Good News/Bad News?

By Charles B. Brownlow, OD (drbrownlow@pmi-eyes.com)

Medicare Fee ScheduleThanks to the tireless efforts of our AOA leadership and staff (along with the AMA and other provider associations) the US Congress has finally ditched the flawed formula used for creating Medicare Fee Schedules each year.  For a decade or longer, the formula had created Medicare’s schedule in November of each year.  The release of each of those schedules, including significant cuts in reimbursement, would launch a flurry of lobbying activity by the health care providers in order to reverse the cuts.

Some years the lobbying was effective prior to the end of the year but in most cases it took until mid to late first quarter of the following year to make the corrections.  That resulted in Medicare having to reconsider and correct any claims submitted and paid during the months of the ‘wrangling’.  This year’s correction took longer, but it is more significant, in that it changes the whole process.  From now on, the official Medicare Fee Schedule will have an across the board 0.5% increase, with additional adjustments made via enhancements.  The enhancements will be paid based to providers who demonstrate completion of or compliance with incentives that the Centers for Medicare and Medicaid Services will announce each year.  So, the schedule will have a 0.05 increase, but actual payments to each provider will be adjusted up or down based on performance.  Good news?  Bad news?

ICD-10I was one of a very few who believed that the American Medical Association was going to swing its weight around at the last minute, in conjunction with the ‘Medicare Fee Fix’ and kill ICD-10.  I wasn’t surprised, though, when the last minute past on April 14 without any such ‘assassination’.  That means that barring any totally unexpected action by Congress in the next few months, October 1, 2015 will indeed be the date that ICD-10 will become the only method for coding diagnoses in the US.  After that date, ICD-9 will only be used with claims for services that were performed on or before September 30, 2015.

Many doctors and staff have been delaying their preparation, hoping that ICD-10 would simply go away.  For those of you in that situation, it’s time to gear up and get educated.  Personally, I think most of us will be pleasantly surprised at how smoothly that process will run. Here are some suggestions for getting ‘geared up’ for ICD-10:

Within the next month or so, whether you are currently using paper or electronic records you should…

  • Purchase the full ICD-10 manual (about $100, 1,100 pages, American Medical Association, amastore.com), and provide time for each doctor and key employee to familiarize her/himself with the layout of the manual (Note: laminated quick find aids and listings abridged for eye care are all right, but should not be used without the full, unabridged manual)
  • Identify 20-30 diagnoses that are frequently identified in your practice (open angle glaucoma, macular degeneration, corneal foreign body, etc.)
  • Work in teams, with doctors and staff learning together
  • Avoid trying to ‘convert’ ICD-9 to ICD-10. Instead, use the Tabular Index (alphabetical) at the front of the manual to look up each diagnosis, eg, non-proliferative diabetic retinopathy with macular edema. The listing is under ‘Diabetes, retinopathy’ in the index, run your finger down to ‘non proliferative, with macular edema’ and find the code, E11.321
  • Turn to the page associated with that diagnosis and you’ll see ‘Type II diabetes mellitus with mild non proliferative diabetic retinopathy with macular edema’, with that code, E11.321
  • Continue through the other diagnoses you’ve identified
  • Refer back to the introduction and guidelines sections of the manual as questions pop up

If you are using electronic records, check with the company to determine

  • Whether they’ve done their testing and are prepared for the big day
  • Whether you will need to do anything special to be sure that ICD-9 and ICD-10 are applied appropriately up to and through October 1
  • Whether the EHR will permit you to choose a diagnosis with the software automatically suggesting the appropriate ICD-10 code
  • Whether the company will provide training guides for docs and staff related to ICD-10

In July or before, have additional sessions to list common diagnosis codes and refer to the AMA ICD-10 manual to identify the proper codes.  For those using electronic records, there should be additional training session guidelines established by the developers.  For those still using paper charts, there is already lots of information available from the AOA at http://www.aoa.org and search for ‘ICD-10’.  There are many, many great articles, tips, webinars, etc. available there to assist in the training process.

I believe that the transition to ICD-10 will be easier than most people think.  ICD-10 is better than ICD-9 in several ways, including the ability to report a many-faceted diagnosis, such as the diabetic retinopathy example above, with a single six or seven character code, rather than two or three four or five character ICD-9 codes.  The closer we get to October 1, the more resources there will be available, as it will be to the advantage of all the players in the system; doctors, staff, insurers, Medicare, etc.; if all are well prepared and trained.  Good news?  Bad news?  It’s up to each of us to make sure the news is as good as it can be; by accepting the reality of ICD-10, preparing for it, and applying it.

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Helping Older American’s with Vision Loss

By Joan Nerderman

Eye care in someone’s home is always EYE opening and can be so rewarding.   I have had the opportunity for the last 13 years to go into patient homes and nursing homes with a senior Ohio State University optometry extern who has expressed an interest in helping people in these areas of need.

What better way for an extern to experience the need, than to see the patient’s environment and the visual challenges: like the TV that’s only 6 feet away and at an angle or seeing them reading the newspaper in their dimly lit house. Often the suggestions to some of these problems are as simple as can the TV be put in a new location or do you have any gooseneck lamps in the house?

With just a few tools by your side like a hand held slit lamp, trial lenses and frame, eye chart (we have a simple one we tape to the wall and measure test distance), tonopen, Perkins or Icare tonometer, small lensometer is nice, drops and your BIO/panoptic, you can visit the patient it their home, and make small adjustments to help improve their life.  One of the most rewarding patients was one who had terrible neck contractures and cataracts.  Although no one could do surgery in her position we were able to get her a stand magnifier that allowed her to see the one thing she wanted–her grandson’s wedding pictures.

Also seeing the interaction of the externs with the fading population of WWII veterans, warms my heart. We can’t always get them seeing great but we can help advise those who may not otherwise get out for vision care, gain some vision independence.

Referral Programs

By Keith Kerns, Esq.

In an effort to increase patient visits, many offices offer incentives to current patients who refer friends and family to the office.  Optometry offices which engage in this practice should be aware of a key provision in Ohio law before instituting such an incentive program.

Ohio has maintained an anti-kickback law for many years.  The law is intended to help protect patients and healthcare payers against fraud and abuse and to prevent financial incentives from influencing health care providers treatment recommendations and decisions.  Though the focus of the law is seemingly meant to address provider-to-provider and agent/broker-to-provider referral corruption, the law is written broadly and actually applies to everyone.  Therefore, offices that are considering establishing a referral incentive program for current and new patients must be familiar with this law in order to avoid pitfalls.

Ohio Revised Code section 3999.22 makes it illegal for anyone to “knowingly solicit, offer, pay, or receive any kickback, bribe, or rebate … in cash or in-kind, in return for referring an individual for the furnishing of healthcare services…for which whole or partial reimbursement…may be made by a healthcare insurer.”  Any violations of this section are considered felonies under the law.

Despite this broad prohibition against any kind of payments – gift cards, cash, gifts, etc. – in exchange for referrals, there are several important exceptions outlined in the law which may still allow offices to pursue a patient referral program.  First, the law excepts those referral payments that are authorized by an health insurance contract and does not apply to deductibles or copayments.  The law also does not apply to a health care practitioner who provides services that are not covered by the patient’s health insurance plan.

Finally, and most importantly, the restriction does not apply to the offering of discounts or reductions in prices.  This exception provides a simple avenue for optometrists to offer incentives to patients who refer their friends and family into the practice.  A discount off of future services, or new pricing structures for certain procedures can be offered in exchange for the referral of new patients under Ohio law.

Optometrists seeking to step up their marketing campaign and attract new patients are strongly encouraged to seek advice from legal counsel prior to instituting a referral incentive program or an advertising campaign to discuss these issues and avoid any difficulties which may arise.

A Follow- up on Direct Messaging

**A follow up to an earlier Blog post by Dr. Snow (Patient-portals-and-direct-messaging-how-do-they-affect-me) 

By Dr. Jay Henry,

Q: How would direct email messaging assist optometrists?   Explain why it’s important for ODs to talk directly with the primary care physician (PCP) through  Direct protocols.    What could optometrists share that would be mutually beneficial to other physicians?

A: Direct messaging would allow optometrists, the primary eye care providers, to discuss results and information of shared patients with PCPs and other specialists.   Every diabetic patient gets a report sent to the PCP with results of the eye exam.   Many times it is the Optometrist who makes the first diagnosis of Hypertension, Thyroid disease, Diabetes, MS, high cholesterol, strokes, and  other systemic conditions.   When these situations occur, Optometrists need to be able to reach out to the patient’s PCP to coordinate care.

Optometrists also see many patients who need to be sent to a specialist or ophthalmologist.   ODs refer patients to a specialist / sub specialist and need to send  the testing results from the patient’s office visit or a clinical summary from their office visit.   A great example is when a patient is sent to a cataract surgeon for cataract surgery.   ODs do the majority of the patient’s pre-op testing and the post-op care from day 1 after the surgery.   ODs need to share this information back and forth with the surgeon.

For a patient with a retinal concern the OD may need to send clinical notes, photos, images, visual field results, OCT results and other information to the retinal specialist so the patient may receive further treatment or surgical intervention.     

All of these could be done via direct messaging.

Q: My eye doctor will be examining my eyes next week, and my neurologist wants him to test me because I’ve had an increase in migraines recently. He said he wanted to know about my “pressures.” Can you explain what this means?

A: This scenario would be the same for an Optometrist or Ophthalmologist.   Often a specialist or PCP wants  further testing done on a patient that the specialist or PCP may not do.   In this case the neurologist is concerned that  intraocular pressure is high and causing headaches to be worse or that preventative medicine you are taking is causing your eye pressure to be high and this can cause vision loss which is the disease of glaucoma.