Security Risk Analysis Q&A

Jason Miller, OD, MBA
OOA President

Jay Henry, OD, MS
OOA Third Party Committee

An OOA member asked, “Is there a template or worksheet available that would allow me to do a security risk analysis to satisfy meaningful use requirements?”

The Security Risk Analysis (SRA) is most often the reason someone fails a MU audit. If you use a company to help with the SRA (cost $1,500-$2,000), the company may update that analysis the following year at no extra cost.  Because it is very important to protect patient data, we recommend hiring someone to make sure that data is not at risk for a breach.

Here is the link to the online tool provided by CMS.   It is a downloadable program that will walk you thru the analysis.

https://www.healthit.gov/providers-professionals/security-risk-assessment-tool

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BREAKING NEWS: Obama Signs MU Hardship Exemption Law

Written By: Dr. Jay Henry

If our members meet meaningful use for 2015 they need to attest.   If they did not meet MU for 2015 they can claim a hardship exemption before March 15, 2016 to avoid penalties in 2017.   The exemption will be approved based on the fact that CMS released the final rule so late in the year.

For up to date information visit us at www.ehrguru.net

Article:

On December 28, 2015, President Obama signed into law the Patient Access and Medicare Protection Act. The law states that the Center for Medicare & Medicaid Services (CMS) will approve hardship exception applications submitted by eligible professionals, hospitals, and critical access hospitals that did not meet Meaningful Use (MU) in 2015. Previously, hardship exceptions were individually reviewed and granted only if CMS determined that a provider demonstrated circumstances that posed a significant barrier to achieving MU. This year, submission of a timely hardship exemption application guarantees that the provider will avoid the 2017 penalty for not meeting MU in 2015. The bill was introduced by Senator Rob Portman (R-Ohio), and included legislative language based on the Meaningful Use Hardship Relief Act, sponsored by Rep. Tom Price, M.D. (R-Ga.), giving CMS the authority to grant hardship exceptions to affected providers for 2015

CMS did not publish the final rule for the 2015-2017 EHR Incentive Program until October 6, 2015. As a result of the delay, fewer than 90 days, which are required for a 2015 reporting period, remained in the calendar year. “The recent modifications rule for Stage 2 of the Meaningful Use program for electronic health records failed to offer physicians and hospitals enough time to actually comply with the new requirements,” said Price in a statement. “This much-needed relief will make the hardship application process much easier for doctors to avoid penalties stemming from the administration’s mistake, and thereby provide more time to care for patients.”

Section 4 of the bill states that eligible professionals must submit a hardship exception application no later than March 15, 2016 and eligible hospitals and critical access hospitals must submit an application before April 1, 2016. Application forms are not available at this time, but Quality Insights will notify providers when CMS posts information on its website.

Please Note:

Providers that meet MU in 2015 must submit an attestation to be eligible for an EHR incentive. The hardship exception is only for providers that were unable to meet MU in 2015.

The reporting period for all providers in 2016 is the full calendar year, except new providers entering the EHR program for the first time who will have a 90-day reporting period. Therefore, it is important to make sure all of the functionalities required for the entire reporting period are available beginning January 1 to meet MU in 2016.

CMS issues EHR Incentive Programs final rule

Change is coming to the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs with new rules that the Centers for Medicare & Medicaid Services (CMS) say indicate a move toward simplicity and flexibility, but AOA believes even more could be done to make the program work.

AOA urged CMS to structure the program in a way that is less burdensome and more helpful.

CMS announced the final rule Oct. 6, noting that the agency took under consideration providers’ concerns regarding the challenges and burdens with using the technology in major changes that ease reporting, support interoperability and improve patient outcomes. Several of the changes finalized were in response to issues and concerns communicated in AOA’s outreach to the agency.

However, the AOA still has serious concerns with how CMS operates the EHR Incentive Programs, and for the second year in a row, the agency has made last-minute changes just months before the end of the current year’s reporting period. These last-minute changes force physicians to scramble to get up to date on program changes and to quickly implement them in their practice.

Since the program’s inception, AOA has urged CMS to structure the program in a way that is less burdensome to physicians and more helpful to patients. The AOA understands the significant time and resource commitment needed to meet the meaningful use requirements and hopes the changes for the 2015 program year, late as they are, will provide some relief.

For doctors of optometry planning to participate in the program this year, there are several changes to take note of immediately, including:

  • 90-day reporting period.Physicians may now choose any 90-day reporting period for 2015. CMS previously intended to require a 12-month reporting period in 2015, but physicians now have the flexibility to select any 90-day reporting period in 2015.
  • Patient electronic access. Physicians are now required to have only one patient view, download or transmit (VDT) to a third party their health information. CMS previously required that 5 percent of a physicians’ patients VDT information. This is a significant reduction that will hopefully provide relief for many doctors of optometry.
  • Secure electronic messaging. Physicians are now required only to have the capability for patients to send and receive a secure electronic message fully enabled during the reporting period. CMS previously required that 5 percent of patients use secure electronic messaging. AOA has often heard from doctors of optometry regarding the difficulty of the secure messaging measure and this change should make this a less onerous requirement.

The AOA will provide more specific information on these changes and Stage 3 program requirements in future updates. If you have questions, please contact Kara Webb, associate director for Coding and Regulatory Policy, at kcwebb@aoa.org.

More about CMS’s changes to the EHR Incentive Programs
The final rules reflect insight from the AOA and more than 2,500 comments with physicians and other providers describing real-world difficulties in making the technology work well for their individual practices and their patients.

According to a CMS fact sheet, significant changes include:

  • “Check box” process measures removed.CMS hopes this will shift emphasis of health IT to a tool for care improvement, rather than as an end in itself.
  • Reduced objectives.CMS cut objectives—from 18 to 10 for 2015 through 2017. For Stage 3 meaningful use in 2017, there are 8 objectives for doctors. CMS indicates physicians also will have to report clinical quality measures (CQMs) only once to receive credit for other programs, aligning CQMs with other CMS quality reporting programs.
  • Extended reporting periods.CMS allows 90-day reporting periods for all physicians in 2015, 90-day reporting periods for physicians new to the program in 2016 and 2017, and to anyone choosing to adopt 2018 measures a year early.
  • Program start date.CMS set the Stage 3 start date to Jan. 1, 2018.
  • Interoperability key.CMS claims they want to put the emphasis on interoperability over data entry. Given the current and significant infrastructure problems that impede interoperability, the AOA is concerned that CMS may again be moving too fast too soon with increasingly difficult program requirements.

Additionally, CMS announced a 60-day public comment period to garner supplementary feedback about Stage 3, specifically as it relates to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This act established the new Merit-based Incentive Payment System (MIPS) to consolidate aspects of federal programs and quality measurements into a more efficient system. Feedback from the public comment period will facilitate rulemaking for MACRA—of which CMS expects new rules released in early 2016.

Click here to find more information on the final rules and the CMS EHR Incentive Programs.

“Bent, Breaking, and Broken”

By: Ryan P. Ames, OD, MBA and Charles B. Brownlow, OD, Medical Records Consultants

ICD-10 Has Arrived…

For the procrastinators among us (or for Rip Van Winkle, OD), ICD-10 is in full swing as of October 1, 2015. It is two years after its original ‘due date’, so we’ve all had plenty of time to prepare, but with the ups and downs; “it’s going to be delayed a year”, “It’s going to be delayed two years”, etc.; it’s no surprise that many doctors and staff put off their preparation, almost expecting a last minute reprieve.  The ‘last minute’ has passed…No reprieve…No excuses.  ICD-9 codes must be used for all services provided on or before September 30, 2015, even if the claim is submitted after October 1.  ICD-10 codes must be used for all services provided on or after October 1, 2015.  We have no idea how you will manage without resources, but there are tons of resources available.  Our recommendation is to buy the AMA version, 2015 ICD-10 (about $100, amastore.com, 800-621-8335), and possibly supplement it with the AOA Codes for Optometry (aoa.org/marketplace. 800-365-2219).  The AOA document is a ‘condensed’ version of the full ICD-10, which will be useful, but no one should enter this brave new world of coding without the full version of ICD-10 codes.  We’ll continue to help you with the occasional strange diagnosis, but we certainly won’t be able to provide a ‘look-up service’ for doctors who don’t care to buy the actual references.

PQRS Reporting Switches to ICD-10 on October 1, Too…

It was not until September 23 that we got our first question about the use of ICD-10 for PQRS.  A quick online search provided us with key information.  Of course all the PQRS measures are based on each patient’s diagnosis, so ICD-10 codes must be used for PQRS reporting on and after October 1, 2015.  AOA was all over this one, too, and offers a new chart, with ICD-10 codes replacing the ICD-9 codes.  It can be downloaded at:

http://www.aoa.org/Documents/2015%20PQRS%20EYE%20CARE%20MEASURES%20FOR%20OPTOMETRISTS%20ICD%2010%20Update.pdf

You’ll find lots of information regarding PQRS reporting at aoa.org/pqrs.  There are still a few ODs who are not participating in PQRS, but that will soon be nearly impossible.  Health care leaders are focusing on outcomes and are rewarding doctors based on reporting…In some cases, requiring doctors to report in order to even participate in their plan.  Those rewards will soon turn to penalties for those choosing to not report.

As an aside, there are lots of reasons to be using electronic health records in 2015 and beyond, and PQRS reporting is certainly one of them.  The use of EHR permits nearly automatic, once per year reporting of PQRS compliance via a ‘registry’, rather than the ‘claims based’ reporting required for doctors with paper charts and claims.  If you are still using paper charts, it’s definitely time to consider going electronic.

The Changing of the Guard—PMI, LLC. Became Foresight, LLC on October 1

After nearly five years of working together to assist doctors and staff with their issues related to medical records, coding, life with third parties, etc., Dr. Ryan Ames and Dr. Charles Brownlow have formally merged their efforts.  On January 1, Dr. Ames will be taking over the lion’s share of answering emails, writing articles, providing education, etc., while Dr. Brownlow will continue to provide support as needed.  The current plan has Dr. Brownlow  involved with the new venture, Foresight, LLC, through the end of 2018, though the extent of his involvement will definitely taper off significantly over the next three years.

When asked if this change means that he will be retiring from the profession he’s been involved with for nearly a half century, Dr. Brownlow responded, “I know, I know…I don’t look old enough to retire, but the calendar doesn’t lie.  I certainly am not ‘old’, but 1946 was a long time ago.  I will continue to be devoted to my colleagues and this profession for several years, but in a greatly reduced capacity.  Of all the people that have said ‘I’ll believe it when I see it’, when considering my retirement, my wonderful wife, Sherry, has been the most insistent.  It really is time for us to share more time together and with our children, grandchildren, and friends.  I love all of you (well, most of you), and I’ll be around if you really need me.  I’m confident that won’t be often, though, and I’ll bet it won’t be for long.  According to the Book of Ecclesiastes…”For everything there is a season”.  For me, the season is now autumn!  Thanks for all the support and friendship so many of you have provided me during my career… Optometry is small in numbers but it has proven itself enormous in accomplishments!  Please make me proud by always pushing the envelope of the scope and range of the services you provide to each patient you see.

Remember…As an association member, you and your staff are able to send questions directly to Dr. Ames at drames@pmi-eyes.com or Dr. Brownlow at drbrownlow@pmi-eyes.com

Steps You Can Do to Prepare for ICD-10

OOA Incoming President Dr. Jason Miller will provide one-hour of practice management CE at each of his President’s Nights in the 12 Ohio zones starting in late August. Contact your Zone Governor for details or email the OOA.

The ICD-10 transition is only two months away –   October 1, 2015.  Are you ready?

Steps You Can Do to Prepare for ICD-10

Following are steps that optometric practices can take to prepare.  The key is to start now (see Additional Links and Resources below for specific timetables for ICD-10 transition).

  1. Go to the Centers of Medicare and Medicaid Services website. Here you can find up-to-date information on ICD-10, e-mail updates, webinars and links for specific provider information as well as timelines for implementation.

http://cms.gov/Medicare/Coding/ICD10/index.html

  1. Evaluate your current documentation. Look at your current records to see how your clinical documentation would be graded in ICD-10.  Remember, the purpose of ICD-10 is to more accurately describe each patient’s condition. Documentation is what drives coding.  Is the history you documented comprehensive enough to fully describe the encounter which will go along with your findings?  One helpful tip would be to practice and improve on your everyday documentation which is driven by each clinical condition.  This will allow you or your coder to have enough information for ICD-10 classification.
  2. Determine who in the office will be affected. Evaluate all aspects of your practice where ICD-9 is currently used.  Examples include authorizations, pre-certifications, physician orders, medical records, superbills, EHR systems, coding manuals and public health reports.  Discuss ICD-10 with key staff members.  Make sure all systems you integrate with are ready to go on October 1, 2015. Allow every affected individual ample time to understand these changes and provide the necessary training.
  3. Know your top codes. There are several programs, websites and services available to help navigate the new ICD-10 codes and allow a comparison to ICD-9.  Look at the current top 10 or 20 ICD-9 codes used in your practice and find out what the ICD-10 codes will be.  These same programs will also allow you to compare ICD-10 codes to their previous classification.  Document these codes as a guide to improve accuracy when ICD-10 comes around.   A main difference will be the greater specificity of these various diseases and condition.  Examples:

http://www.aapc.com/icd-10/codes/

http://www.icd10data.com/.

Although it sounds overwhelming, taking the time to prepare ahead of time will save some stress on October 1, 2015 when the change must occur.  Encourage doctors and staff in your practice to concentrate on medical record documentation that will help choose the correct code when necessary.

Available ICD-10 Resources:

There are many resources available to prepare your practice for ICD-10 available on the Center of Medicare and Medicaid Services website.  The following links provide useful tools to guide your practice as you e transition to ICD-10.

– American Optometric Association

www.aoa.org

An optometry focused ICD-10 webinar series provides thorough and accurate information. AOA members who have an ICD-10 question that is not answered in AOA resources can direct a question to AOA’s coding experts.

 

– CMS Provider Resources http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

o   FAQ:  ICD-10 Transition Basics

o   ICD-10 Transition: An Introduction Fact Sheet

o   ICD-10 Basics for Medical Practices

o   ICD-10 Basics for Payers

o   The ICD-10 Transition: Focus on Non-Covered Entities

o   Checklists, Timelines, and Implementation

o   Implementation Planning

o   Communicating About ICD-10

o   Medscape Education:  Webinar and Articles Available

 

– American Association of Professional Coders – www.aapc.com

Optometrists’ Integration with Accountable Care Organizations Obvious Key to Health Care Delivery and Cost Containment

By Charles B. Brownlow, OD  PMI, LLC drbrownlow@pmi-eyes.com

As healthcare continues to evolve, providers have been inundated with new policies, regulations, and code sets that they must master in order to be compliant, but also to simply survive. If you are like many ODs, you have spent the last few years focusing on EHR implementation, Meaningful Use (MU), new HIPAA regulations, and, of course, the looming transition to ICD-10. Those issues are all very important to you and your patients, but have you also been paying attention to Accountable Care Organizations (ACO), and how you can be part of them?

An ACO is a group of providers who are jointly held accountable for the care of a group of patients.  The concept is unique, in that the providers are expected to work with the payer in achieving measurable quality improvements and reducing the rate of spending growth. These groups of providers are often part of large health systems and hospital groups, but they can also be a collaboration of a number of smaller providers.

The President of Blue Cross and Blue Shield of North Carolina recently stated: “Even if federal health overhaul is rejected by the Supreme Court or revamped by Congress, the market must continue to change. The [health care delivery/payment] system that brought us to this place is unsustainable. Employers who foot the bill for workers’ health coverage are demanding that Blue Cross identify the providers with the highest quality outcomes and lowest costs.”

Although we might believe that ACOs would not be interested in talking to individual eye doctors, this is not actually the case. In order for an ACO to prove “quality,” one of the items on which they are measured is whether their diabetic patients have a yearly eye exam. This is one of the items factored into their HEDIS score. Very few ACOs have enough eye care providers included on their panels to provide that volume of care. For that reason, they will need to partner with sufficient numbers of individual optometrists to fill in that gap. Failure to integrate optometric services into the ACOs creates an unnatural barrier to patient care, and it hampers the ability of doctors to provide seamless and effective care for their patients.

Using optometrists has also been proven to lower insurers’ costs in urgent eye care situations. The American Optometric Association commissioned a study by SCIO Health Analytics in 2013 to determine the potential benefit of providing appropriate eye care services in different settings (eye care professional’s office, emergency department, and primary care provider’s office). The results of the study indicated that if the cases analyzed had been treated at an optometrist’s office, the cost would have been less than 10% of what was actually spent.

To maximize the savings of eye care services, barriers to optometric care need to be eliminated. Often vision plans are not integrated with health plans.  Instead, they separate “routine” eye care and medical services. This creates an artificial separation between ‘Eye Health’ and ‘Vision’ benefits, and it creates a barrier to patients receiving essential eye care.

The AOA has created a great resource at http://www.rethinkeyecare.com. The amount and quality of information is fantastic. Visit this site to learn more about ACOs, how they work, and to access guides on how to get your practice involved. You can also see a list of all the ACOs in your state at www.aoa.org.  If you are not at least informed regarding the potential changes to the delivery of healthcare through ACOs, your efforts in MU and ICD-10, may be for naught.

Remember…As an association member, you and your staff are able to send questions directly to Dr. Ames at drames@pmi-eyes.com or Dr. Brownlow at drbrownlow@pmi-eyes.com

House Bill 157

By Executive Director Keith Kerns Esq.

This Bill would change Ohio’s medical liability system.

House Bill 157, introduced by State Representative Jim Butler (R-Oakwood), would dramatically alter Ohio’s medical injury compensation program and make other changes to how Ohio administers the Medicaid program. Rep. Butler hopes to accomplish three primary goals with the legislation: lowering Medicaid spending, lowering overall healthcare spending and applying Medicaid savings to care for needy populations.

To accomplish this mission, his bill would create hospital ER diversion programs, institute price transparency for healthcare services, promote small business health coverage through Multiple Employer Welfare Arrangements (MEWAs), incentivize Medicaid recipients to utilize preventative services and reduce defensive medicine by establishing a new Medical Injury Compensation System.  The 386 page bill is aggressive and would impact nearly every stakeholder in the healthcare industry.  For optometry, one provision in the bill stood out as a cause for concern.

HB 157 calls for the creation of a new Health Care Professional Standards Board.  This board would be comprised of three members appointed by the state medical board, one member appointed by the state dental board, one member appointed by the state chiropractic board, one member appointed by the state board of pharmacy, two members appointed by the state board of nursing, and one member appointed by the state board of optometry.  The new board would have immense authority.  It would be charged with investigating malpractice claims brought against providers, imposing discipline against providers, maintaining a database of claims and complaints and establishing the standard of care for health professionals.

While important functions, all of these activities are currently being performed within state or federal government.  State regulatory boards, including the Ohio State Board of Optometry, maintain access to the National Practitioners Data Bank (NPDB) in order to review and investigate malpractice awards.  The boards also establish the standard of care for a profession and impose discipline when warranted.  Finally, the Ohio Licensure System provides public information on formal actions taken against health care providers and the NPDB tracks similar information for use by government entities and insurers.  Simply stated, the functions delegated to the Health Care Professional Standards Board are duplicative and would only serve to create another costly level of bureaucracy within health care system.

The OOA has communicated these concerns to Rep. Butler and other members of the House of Representatives.  At the same time, the OOA acknowledges that medical liability laws are a key component to establishing a cost-effective health care delivery system that keeps medical professionals in Ohio.  But recent tort reform efforts, including the establishment of caps on damages and the creation of a statute of repose, are already helping to achieve these goals.  For optometry, malpractice rates and the number of licensed optometrists are stable in Ohio.  So while there is always value in searching for ways to improve our medical liability system, the current structure appears to be working.  Dramatic changes, such as the creation of a Healthcare Professional Standards Board, could disrupt this stability.

The OOA will continue to monitor HB 157 and other bills impacting the practice of optometry.  Be sure to visit www.ooa.org to view the latest updates on these important legislative issues and to get involved in the OOA’s Key OD grassroots advocacy program.

Straight Talk Regarding ‘Elephants in the Room’

By Charles B. Brownlow, OD

When I did my first presentation on medical record keeping after the release of the 1997 Documentation Guidelines for the Evaluation and Management Services (99000 codes), I was sure that the document would finally spur doctors and insurers to learn and follow the rules.  The ‘DGs’, as we refer to them, provide a very simple explanation of the logic of the delivery of health care services, followed by a very objective, detailed set of instructions for creating good medical records and for choosing 99000 codes accurately.

The word ‘objective’ in the previous sentence means that doctors and staff could choose codes exactly as insurers are required to choose them.  Doctors adhering to the definitions for services provided by the Current Procedural Terminology (CPT © American Medical Association) and the DGs would never have to worry about an audit by Medicare or any other insurer.  All a doctor would need to do for visits would be to provide the care the patient needs; no more, no less; keep an excellent record of all that happened during the visit, and then choose a code to represent the content of the record.

For the first time in history, the process of choosing visit codes can be accurate, objective, and repeatable, with those three characteristics ensuring appropriate reimbursement for services provided and ‘no hassle’ chart reviews or audits.  When I first read the DGs in July of 1997, I was ecstatic!  Our colleagues would no longer have to worry about choosing codes nor about being audited.  I was doubly ecstatic because the 1997 DGs were the first guidelines to provide guidelines customized for eye specialists.

The original guidelines required doctors to examine at least nine organs systems, actually doing at least two tests on each system for the physical examination portion of a visit to qualify as ‘comprehensive’. With the 1997 DGs, eye doctors could reach the previously acrophobic level of comprehensive physical examination (and thus the higher level codes that require comprehensive physical examinations) simply by doing twelve ophthalmic elements and two psychiatric elements (mood and affect and orientation to time, place and person.)

Furthermore, the required ophthalmic elements have traditionally been included in a typical eye examination; acuities, gross fields, examination of the adnexa, pupils and irises, motility and versions, corneas, anterior chambers, crystalline lenses, bulbar and palpebral conjunctiva, IOPs, and dilated ophthalmoscopy (discs and peripheral retina). Wow!  The 1997 DGs made it possible for eye doctors to appropriately choose the higher level 99000 codes; 99215, the 99204 and even the 99205 (albeit rarely); for the first time since CPT created the 99000 codes in 1992!

Being the eternal optimist that I am (or that I was in 1997), I assumed the 1997 DGs would be immediately embraced by ODs and OMDs, who would quickly learn of their simplicity and accuracy and objectiveness and repeatability, and would begin using them immediately.  Obviously, I could not have been more wrong.  Here we are, eighteen years after the introduction of the 1997 DGs, and the typical OD and OMD still don’t understand the power that the document provides them.

As a matter of fact, based on my experience with the hundreds of audiences I’ve faced during those years, I’m pretty confident in estimating that fewer than 30% of all eye doctors have ever read the 1997 DGs, even though a relatively high percentage of eye doctors use them in their practices every day!  Talk about self-destructive behavior.  Without understanding the DGs, it doesn’t matter whether the doctor, the doctor’s staff, or the doctor’s EHR software is choosing the codes, the audit will be ugly.  Even worse, without knowledge of the DGs, the doctor and staff will be helpless in attempting to defend themselves in an audit…Even though the auditor probably doesn’t know the DGs well, either.

As long as we’re getting depressed, let’s consider another ‘elephant in the room’, probably larger than the DG issues.  Thousands of eye doctors in the US are reporting their visits to insurers using the comprehensive ophthalmological services (CPT©AMA codes 92004/92014), without knowing the definition for those services.  Let’s do a little math.  If we assume that 40,000 eye doctors in the US are each using these codes 2,000 times per year, that would represent 80 million uses of that code per year.  If we generously assume 50% of those doctors actually have read the CPT definition, understand it, and appropriately apply it, that could mean up to 40 million potential incorrect choices of the code every year.   Imagine the potential impact on these two professions that a sweeping audit of those two codes would produce.  40 million incorrect claims, even at $100/claim would be $4 billion!

Will thoughts such as these get the attention of America’s eye doctors and staff?  Will thoughts such as these get the attention of American insurers? Sadly, I’d bet on the latter before the former, though it is clearly the former; America’s eye doctors; that I have devoted my professional life to.

What can be done about this?  What can the AOA and AAOphthalmology do?  What should the educational programs for tomorrow’s doctors of optometry and ophthalmologists do to correct these issues?  I believe it starts where it should have started back in 1997; with the practicing doctors.  It starts with downloading a FREE copy of the 1997 Documentation Guidelines for the Evaluation and Management Services from the CMS website; https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf  It starts with buying the 2015 American Medical Association Current Procedural Terminology from AMA ($114.95) amastore.com, 800-621-8335) or at a member discount (approximately $100) through the American Optometric Association (aoa.org/marketplace, 800-991-4100).  AMA is the only CPT that is the national standard for procedural coding, so don’t mess with substitutes…They cost more and you cannot defend yourself in an audit without the official AMA CPT.

In short, no more excuses.  Just reading the first few pages of the AMA CPT and the 1997 DGs will help docs and staff understand the key links between excellent patient care and excellent records.  In my opinion those two documents should be ‘required equipment’ for all eye doctors and all future eye doctors.  CPT is only good for twelve months, so new copies must be ordered each December for the coming year.  I know, I know, $100/year seems like a lot of money to some, but measured against the huge, looming expense of ugly audits, it’s ‘peanuts’!  Let’s face it, CPT and the DGs; though they’ve largely been ignored by health care providers for decades; are priceless.

Please don’t put it off another 18 years.  Act today!

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.

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.