1. ROBERT SHESSER M.D. MPH GEORGE WASHINGTON UNIVERSITY Patient Care Services Reimbursement: 2011

2. Patient care services reimbursement Revenue cycle Diagnosis coding Procedure coding Credentialing Compliance Productivity Monitoring Reports

3. Revenue cycle I Chart acquisition Coding Data entry  Charge lag- interval between treatment and billing Billing  Primary and secondary Charge posting, clean up, reporting Accounts receivable  everything that has been billed, but not collected  Unit is “days” (total receivables/average charges/day)

4. 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

5.  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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Emergency Medicine E and M codes

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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