case series
V Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
60

 Bundled payment models de-emphasize services that increase utilization and cost
 Initiative by Center for Medicare and Medicaid
Innovation called Bundled Payments for Care
Improvement
 Working to identify procedure groups to bundle, based on diagnosis rather than procedure(s)
61

 Medicare screens for procedures reported together => new, combined procedure CPT codes (92540, 92550, 92570)
 Re-survey and re-validation of procedure value (92587)
 Bundled payments under Medicaid reform
(more on this later)
62

 Primary care physician becomes medical manager
 All referrals will go through PCP
 Different from “gate-keeper” concept of HMOs
 PCP paid to coordinate and manage all care of that patient
 With rare exception, no physician/health care provider will have “direct access” under medical home model
63

 Physicians are facing same pressures as hospitals
 Leaving private practice to become salaried employees of hospitals and other large medical organizations
 Lower costs
 Meet government mandates on electronic medical records
 Percentage of physicians who own their own practices
 2000 – 57%
 2009 – 43%
 2013 – 33% (projected)

 Giving up fee for service or a salary…
 Physicians lose autonomy
 Gain more regular hours
 Gain more predictable income level
 Hospitals gain a guaranteed supply of patients from the physicians practices
 Intent of health care changes under Obama
 More coordinated care (shared patient management)
 Leading to cost reductions and better patient outcomes
 Eliminate “silo” style of operation for patient care

 Patient Satisfaction and Wellness
 Patient Centered (What do you want me to do?)
 FQHC payment per encounter
 Average payment
 Diagnosis based
 Influence by Medical Home
 Shared responsibility for care (Again, emphasis on
Care Coordination and elimination of silos)
66

 Remove traditional prescriptive perspective from
SLPs and Auds
 Patient / family actively participate in decisionmaking
 Patient / family establish goals to be achieved
 SLP / Aud role to educate, evaluate, guide, empower

 Every procedure must be supported by history or other test findings
 Every protocol must be customized for each patient based on the clinical question to be answered
 What we currently know of reimbursement directions indicate that it will be necessary to do what is necessary and stop there
 Bottom line: the individualized clinical question will be the driving force for what is done diagnostically

 We are not physicians, but sometimes the system treats us like physicians for payment and policy
 We don’t know what our reimbursement will look like, but we have some hints based on physiciancenter proposals and movements away from fee-forservice
 Pay attention to the diminishing physician private practice and move toward joining large health care organizations

 Changes in health care will require that you determine cost of service delivery
 Carefully evaluate each procedure being performed
(e.g., develop a clinical question and determine what tools are necessary; stay away from graduate school protocol …
 Time is money and each additional procedure is time
 Justify what you do based on case history and outcome of previous test
70

 Anticipation that payment may be based on diagnosis or “per patient” rather than procedure
 Replace fee-for-service with bundled code crosswalked to diagnosis
 Bundled fee based on data-mining median costs of procedures “typically done” to derive diagnosis
 May combine severity with diagnosis via ICF or similar scale
 Focus on participation in life activities (NOT ADLs—life activities)
71

 Anticipate episodic / periodic payments
 Single payment
 Covers all services
 Covers specified period of time
 Already appearing in Medicaid “reform”
 Single payment for date of service
 Based on diagnosis and level of severity
 Focus on FUNCTIONAL outcomes
 Realistic achievement of goals
 Activities of life

 Unsustainable increasing cost of medical care
 Patient Protection and Accountable Care Act
 Increasing demands for quality, efficiency, and accountability by
 Regulators
 Health Care Rating Organizations
 Accrediting bodies
 Employers
 Commercial payers
 The Public

 Improving the patient experience of care (including quality and satisfaction)
 Improving the health of populations
 Reducing the per capita cost of health care

 Teach clinical judgment rather than strictly procedures and protocol
 Mechanics of test administration are important, but know when to stop (emphasis: Aud)
 Mechanics of test administration and therapy techniques are important, but know how to set realistic goals (emphasis: SLP)
 Develop a true sense of medical necessity, clinical questions, patient-centered recommendations and plan of care

Peter Hollmann, MD
Chair, AMA CPT Editorial
Panel
October 2011