Breaking the Code on the Codes Grant P. Bagley, M.D., J.D. March 27, 2007 Doc # February 22, 2019 TrackB.Bagley@2.20pm MD*
AND USEFUL CODING SYSTEM 2007 CMS WILL ADOPT A FAIR AND USEFUL CODING SYSTEM Doc # February 22, 2019 TrackB.Bagley@2.20pm MD*
THE WORLD OF CODES CODES ARE NOT NEW CODES ARE SOMETIMES MYSTERIOUS CODES ARE VITAL Doc # February 22, 2019
WHICH ONE IS THE BIGGER MYSTERY? Or IS IT Really? HCPCS Doc # February 22, 2019
OUR UNIVERSAL MESSAGE TO OTHERS IN SPACE GOLD PLATE WITH A MESSAGE FOR OTHERS SENT INTO SPACE BY NASA OUR UNIVERSAL CONCEPTS--WHAT ARE THEY SAYING? Doc # February 22, 2019
THE REAL QUESTION IN OUR WORLD I WONDER IF OTHER CIVILIZATIONS CAN GET A HCPCS CODE FROM THEIR WORK GROUP NO I’M SURE IT’S JUST A LAW OF NATURE FOR HCPCS TO REFUSE Doc # February 22, 2019
THE WORLD OF CODES DRGs APCs ICD9 CPT HCPCS Doc # February 22, 2019
THE MEDICARE VISION OF CODES For Medicare and other health insurance programs to ensure that these claims are processed in an orderly and consistent manner, standardized coding systems are essential. Doc # February 22, 2019
CPT CODES IN PARTICULAR Decisions regarding the addition, deletion, or revision of CPT codes are made by the AMA. Doc # February 22, 2019
WHAT IS THE ROLE FOR CMS IN CODE DEFINITION? Doc # February 22, 2019
DO CPT CODES WORK? INDUSTRY HAS NO VOICE IN THE PROCESS THE PUBLIC HAS NO VOICE IN THE PROCESS CONTROLLED BY THIRD PARTY PAYERS IN SPITE OF HIPPA--NO UNIFORMITY Medicare contractors and insurers change code definitions and applications at will CMS exercises little or no oversight Doc # February 22, 2019
HCPCS LEVEL II CODES FOR DEVICES FOR SUPPLIES FOR UNIQUE MEDICARE PURPOSES DRUGS/BIOLOGICS Doc # February 22, 2019
THE HCPCS DECISION TREE Doc # February 22, 2019
CRITERIA FOR A “NEW CODE” EVIDENCE OF IMPROVED OUTCOMES “PEER REVIEWED LITERATURE” COMPARATIVE STUDIES NOT CLEARLY DEFINED Doc # February 22, 2019
A DIFFERENT APPROACH FOR THE SAME SERVICE REQUIRES LITTLE EVIDENCE BUT THE SAME CODE Doc # February 22, 2019
OR A LOWER COST TO GET A CODE? DO I NEED MORE EVIDENCE OR A LOWER COST TO GET A CODE? E V I D N C COST TO THE PROGRAM Doc # February 22, 2019
ITEMS THAT PERFORM THE SAME FUNCTION MUST USE THE SAME CODE UNLESS THEY HAVE PROOF OF IMPROVED OUTCOMES Doc # February 22, 2019
The MEDICARE Policy Dilemma WHO WILL PROTECT THE TRUST FUND? CODING PAYMENT COVERAGE Doc # February 22, 2019
POLICIES IN CODE CLOTHING SHARING OF A CODE (REFERENCE PRICING) DENIAL OF A CODE CHANGING DESCRIPTION OF A CODE GENERIC/COMPOUNDING SUBSTITUTION PRICING “EXPERIMENTAL/INVESTIGATIONAL” DETERMINATION Doc # February 22, 2019
WHO WILL PROTECT THE TRUST FUND FROM THE WOLF? Doc # February 22, 2019
EVIDENCE BASED MEDICINE WHAT DOES IT PROMISE US? Doc # February 22, 2019
FORMULATE THE QUESTION Doc # February 22, 2019
THE ANSWER FROM MEDICARE PERSPECTIVE--- Doc # February 22, 2019
THE MEDICARE TRUST FUND UNDER ATTACK Doc # February 22, 2019
THE FIRST CMS GROUP SAID WE WILL PROTECT THE TRUST FUND WITH COVERAGE POLICIES. AND THE WOLF DID STUDIES, HAD THEM PUBLISHED AND APPLIED FOR AN NCD. Doc # February 22, 2019
THE SECOND CMS GROUP SAID, WE WILL PROTECT THE TRUST FUND WITH A FEE SCHEDULE. AND THE WOLF DEVELOPED COMMENTS TO THE PROPOSED FEE SCHEDULE AND THE FINAL RULE WAS OK. Doc # February 22, 2019
BUT THE CLEVER THIRD GROUP SAID WE WILL PROTECT THE TRUST FUND WITH A HOUSE MADE OF CODES WE WILL MAKE THIS HOUSE FROM STRONG CODES-- HCPCS CODES, CPT CODES, ICD9 CODES, J CODES K CODES, C CODES, XYZ CODES AND SO THEY DID. Doc # February 22, 2019
AND THE WOLF CAME TO THE CODE HOUSE… AND THERE WAS NOTHING THE WOLF COULD DO BECAUSE THERE WAS NO APPEAL PROCESS OR WAY THAT HE COULD PARTICIPATE IN CODES. Doc # February 22, 2019
Doc # February 22, 2019
THE EXISTING HCPCS CODE SET IS POORLY MANAGED AND MAINTAINED SERVES TO HIDE OTHER POLICY AGENDAS IS HOSTILE TO NEW TECHNOLOGY LACKS ADEQUATE COORDINATION FAILS TO SERVE THE NEEDS OF PUBLIC HEALTH FAILS TO MEET THE NEEDS OF OTHER AGENCIES FAILS TO SERVE THE NEEDS OF HOMELAND SECURITY FAILS TO MEET THE NEEDS OF MEDICA RESEARCH IS UNRESPONSIVE TO QUALITY IMPROVEMENT CONTROLLED BY PAYERS ONLY Doc # February 22, 2019
WHAT NEEDS TO BE DONE USE MODERN TECHNOLOGY MAKE CODING AS SPECIFIC AS POSSIBLE PROVIDE A BASIS FOR INFORMATION ABOUT OUTCOMES INVOLVE ALL STAKEHOLDERS Public Industry Providers Payers Government Doc # February 22, 2019