2010 CMS Update Coding for Stroke and Pay for Performance 2010 CMS Update Coding for Stroke and Pay for Performance © Copyright 2009 NeuStrategy All rights

2010 CMS Update

Coding for Strokeand

Pay for Performance

Debbie Lombardi HillNeuStrategy, Inc.

Stroke Centers of Excellencefor Hospitals and Health Systems

ACI Meeting – ChicagoNovember 5, 2009

©Copyright 2009 NeuStrategy All rights reserved.

1. Coding for Stroke-Drip and Ship Code-Critical Care Codes-”Telehealth” (Telemedicine) Codes

2. Pay for Performance -Physician Quality Reporting Initiative

-Hospital Quality Reporting Initiative-Premier Hospital Quality Incentive Demonstration



Standardized Coding Conventions

ICD-9-CM Codes(1)

Hospital billing codes

◦ Diagnosis codes and procedure codes Pertinent to a hospital admission Used to classify inpatients into a MS-DRG used to

determine payment

◦ V-codes Report factors that may influence present or future care Usually listed as a secondary diagnosis Supplemental tracking codes used to facilitate data

collection

(1)International Classification of Diseases, 9th Revision, Clinical Modification ©Copyright 2009 NeuStrategy All rights reserved.

Standardized Coding Conventions CPT® Codes(1)

Physician, laboratory, radiology and other billing codes

◦ CPT I(2)

Medical or procedural service Assigned a relative value unit based on skill and time required Modifiers used to indicate that a service or procedure has been

altered but not changed in its definition Used to determine payment

◦ CPT II Supplemental tracking codes used for performance measurement

◦ CPT III Temporary tracking codes used to facilitate data collection for

emerging technology, services and procedures

(1)Current Procedural Terminology(2) Same as HCPCS Level I codes ©Copyright 2009 NeuStrategy All rights reserved.

Standardized Coding Conventions HCPCS Codes(1)

Physician and supplier billing codes

◦ Level I codes Same as CPT I codes Medical or procedural service Used to determine payment

◦ Level II codes Drugs and biologics Medical items or services billed by suppliers other than physicians

◦ Ambulance services, durable medical equipment

Used to determine payment

◦ G-codes Supplemental codes used to measure quality of services

(1)Healthcare Common Procedure Coding System


CMS Annual Update Cycle

Hospital Inpatient Prospective Payment System (IPPS)

Fiscal Year (FY) October - September

Proposed Update May 1, 2009

Comment Period June 30, 2009

Final Rule August 27, 2009

Effective Date October 1, 2009(1)

Medicare PhysicianFee Schedule (MPFS)

Oct Aug NovJan Jul

(1) Unless otherwise indicated

Fiscal Year (FY) January - December

Proposed Update July 1, 2009

Comment Period August 31, 2009

Final Rule November 1, 2009

Effective Date January 1, 2010(1)

May Jun Feb Mar Apr Sept Dec



Source: Federal Register / Vol. 73, No. 161, August, 19, 2008, Changes to the Hospital Inpatient Prospective Payment Systems ©Copyright 2009 NeuStrategy All rights reserved.

V45.88Status post administration of tPA in a different facility within the last 24 hours prior to admission at current facilityICD-9-CM

Source: Federal Register / August, 27, 2009, Changes to the Hospital Inpatient Prospective Payment Systems ©Copyright 2009 NeuStrategy All rights reserved.

V45.88Status post administration of tPA in a different facility within the last 24 hours prior to admission at current facilityICD-9-CM


Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9, 2008, and AAN website for additional details

CPT Definition – Critical Care

“Critical care is defined as the direct delivery by a physician(s) of

medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening

deterioration in the patient’s condition.”



99291 Critical Care Services - First hour (30-74 minutes)

99292 Critical Care Services - Each additional 30 minutes

CPT

CPT

Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9, 2008, and AAN website for additional details

Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9, 2008, and AAN website for additional details ©Copyright 2009 NeuStrategy All rights reserved.


99243 New OP Consult – 40 min $ 99.26



99255 New IP Consult – 100 min $ 203.55

Code Description

Medicare Allowable Amount(1)

(1)Medicare Allowable FY09 Area 99 (Orlando, FL)

99291 Critical Care - 30-74 min $ 214.98

99292 Critical Care–Each add’l 30 min $ 107.63

Payment Rate Recognizes Complexity of Care

Payment Rate for “Routine” Care

Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9, 2008 ©Copyright 2009 NeuStrategy All rights reserved.

0188TRemote real-time video-conferenced critical careFirst hour (30-74 minutes)

0189T Each additional 30 minutes

CPT

CPT


Code Description


0188T Remote Critical Care - 30-74 min $ 0

0189T Remote Critical Care–Each add’l 30 min

$ 0

(1)Medicare Allowable FY 09 Area 99 (Orlando, FL)

99291 Critical Care - 30-74 min $ 214.98

99292 Critical Care–Each add’l 30 min $ 107.63

Payment Rate for Critical Care

Not on CMS list of approved telehealth services




Spoke Hub

Metropolitan Statistical Area - A geographic cluster of population defined by the United States Census Bureau. An MSA includes a city of at least 50,000 people or urbanized area of at least 100,000 people and the counties that include these areas.

Hospital where patient is located

Location of the physician delivering the medical service

*Some exceptions exist for Federal telemedicine demonstration projects in Alaska and Hawaii ©Copyright 2009 NeuStrategy All rights reserved.


99241-99255

IP/OP ConsultationsMinor to Severe Problem15 min-110 min

99201-99215

Office or OP VisitsMinor to Severe Problem5 min-60 min

Refer to CMS Manual Pub 100-02, Transmittal 74, June 29, 2007

CPT

CPT


G0406 Follow-up Inpatient Telehealth Consultation (Limited)

G0407 Follow-up Inpatient Telehealth Consultation (Intermediate)

G0408 Follow-up Inpatient Telehealth Consultation (Complex)

Refer to CMS Manual Pub 100-04, Transmittal 1654, December 24, 2008 and MLN JA 6130, January 5, 2009

HCPCS

HCPCS

HCPCS

©Copyright 2009 NeuStrategy All rights reserved. Refer to CMS Manual Pub 100-04, Transmittal 1654, December 24, 2008 and MLN JA 6130, January 5, 2009

99241-99255

99201-99215

G0406-G0408

IP/OP Consultation

Follow-up inpatient Telehealth

Office or OP Visits


Code Description


(1)Medicare Allowable FY 09 Area 99 (Orlando, FL)

G0406 F/U Inpatient Telehealth Consultation (15 min)

$ 37.40

G0407 F/U Inpatient Telehealth Consultation (25 min)

$ 66.84

G0408 F/U Inpatient Telehealth Consultation (<35 min)

$ 95.85

99255 New IP Consult – 100 min $ 203.55

Payment Rate for Initial Critical Care

Payment Rate for Follow-up Care

Refer to Federal Register / Vol. 73, No. 161, August, 19, 2008, Changes to the Hospital Inpatient Prospective Payment Systems ©Copyright 2009 NeuStrategy All rights reserved.

Q3014 Telehealth facility feeOriginating Site

HCPCS

1Refer to Center for Telehealth and E-Health Law for more information ©Copyright 2009 NeuStrategy All rights reserved.

2. Pay for Performance -Physician Quality Reporting Initiative

-Hospital Quality Reporting Initiative-Premier Hospital Quality Incentive Demonstration



Source: www.cms.hhs.gov/pqri/ www.qualitynet.org

http://www.cms.hhs.gov/pqri/

http://www.qualitynet.org/









6,722,753 Measures Reported

$3,600,000 Bonus Payments(1)

109,349 Attempted to Participate

56,722 Satisfactorily Reported

$4,713 Average Bonus Earned

3.6 Average Measures Reported

Physician Quality Reporting Initiative (PQRI)

(1)Expected

Source: www.cms.hhs.gov Fact Sheet “PQRI Makes Payments for the 2007 Reporting Period

CY 2007 Reported Experience


http://www.cms.hhs.gov/


Source: Federal Register, November 19, 2008 Section 01, MPFS

“Stroke Related” Measures

10. CT or MRI of brain within 24 hrs of hospital admission

11. Carotid Imaging Reports with reference to stenosis measurements

31. DVT prophylaxis received by end of hospital day two

32. Discharged on Antiplatelet Therapy

33. Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge

34. Tissue Plasminogen Activator (t-PA) Considered (<3 hrs)

35. Screening for Dysphagia

36. Consideration of rehabilitation services is documented

114. Inquiry Regarding Tobacco Use

115. Advising Smokers to Quit



Physician Quality Reporting Initiative (PQRI)




Refer to www.outcome.com/pqri.htm for more information

http://www.outcome.com/pqri.htm


Source: Federal Register July 13, , 2009 and August 5, 2009 Proposed Rule Section 02 MPFS

CY 07 CY 08 CY 09 CY 100

50

100

150

200

Number of Measures Available

74

119

153175

Proposed

©Copyright 2009 NeuStrategy All rights reserved.Source: www.cms.hhs.gov/hospitalqualityinit www.qualitynet.org

http://www.cms.hhs.gov/hospitalqualityinit



Source: www.cms.hhs.gov/hospitalqualityinit www.qualitynet.org





FY 04 FY 08 FY 09 FY 10 FY 110

20

40

60

Number of Measures Required

10

69 Proposed

30

43 46











©Copyright 2009 NeuStrategy All rights reserved.Source: Federal Register / August, 27, 2009, Changes to the Hospital Inpatient Prospective Payment Systems


Source: Federal Register / August, 27, 2009, Changes to the Hospital Inpatient Prospective Payment Systems

©Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/hospitalqualityinit


©Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/hospitalqualityinet



©Copyright 2009 NeuStrategy All rights reserved. Source: www.cms.hhs.gov/hospitalqualityinit




Please Note: Coding and reimbursement information provided is gathered from sources referenced on each slide and is presented for informative and illustrative purposes only. By making this information available, neither the author nor NeuStrategy, Inc. make representation or warranty regarding its completeness, accuracy, timeliness, or applicability for a particular patient case. This information does not constitute reimbursement or legal advice. Laws, regulations and payer policies concerning reimbursement are complex and change frequently. Providers are responsible for making appropriate decisions relating to coding and reimbursement submissions. Accordingly, the author and NeuStrategy, Inc. recommend that you consult with your payers, reimbursement specialist and/or legal counsel regarding coding, coverage and reimbursement matters.

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2010 CMS Update Coding for Stroke and Pay for Performance 2010 CMS Update Coding for Stroke and Pay for Performance © Copyright 2009 NeuStrategy All rights