Impact on your practice….Health Care Reform

On April 9th, 2010, posted in: Industry News by

The legislation makes a number of changes to the Medicare program that will impact your practice over the next several years.  Some examples:

  • A new government board will play a role in deciding how you are paid for providing care to your patients
  • You will be forced to participate in PQRI or watch your payments drop in the next five years
  • Primary care will be paid for providing an annual preventative check-up for Medicare patients
  • The bill extends the geographic price cost indices work floor of 1.000 through 2010
  • There will be a national pilot program on payment bundling by 2013.  The voluntary program will encourage hospitals, doctors and post-acute providers to “improve patient care and achieve savings for the Medicare program through bundled payment models.”
  • The Medicare therapy exception cap is extended through December 31, 2010.
  • The physician fee schedule for mental health add-ons extend through the end of the year.  The add-on increases payments for psychiatric care by 5%.
  • Payment for bone density tests are restored to 70% of the 2006 Medicare rate.  The law revises 2010 and 2011 payments for codes 77080-77081 to roughly $98 and $29.50 respectively.
  • CMS will be required to review fee schedules rates.  A summary of the law says the bill strengthened CMS’s authority to adjust rates.
  • Medicare Advantage plans will have to go through a bidding process and payments to plans will be based on the average bid in each market.  This will be transitioned over a four year period starting 2011.
  • The law allows patients to disenroll from a Medicare Advantage plan and return to traditional Medicare between January 1st and March 15th each year.
  • Primary care and general surgery physicians practicing in designated health shortage areas will receive a 10% payment bonus starting 2011.
  • In 2015, CMS will start to phase in “a valued-based payment modifier” to the physician fee schedule.  The modifier will adjust your payments based on the quality and cost of care physicians deliver.  The program will start to develop in 2012 and they will be starting “from scratch” in terms of recommendations for quality measures.

Clarification on NPP/Physician “Shared Visits” – Facility Setting

According to the Medicare Claims Processing Manual, Chapter 12, Section 30.6.1:  “When a hospital inpatient; hospital outpatient or emergency room E/M visit is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician’s or the NPP’s UPIN (unique physician identification number)/PIN number.”“However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP’s UPIN/PIN.”

The Medicare manual states this example:  “If the NPP sees a hospital inpatient in the morning, and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.”

CMS cracking down with signature requirements

Because of an increase in errors that CERT auditors found in 2009, CMS has detailed new rules on signatures in Transmittal 327 in the Medicare Integrity Manual.   Outlined below – steps on what and what not to do.

What is acceptable?

  • Provide a legible full signature (a readable first name and last)
  • Provide a legible first initial and last name
  • Write an illegible signature over a typed or printed name
  • Write an illegible signature on letterhead with information indicating the identity of the signer (Example: There is an illegible signature appearing on a prescription.  The letterhead of the prescription lists three names, circle your name, this indicates the identity of the signer).
  • Use an illegible signature accompanied by a signature attestation statement (found after this article).  If used, suggest keeping a copy in every chart.  (Scan it for EMR)
  • Have a signature log – create a log and keep it handy in your practice.  An auditor must consider a signature log regardless of the date the log was created, CMS says.
  • Write initials over a typed or printed name
  • Write initials, but have it accompanied by a signature log or attestation in the chart
  • Neglect to sign a portion of a handwritten note – ok , if other entries on the same page in the same handwriting are signed

Most Medicare Contractors state signatures on plans of care must be present before services are rendered.

What is unacceptable?

  • Use an illegible signature not over a typed name or on letterhead without a signature log or attestation statement.
  • Write initials, but leave out a typed name without having a signature log or attestation.
  • Forget to sign a typed note that includes your typed name
  • Neglect to sign a typed note that does not include the provider’s typed or printed name.
  • Neglect to sign a handwritten note with no other signatures on the page.
  • Use the words “signature on file” in lieu of a signature
  • Use a signature stamp

EXCEPTIONS to the rule

CMS admits there are existing policies that do not require signatures.  Example:  Orders for clinical diagnostic tests are not required to be signed.  Medical documentation, such as your progress note, can support the need for the order.  However, the note must have a valid signature.

Part B drugs order through a qualified e-prescribing system do not require a pen and paper order, CMS says.  But remember, you can’t order controlled substances electronically.  Therefore, auditors will be looking for a signed hardcopy record to support an order for a controlled substance.

Example of attestation statement from CMS:

“I,_______________________(print full name of the physician/practitioner), hereby attest that the medical record entry for_____________________(date of service) accurately reflects signatures/notations that I made in my capacity as_______________(insert credentials, e.g. M.D.) when I treated/diagnosed the above listed Medicare beneficiary.  I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission or concealment of material fact may subject me to administrative, civil, or criminal liability.”

Be sure you legibly sign and date the statement.  Again, the other option is simply have a signature log in the office by typing your name and signing with a clear, legible signature.  Keep the log in a safe, easily accessible place in your office.

If you ever are audited for any reason by Medicare, I will request a copy of the signature log, along with other documentation they have requested, so we may immediately send the legible signature.  By providing it up front, we won’t risk paying money back because of signature issues.

Have a great weekend, enjoy the warm weather

With best regards,