Industry Developments

• ICD-10 Implementation Date Announced
• Blue Shield Planning to Publish Physician
• CMS Eliminates Medicare Consult Codes
• State Proposes Sweeping Changes to Medi-Cal Program

 

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ICD-10 Implementation Date Announced

January 15th, 2009
The Centers for Medicare & Medicaid Services (CMS), with approval from the Office of Management and Budget (OMB), has finalized and approved the ruling on implementation dates for ICD-10-CM. In quick summary, the ruling requires the implementation of X12 standard, version 5010 electronic filing standards by October 1, 2012, and ICD-10-CM code set by October 1, 2013. The original proposed ruling from HHS was for both 5010 standards and the ICD-10-CM code set to be required on October 1, 2011; thus in the final ruling, 5010 standards was moved back by one year and ICD-10-CM codes moved back by two years. ICD-10-CM is a new code set with approximately 68,000 codes and will replace the 13,000 ICD-9-CM codes currently in use.

The efforts of the American Academy of Professional Coders (AAPC) and its members by providing comments to the initial proposed ruling requesting a delay of two to three years made a significant impact on the Department of Health and Human Services. The AAPC believes the final announcement is a huge victory for providers, payers and coders in giving them time to properly prepare for this significant code set change.

“Since the original proposal was announced last August, AAPC held firm in its stance that the original proposal of an October 1, 2011, implementation date would pose serious issues and hardships across the health care industry,” said Reed E. Pew, CEO and president of AAPC. “AAPC is very pleased with the final rule. We believe this delay is a victory for providers, payers and coders and allows for a more efficient transition, giving the proper amount of time to implement system and coding changes without impacting the daily operations of practices, facilities and payers.”

Blue Shield Planning to Publish Physician

Ratings Based on Faulty CPPI Data
The California Cooperative Healthcare Reporting Initiative (CCHRI) is operating a quality reporting pilot project called the California Physician Performance Initiative (CPPI). Over the past two years, CPPI has used claims data from private PPO patients from Anthem Blue Cross, Blue Shield, and United Healthcare to measure physicians on a set of quality measures.

CMA continues to have serious concerns with the validity and accuracy of the data that has been collected. Results of CCHRI’s own reconsideration process in 2009 found significant inaccuracies, with 33 percent of physician scores being overturned during the reconsideration process.

CMA also surveyed members who completed the reconsideration process and found similar results. Because the CPPI program relies solely on claims data, it fails to comprehensively document the care a patient receives or the reasons why a patient may not receive the care that is the focus of a quality measure. For example, one physician reported that he was marked down for not recommending cervical cancer screening to patients who had undergone hysterectomies. Another physician was penalized for a procedure that he recommended, but that was subsequently denied by the HMO for medical necessity.

Many organizations have voiced similar concern with the validity of the CPPI data, including county medical associations, major physician groups, the University of California at San Diego, and CCHRI’s own physician advisory group (PAG).

Despite the recommendation from CCHRI’s physician advisory group not to release the faulty data, Blue Shield has indicated that it will likely publish the results. At this point, Blue Cross and United have not said whether they will publish the 2009 CPPI results.

CMA has learned that Blue Shield is planning to give digital “blue ribbons” to physicians who scored in the top 50th percentile, and will possibly reopen the reconsideration process for physicians who are interested in improving their scores. Blue Shield has tentative plans to publish this information by the end of December.

CMA is very concerned about the implications of making this data public, given the serious concerns about its accuracy. Even a “partial” publication of the results, as is being planned by Blue Shield, is problematic given the faulty data used to score physicians. It also infers that some physicians are not quality doctors because they did not receive a “blue ribbon.”

CMA continues to work to dissuade payors from publishing the 2009 CPPI results, and to persuade CCHRI to fix the flaws in the CPPI data gathering process before moving forward with the project.

 

CMS Eliminates Medicare Consult Codes

 

Despite objections from CMA and others in organized medicine, the Centers for Medicare & Medicaid Services last week decided to move forward with its controversial plan to eliminate payments for inpatient and outpatient consultation codes and require physicians to instead bill for either new or established office visits or for initial hospital stays. Effective, Jan. 1, 2010, consult codes (99241-99255) will no longer be recognized for Medicare Part B payment.

Although the payment rule will provide minor increases in payments for some inpatient and outpatient E&M visits to offset losses that will result from the elimination of these codes, physicians asked to provide expert opinions will could see an 8 percent reduction or more in reimbursement as a result of this new policy.

Although CMS's decision was intended to alleviate confusion that has surrounded the reporting of these codes for years, the new policy will likely cause additional confusion as physicians and billing managers try and make sense of the new rules. (CMA Alert Issue 2173)

 

State Proposes Sweeping Changes to Medi-Cal Program

 

The state Legislature recently held public hearings on a Department of Health Care Services' concept paper that contemplates significant changes to the Medi-Cal program, with the goal of providing patients with access to better coordinated care that will improve outcomes and help slow the long-term growth in program costs.

The concept paper, which contains no specific details, is the first step in the process of renewing – and expanding – California's Section 1115 Medicaid waiver. (Under the federal Medicaid program, certain laws and rules can be waived to grant states greater program flexibility.)

The proposal calls for shifting the most vulnerable enrollees (nearly all of the population of children and adults with disabilities, the blind, mental health needs and seniors) out of the fee-for-service program into an "organized delivery systems of care," such as managed care or medical homes.

CMA submitted comments on the proposal, telling DHCS that the physicians of California strongly support the idea of developing a model for patient-centered medical homes in the Medi-Cal program. However, CMA made it clear that any new treatment models must be carefully constructed so as not to overburden safety net physicians.

"Persistently low Medi-Cal reimbursement rates have forced many physicians to reduce or eliminate their Medi-Cal patient loads, and those physicians who continue to actively treat Medi-Cal recipients often serve very large patient panels, on very tight financial margins," CMA wrote in the comments. "Any new requirements on these physicians without an increase in resources available, will force many of these safety net providers out of the program."

 

CMA also told DHCS that only a physician should lead a medical home. While nurse practitioners and other allied health professionals play a crucial role in the health care delivery system, only a physician has the training and experience to properly coordinate patient care, particularly the high-risk patients that would be most impacted by this proposal.

Additionally, CMA expressed concerns that forcing patients into managed care might disrupt existing physician-patient relationships, and negatively impact access to care. CMA urged DHS to address these concerns by involving physicians in any local health system planning.

"Physician input in the process of establishing the treatment protocols for Medi-Cal Managed Care is essential," CMA wrote. "Physicians are often a patient's primary connection to the health care system, and they have a unique perspective on their patient's needs. While managed care can work well for some patients, one size does not fit all."

CMA also expressed significant concern over the program's pitifully low reimbursement rates. In many cases, the reimbursement does not even cover the cost of providing care. A number of legislators also echoed CMA's concerns.

"I really don't believe you can continue to ask the providers to pay for the privilege of treating Medi-Cal patients," said Senator Dave Cox, a member of the Senate Health Committee. "There comes a point in time when the physician is just simply going to say thank you very much, I will not pay to treat your patients and I think we are rapidly approaching that particular situation in the state of California."

CMA will continue to participate in the discussion and planning as the 1115 waiver proposal is fleshed out over the coming months. (CMA Alert Issue 2173)