CPT fee differentials and visit upcoding under Medicare Part B.

Medicare Part B pays outpatient physicians according to the billed Current Procedural Terminology (CPT) codes, which differ in procedure and intensity. Since many performed services merely differ by intensity, physicians have an incentive to upcode services to increase profitability of a visit. Using nationally representative data from the 2001 to 2003 Medicare Current Beneficiary Survey, this paper explores the effect of Medicare Part B fee differentials on the upcoding of general office visits (i.e. for established patient visits with CPT codes of 99212-99215). It finds strong evidence that these fee differentials influence physician's coding choice for billing purposes across a variety of specialties. For general office visits, Medicare outlays attributable to upcoding may sum to as much as 15% of total expenditures for such visits. Medicare has much to gain financially by clarifying its classification rules. Until the distinctions between types of Medicare visits are redefined in a way that eliminates ambiguity, upcoding under Medicare Part B is likely to continue.

Facts you should know about ordering/referring providers for Medicare Part B items and services.

To avoid Medicare Part B claim rejection, wound care providers and suppliers, who are qualified to bill Medicare Part B, should ensure that they are correctly and currently enrolled in the Internet-based PECOS. In addition, wound care providers, who are billing for Medicare Part B-covered items and services that were ordered or referred, need to ensure that the physicians and nonphysician practitioners from whom they accept orders and referrals have current Medicare enrollment records (ie, they have enrollment records that contain their NPIs in PECOS) and are of a type/specialty that is eligible to order or refer in the Medicare program.Wound care providers can verify this by checking the Internet-based Ordering Referring Report. If ordering/referring providers are not yet enrolled in PECOS, remind them that time is running out before the full implementation of the Medicare Part B claims edits on January 3, 2011! For a complete review of the ordering/referring edit process, visit http://www.cms.gov/MLNMattersArticles/downloads/SE1011.pdf.

Pilot study comparing patients' valuation of health-care services with Medicare's relative value units.

BACKGROUND AND AIMS: Physician reimbursement for services and thus income are largely determined by the Medicare Resource-Based Relative Value Scale. Patients' assessment of the value of physician services has never been considered in the calculation. This study sought to compare patients' valuation of health-care services to Medicare's relative value unit (RVU) assessments and to discover patients' perceptions about the relative differences in incomes across physician specialties. DESIGN: Cross-sectional survey. PARTICIPANTS AND SETTING: Individuals in select outpatient waiting areas at Johns Hopkins Bayview Medical Center. METHODS: Data collection included the use of a visual analog 'value scale' wherein participants assigned value to 10 specific physician-dependent health-care services. Informants were also asked to estimate the annualized incomes of physicians in specialties related to the above-mentioned services. Comparisons of (i) the 'patient valuation RVUs' with actual Medicare RVUs, and (ii) patients' estimations of physician income with actual income were explored using t-tests. OUTCOMES: Of the 206 eligible individuals, 186 (90%) agreed to participate. Participants assigned a significantly higher mean value to 7 of the 10 services compared with Medicare RVUs (P<0.001) and the range in values assigned by participants was much smaller than Medicare's (a factor of 2 vs. 22). With the exception of primary care, respondents estimated that physicians earn significantly less than their actual income (all P<0.001) and the differential across specialties was thought to be much smaller (estimate: $88,225, actual: $146,769). CONCLUSION: In this pilot study, patients' estimations of the value health-care services were markedly different from the Medicare RVU system. Mechanisms for incorporating patients' valuation of services rendered by physicians may be warranted.

Reimbursement for carotid stenting: unique challenges for medical centers and physicians.

Carotid artery stenting has been identified as an important therapeutic option for patients with atherosclerotic occlusive disease of the extracranial carotid artery. While the preferred application of this technology remains an area of active clinical investigation and its optimal role may continue to evolve, a preponderance of opinion supports its present application in carefully selected patients. Enabling the introduction of this technology into the broader patient community mandated a consensus between a large number of specialty societies and the Centers for Medicare and Medicaid Services to define both currently acceptable procedures to be performed and appropriate clinical criteria for its suitable application. This report reviews the collaborative process, which evolved to achieve this consensus and the current guidelines for procedural coding, facility accreditation, and reimbursement for carotid artery stenting. Related requirements for Medicare coverage of patients in clinical trials and registries are also discussed.

Institute of Medicine recommends new P4P system for Medicare.

IOM asserts fee-for-service program actually discourages quality improvement. Report claims jury is still out on approach; current research contains conflicting results. Ten design principles recommended for pay for performance and its implementation.

Avoiding audits by benchmarking your E/M coding.

Providers are well aware that appropriate coding is the key to prompt payment of claims submitted for services. Payers do reserve the right to review payments at a later date, however. The auditing process is costly, time consuming, and often traumatic for practices. This article provides an overview of the coding and payment process. The author suggests that practices audit their own clinical records on a periodic basis and compare the distribution of their codes with national and/or specialty benchmarks. In addition, practices must weigh whether the coding level is supported by appropriate documentation.

Medicare reimbursement for geriatric assessment: report of the American Geriatrics Society Ad Hoc Committee on Geriatrics Assessment.

This ad hoc committee report from the American Geriatrics Society proposes the prompt initiation of Medicare reimbursement for geriatric assessment (GA) services (also termed comprehensive geriatric assessment or geriatric evaluation and management services). Despite an extensive body of literature documenting the effectiveness of GA for improving health care outcomes in many settings for identifiable groups of frail elderly patients, no explicit Medicare reimbursement mechanisms currently exist to cover GA services provided by either hospital or physician. We believe that new physician reimbursement codes specific for geriatric assessment should be established in the Current Procedural Technology (CPT-4) manual and that reimbursement for GA should be specifically provided under Part B of Medicare. Further, we believe that hospital reimbursement within the Medicare prospective payment system should be modified to encourage GA during inpatient stays for appropriate patients. This paper summarizes the background for these recommendations. It defines the major content of GA at three levels of intensity--screening, intermediate, and comprehensive. It describes the major sites for conducting GA--hospital, office, home, nursing home. Finally, it proposes criteria for targeting patients most likely to benefit from GA.

Accuracy of coding in Medicare part B claims. Cataract as a case study.

We studied the accuracy of Medicare part B coding for cataract extraction to provide validation for research involving Medicare data. Hospital and physician office records associated with a sample of 802 paid claims for cataract surgery were reviewed. The sample was randomly selected from 118,420 Medicare part B claims for cataract surgery submitted by physicians in an 11-state sample during the first quarter of 1988. Medical records were successfully obtained for 796 cataract surgery episodes (99.2%), of which 794 (99.7%) indicated that cataract extraction had been performed. In the remaining two cases, cataract surgery was attempted but aborted. In 24 (3%) of the 794 cases, the surgical approach (intracapsular or extracapsular) indicated in the operative note differed from the coded on the physician's bill. In all cases in which the operative note indicated a secondary procedure performed at the time of surgery, the billing information was in agreement. We conclude that, at least in the case of cataract surgery, the Medicare part B database is 99% accurate (95% confidence interval, +/- 0.6%) for cataract surgery having occurred and 96% accurate (95% confidence interval, +/- 1.4%) in terms of surgical approach.

The reformation of Medicare and its effect on pathology.

Medicare policies have gradually restricted the scope of pathologist services payable under the rules applicable to physician services. Recent changes applying relative value scales has provided an opportunity for national standardization of pathology codes, and has permitted the introduction of clinical pathology interpretations as compensable physician services.

Underreimbursement of obstetric and gynecologic invasive services by the resource-based relative value scale.

OBJECTIVE: To compare the relative value of work and reimbursement by the resource-based relative value scale (RBRVS) and the charge-based McGraw-Hill relative value scale for invasive services performed for women only (obstetric-gynecologic), for men only (urology), and in a gender-neutral specialty (general surgery). METHODS: Two hundred nineteen obstetric-gynecologic, 125 urology, and 105 general surgery invasive procedures were compared by the mean for each specialty of 1) the ratio of the procedure-specific work component of the RBRVS unit to the total relative value unit, and 2) the ratio of the procedure-specific total RBRVS unit to the McGraw-Hill relative value unit. All procedures were weighted equally. Ratios are reported as percentages. Statistics were compared by analysis of variance with Newman-Keuls test for multiple pairwise comparisons when significant differences were identified. Statistically significant differences were defined as P < .05. RESULTS: The mean percentage of the procedure-specific work component of the RBRVS unit to the total relative value unit and the total RBRVS unit to the McGraw-Hill unit were significantly lower (P < .01 for all comparisons) for obstetric-gynecologic (49.7 and 139.5) than for urology (55.1 and 207.1) or general surgery services (53.2 and 181.0). There were no significant differences between urology and general surgery services among the procedures studied. CONCLUSION: The data support a lower relative value of work and reimbursement for services performed for women only. This may be the result of 1) high initial estimates of work for urology and general surgery services, 2) low initial estimates of work for obstetric-gynecologic services, or 3) a carry-over of reimbursement bias from the charge-based environment to the RBRVS by the methods used in its development.

Differences in the structure of CAHPS measures among the medicare fee-for-service, medicare managed care, and privately insured populations.

OBJECTIVE: To confirm in a new population, the Medicare fee-for-service population, the factor structure previously found in two Consumer Assessment of Health Plans Study (CAHPS) field-test surveys with Medicare HMO and adult privately insured populations. DATA SOURCES: Primary data were collected in the fall of 1998. Survey responses from the Medicare Fee-for-Service CAHPS survey field test were compared to results from the Medicare HMO and adult privately insured field-test studies conducted in the fall of 1996. STUDY DESIGN: Respondents for the field-test survey were a random sample of Medicare beneficiaries in five states who had opted for the original Medicare plan (fee-for-service). DATA COLLECTION: Data were collected by a mailed survey with a telephone follow-up survey to those who did not return the mailed survey. PRINCIPAL FINDINGS: A confirmatory factor analysis in two different samples of Medicare fee-for-service beneficiaries provided basic support for a previously reported three-factor structure underlying the CAHPS reports and rating items: (1) quality of provider or staff communications; (2) timely access to quality health care; and (3) quality of plan administration. An exploratory factor analysis revealed a variant three-factor structure. CONCLUSION: Because of differences in the factor structures among the different populations discussed, caution needs to be exercised in any composite development, based on factor analysis or any other basis, by which cross-population comparisons will be made. Comparisons should only be made on composites representing stable structure across all populations concerned.

Combining health plan performance indicators into simpler composite measures.

We investigated how the Consumer Assessment of Health Plan Study (CAHPS) survey and the Health Plan Employer Data Information System (HEDIS) measures from Medicare managed care (MMC) plans could be combined into fewer summary performance scores. Four scores summarize most of the variability in these measures, representing (1) care at the doctor's office, (2) customer service and access, (3) vaccinations, and (4) clinical quality measures. These summaries are substantively interpretable, internally consistent, and describe the majority of variation among units in the performance scores analyzed.

Combining HEDIS indicators: a new approach to measuring plan performance.

We developed a new framework for combining 17 Health Plan Employer Data and Information Set (HEDIS) indicators into a single composite score. The resultant scale was highly reliable (coefficient alpha = 0.88). A principal components analysis yielded three components to the scale: effectiveness of disease management, access to preventive and followup care, and achieving medication compliance in treating depression. This framework for reporting could improve the interpretation of HEDIS performance data and is an important step for CMS as it moves towards a Medicare managed care (MMC) performance assessment program focused on outcomes-based measurement.

Strategies for Medicare health plans serving racial and ethnic minorities.

The Medicare Managed Care (MMC) Consumer Assessment of Health Plans Study (CAHPS) survey offers an opportunity to examine differences in health plan experiences and patterns of use of services of racial and ethnic minority beneficiaries enrolled in health plans. Analysis of the survey data and review of prior literature indicate significant health disparities and different patterns of health care use by racial and ethnic minorities. Improved measurement of health plan performance in serving minority enrollees, and development of performance improvement strategies, could have the potential to reduce the observed health disparities.

Medicare Home Health Initiative: current activities and future directions.

This article describes the Medicare home health benefit and summarizes the growth and change in the use of the benefit and in the industry providing home health care. The article details the progress the Home Health Initiative has achieved in the key areas of quality assurance, administration and operations, and policy. It concludes with a discussion of future directions for reforming Medicare's home health benefit.

Prescription drugs: elderly enrollee reports of financial access, receipt of free samples, and discussion of generic equivalents related to type of coverage.

OBJECTIVE: To compare elderly health plan enrollee's survey responses regarding access to prescription drugs, receipt of samples, and discussion of generic equivalents across healthcare delivery systems and to examine the extent to which member characteristics are related to responses. STUDY DESIGN: Cross-sectional, observational study. PATIENTS AND METHODS: Elderly enrollees (aged 65 and over) in the Preferred Provider Organization (PPO in = 10,2201) and Medicare cost contract (n = 14,635) of a single health insurer responded to a 2001 member satisfaction survey. Multivariable logistic regression was used to estimate the relationship between outcomes (eg, not filling prescriptions) and patient characteristics. RESULTS: Elderly enrollees in a PPO had more comprehensive drug coverage and better access to pharmaceuticals than Medicare enrollees, with 14% of Medicare enrollees reporting that they "occasionally" or "always" skipped filling prescriptions due to cost, compared with 6% of PPO members (P < .001). Similarly, 14% of Medicare enrollees reported taking less medication than prescribed to save money, compared with 7% of PPO members. Ethnicity was one of the strongest predictors of financial access to pharmaceuticals among elderly enrollees, with the predicted probability of "occasionally" or "never" filling medications ranging from 0.06 for Japanese to 0.16 for Filipinos. A majority of members in both health plans reported receiving free samples of pharmaceuticals from their physicians. CONCLUSIONS: Further research is needed to determine which medications are not being filled, the impact of sampling on subsequent drug utilization, and specific chronic conditions for which more extensive coverage is cost effective.

Measuring access to effective care among elderly medicare enrollees in managed and Fee-for-Service care: a retrospective cohort study.

BACKGROUND: Our aim was to compare access to effective care among elderly Medicare patients in a Staff Model and Group Model HMO and in Fee-for-Service (FFS) care. METHODS: We used a retrospective cohort study design, using claims and automated medical record data to compare achievement on quality indicators for elderly Medicare recipients. Secondary data were collected from 1) HMO data sets and 2) Medicare claims files for the time period 1994-95. All subjects were Medicare enrollees in a defined area of New England: those enrolled in two divisions of a managed care plan with different physician payment arrangements: a staff model, and a group model; and the Medicare FFS population. We abstracted information on indicators covering several domains: preventive, diagnosis-specific, and chronic disease care. RESULTS: On the indicators we created and tested, access in the single managed care plan under study was comparable to or better than FFS care in the same geographic region. Percent of Medicare recipients with breast cancer screening was 36 percentage points higher in the staff model versus FFS (95% confidence interval 34-38 percentage points). Follow up after hospitalization for myocardial infarction was 20 percentage points higher in the group model than in FFS (95% confidence interval 14-26 percentage points). CONCLUSION: According to indicators developed for use in both claims and automated medical record data, access to care for elderly Medicare beneficiaries in one large managed care organization was as good as or better than that in FFS care in the same geographic area.