2010 CMS Update
Coding for Stroke
and
Pay for Performance
Debbie Lombardi Hill
NeuStrategy, Inc.
ACI Meeting – Chicago
November 5, 2009
©Copyright 2009 NeuStrategy All rights reserved.
1. Coding for Stroke
-Drip and Ship Code
-Critical Care Codes
-”Telehealth” (Telemedicine) Codes
2. Pay for Performance
-Physician Quality Reporting Initiative
-Hospital Quality Reporting Initiative
-Premier Hospital Quality Incentive
Demonstration
©Copyright 2009 NeuStrategy All rights reserved.
A Primer
Coding Conventions
CMS Annual Update Cycle
©Copyright 2009 NeuStrategy All rights reserved.
Standardized Coding Conventions
ICD-9-CM Codes(1)

Hospital billing codes
◦ Diagnosis codes and procedure codes
 Pertinent to a hospital admission
 Used to classify inpatients into a MS-DRG used to
determine payment
◦ V-codes
 Report factors that may influence present or future care
 Usually listed as a secondary diagnosis
 Supplemental tracking codes used to facilitate data
collection
(1)International
©Copyright 2009 NeuStrategy All rights reserved.
Modification
Classification of Diseases, 9th Revision, Clinical
Standardized Coding Conventions
CPT® Codes(1)

Physician, laboratory, radiology and other billing codes
◦ CPT I(2)
 Medical or procedural service
 Assigned a relative value unit based on skill and time required
 Modifiers used to indicate that a service or procedure has been
altered but not changed in its definition
 Used to determine payment
◦ CPT II
 Supplemental tracking codes used for performance measurement
◦ CPT III
 Temporary tracking codes used to facilitate data collection for
emerging technology, services and procedures
(1)Current
©Copyright 2009 NeuStrategy All rights reserved.
(2) Same
Procedural Terminology
as HCPCS Level I codes
Standardized Coding Conventions
HCPCS Codes(1)

Physician and supplier billing codes
◦ Level I codes
 Same as CPT I codes
 Medical or procedural service
 Used to determine payment
◦ Level II codes
 Drugs and biologics
 Medical items or services billed by suppliers other than physicians
◦ Ambulance services, durable medical equipment
 Used to determine payment
◦ G-codes
 Supplemental codes used to measure quality of services
(1)Healthcare
©Copyright 2009 NeuStrategy All rights reserved.
Common Procedure Coding System
CMS Annual Update Cycle
Hospital Inpatient
Prospective Payment
System (IPPS)
Jan
Feb
Mar
Apr
May
Medicare Physician
Fee Schedule (MPFS)
©Copyright 2009 NeuStrategy All rights reserved.
Fiscal Year (FY)
Proposed Update
Comment Period
Final Rule
Effective Date
Jun
Jul
Aug
October - September
May 1, 2009
June 30, 2009
August 27, 2009
October 1, 2009(1)
Sept
Oct
Nov
Dec
Fiscal Year (FY) January - December
Proposed Update July 1, 2009
Comment Period August 31, 2009
Final Rule
November 1, 2009
Effective Date
January 1, 2010(1)
(1) Unless
otherwise indicated
Coding for Stroke Hospitals
Drip and Ship
©Copyright 2009 NeuStrategy All rights reserved.
Hospital Coding Update – Drip and Ship
• Effective October 1, 2008
V45.88
ICD-9-CM
•
•
•
•
•
Status post administration of tPA in a
different facility within the last 24
hours prior to admission at current
facility
Coded by Hospitals Receiving Patients
Requires a primary diagnosis code of stroke
V-Code is secondary diagnosis
Used for tracking purposes only
Will provide data for future payment decisions
©Copyright 2009 NeuStrategy All rights reserved.
Source: Federal Register / Vol. 73, No. 161, August, 19, 2008,
Changes to the Hospital Inpatient Prospective Payment Systems
Hospital Coding Update – Drip and Ship
• No changes on October 1, 2009
V45.88
ICD-9-CM
Status post administration of tPA in a
different facility within the last 24
hours prior to admission at current
facility
• Commenter's to proposed rule for CMS
FY 2009/2010 requested expedited review:
“Is the code being used?”
• CMS declined to review
©Copyright 2009 NeuStrategy All rights reserved.
Source: Federal Register / August, 27, 2009,
Changes to the Hospital Inpatient Prospective Payment Systems
Coding For Stroke –
Physicians
Critical Care Codes
©Copyright 2009 NeuStrategy All rights reserved.
Physician Coding Update – Critical Care
Codes
CPT Definition – Critical Care
“Critical care is defined as the
direct delivery by a physician(s) of
medical care for a critically ill or critically injured
patient. A critical illness or injury acutely impairs
one or more vital organ systems such that there is
a high probability of imminent or life threatening
deterioration in the patient’s condition.”
©Copyright 2009 NeuStrategy All rights reserved.
Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9,
2008, and AAN website for additional details
Physician Coding Update – Critical Care Codes
• Coded by Physicians Managing Critically Unstable
Patients
99291
Critical Care Services - First hour
(30-74 minutes)
CPT
99292
CPT
Critical Care Services - Each
additional 30 minutes
• Often under-utilized in the ED for stroke patients
• Based on services performed, not physician
specialty
• More than one physician can if one or more critical
illness(es) or injur(ies) in whole or in part
©Copyright 2009 NeuStrategy All rights reserved.
Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9,
2008, and AAN website for additional details
Physician Coding Update – Critical Care Codes
• Suggests high level of medical decision-making,
“real time access and capability”
• Key requirements which must be met for critical
care
• Medical necessity/criticality and intervention(s)
• Cumulative time spent with patient
• during 1 day
• coordinating care counts - reviewing labs, images,
speaking with family, seeking consults, etc.
• Certain procedures that may be billable are
included
©Copyright 2009 NeuStrategy All rights reserved.
Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9,
2008, and AAN website for additional details
Physician Coding Update – Critical Care Codes
Code
Medicare
Allowable
Amount(1)
Description
Payment Rate Recognizes Complexity of Care
99291
Critical Care - 30-74 min
$ 214.98
99292
Critical Care–Each add’l 30 min $ 107.63
Payment Rate for “Routine” Care
99243
New OP Consult – 40 min
$ 99.26
99244
New OP Consult – 60 min
$ 155.78
99245
New OP Consult – 80 min
$ 194.75
99255
New IP Consult – 100 min
$ 203.55
©Copyright 2009 NeuStrategy All rights reserved.
(1)Medicare
Allowable FY09 Area 99 (Orlando, FL)
Physician Coding Update – Remote Critical Care Codes
• New CPT III Codes implemented in July 2008
• Coded by Physicians Managing Critically Unstable
Patients Remotely
0188T
CPT
0189T
Remote real-time video-conferenced
critical care
First hour (30-74 minutes)
Each additional 30 minutes
CPT
• RVUs not assigned
• Payment based on individual payer policy
• Not on CMS’s list of approved telehealth services
©Copyright 2009 NeuStrategy All rights reserved.
Refer to CMS Manual Pub 100-04, Transmittal 1548, July 9, 2008
Physician Coding Update – Critical Care Codes
Code
Medicare
Allowable
Amount(1)
Description
Payment Rate for Critical Care
99291
Critical Care - 30-74 min
$ 214.98
99292
Critical Care–Each add’l 30 min
$ 107.63
Not on CMS list of approved telehealth services
0188T
Remote Critical Care - 30-74 min
$
0
0189T
Remote Critical Care–Each add’l
30 min
$
0
©Copyright 2009 NeuStrategy All rights reserved.
(1)Medicare
Allowable FY 09 Area 99 (Orlando, FL)
Coding Update
“Telehealth” or
Telemedicine Codes
©Copyright 2009 NeuStrategy All rights reserved.
Coding Update – Telemedicine Codes
• Terminology Used in Discussing
Telemedicine/Telehealth
• Telemedicine or “Telehealth”
The use of medical information
exchanged from one site to another via
electronic communications to improve
a patient's health
• Electronic communication
The use of interactive telecommunications
equipment that includes, at a minimum, audio
and video equipment permitting two-way, real
time interactive communication between the
patient, and the physician or practitioner at
the distant site
©Copyright 2009 NeuStrategy All rights reserved.
Coding Update – Telemedicine Codes
• Terminology Used in Discussing
Telemedicine/Telehealth
• MSA = Metropolitan Statistical Area
• RHPS = Rural Health Professional Shortage area
Originating Site
Hospital where patient
is located
Spoke
©Copyright 2009 NeuStrategy All rights reserved.
Distant Site
Location of the physician
delivering the medical service
Hub
Metropolitan Statistical Area - A geographic cluster of population defined by the United
States Census Bureau. An MSA includes a city of at least 50,000 people or urbanized
area of at least 100,000 people and the counties that include these areas.
Coding Update - Telemedicine Codes
• Medicare telemedicine reimbursement is
conditioned by:
• Type of services provided*
• Interactively with video/audio communications
• Communication must occur between patient and remote physician
• Professional services must be within a certain range of CPT codes
• Geographic location
• Originating site must be in a non-MSA county or RHPS area
• No limitation to the location of the physician delivering the medical
service
• Type of institution delivering the services (originating
site)
• For stroke, must be a hospital (including critical access hospital)
• Type of provider
• For stroke, must be a physician
©Copyright 2009 NeuStrategy All rights reserved.
*Some exceptions exist for Federal telemedicine
demonstration projects in Alaska and Hawaii
Physician Coding Update – Telemedicine Codes
• Medicare “Designated Telehealth Services”
9924199255
IP/OP Consultations
Minor to Severe Problem
15 min-110 min
CPT
9920199215
Office or OP Visits
Minor to Severe Problem
5 min-60 min
CPT
• The use of a telecommunication system may
substitute for face-to-face, “hands on” encounter
for designated telehealth services
• Effective January 1, 2008
©Copyright 2009 NeuStrategy All rights reserved.
Refer to CMS Manual Pub 100-02, Transmittal 74,
June 29, 2007
Physician Coding Update – Telemedicine Codes
• Coded by Physicians Performing Follow-up Inpatient
Telehealth Consultations
G0406
Follow-up Inpatient Telehealth
Consultation (Limited)
HCPCS
G0407
Follow-up Inpatient Telehealth
Consultation (Intermediate)
HCPCS
G0408
Follow-up Inpatient Telehealth
Consultation (Complex)
HCPCS
• Effective January 1, 2009
• Physician cannot be attending physician
• Services include related services before, during and
after communicating with the patient via telehealth
• Conditions for payment are the same
©Copyright 2009 NeuStrategy All rights reserved.
Refer to CMS Manual Pub 100-04, Transmittal 1654, December 24,
2008 and MLN JA 6130, January 5, 2009
Physician Coding Update – Telemedicine Codes
99241-99255
IP/OP Consultation
99201-99215
Office or OP Visits
G0406-G0408
Follow-up inpatient Telehealth
• GT Modifier must be used to:
• designate interactive audio and video telecommunication
systems
• certify that patient was present at an eligible originating
site
• Physician reimbursed as if he/she was on-site
• Claims are submitted to carrier in physician’s
service area
©Copyright 2009 NeuStrategy All rights reserved.
Refer to CMS Manual Pub 100-04, Transmittal 1654, December 24,
2008 and MLN JA 6130, January 5, 2009
Physician Coding Update – Telemedicine Codes
Code
Medicare
Allowable
Amount(1)
Description
Payment Rate for Initial Critical Care
99255
New IP Consult – 100 min
$ 203.55
Payment Rate for Follow-up Care
G0406
F/U Inpatient Telehealth
Consultation (15 min)
$ 37.40
G0407
F/U Inpatient Telehealth
Consultation (25 min)
$ 66.84
G0408
F/U Inpatient Telehealth
Consultation (<35 min)
$ 95.85
©Copyright 2009 NeuStrategy All rights reserved.
(1)Medicare
Allowable FY 09 Area 99 (Orlando, FL)
Hospital Coding Update – Telemedicine Codes
• Medicare “Facility” Services for Spoke Hospitals
Q3014
Telehealth facility fee
Originating Site
HCPCS
• Additional payment billed separately to CMS Part B
• Conditions for payment are the same
• Payment rate updated annually
• 2009 rate is $23.72
“Are spoke hospitals billing for the facility fee?
Variable – “not worth the effort to bill”
©Copyright 2009 NeuStrategy All rights reserved.
Refer to Federal Register / Vol. 73, No. 161, August, 19, 2008,
Changes to the Hospital Inpatient Prospective Payment Systems
Public Policy Efforts - Telehealth
• H.R. 2068 Medicare Telehealth Enhancement Act
• Sponsored by Rep. Mike Thompson, D-CA
• Would eliminate geographic restrictions on reimbursement
• Would provide grants for development of telehealth networks
• House Ways and Means Committee
• Approved Components of H.R. 2068 for inclusion in H.R. 3200
• Establishment of a Telehealth Advisory Committee to advice
Secretary of HHS on CMS policies concerning telehealth
• Clarifies hospital credentialing requirements of telehealth
providers
• Authorizes renal dialysis facilities to participate in telehealth
• Not included:
• Removal of geographic restrictions
• Licensing of physicians to practice across boarders
©Copyright 2009 NeuStrategy All rights reserved.
1Refer
to Center for Telehealth and E-Health Law for more information
2. Pay for Performance
-Physician Quality Reporting Initiative
-Hospital Quality Reporting Initiative
-Premier Hospital Quality Incentive
Demonstration
©Copyright 2009 NeuStrategy All rights reserved.
Pay for Performance
Physician Quality Reporting Initiative
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/pqri/
www.qualitynet.org
Physician Quality Reporting Initiative (PQRI)
• 2006 – Physician Quality Reporting System
established
• Financial incentive to report data on quality
measures
• Voluntary for eligible professionals
•MD, DO
•NP, PA, Clinical Psychologist, Registered Dietitian, etc.
•PT/OT/SP
•Audiologists (added in 2009)
• 74 clinical quality measures
• None specific to stroke
• Reporting occurred via claims submission
(on same claim as associated professional services)
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/pqri/
www.qualitynet.org
Physician Quality Reporting Initiative (PQRI)
• Bonus payment available
• Must satisfactorily report of the 3 quality measures for
at least 80% of cases in which chosen measure is
reportable
• Bonus - 1.5% of TOTAL allowed charges for covered
professional services
• Lump sum payable ~ July 2008
• No public reporting
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/pqri/
www.qualitynet.org
Physician Quality Reporting Initiative (PQRI)
CY 2007 Reported Experience
6,722,753
Measures Reported
$3,600,000
Bonus Payments(1)
109,349
Attempted to Participate
56,722
Satisfactorily Reported
$4,713 Average Bonus Earned
3.6 Average Measures Reported
(1)Expected
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov Fact Sheet “PQRI Makes Payments for
the 2007 Reporting Period
Physician Quality Reporting Initiative (PQRI)
• CY 2009 – Physician Quality Reporting System
is permanent
• Still voluntary
• Bonus payment – increased to
• Measures expanded
•
2%
153 clinical quality measures
• 8 measures relate to stroke care
• Operates on a calendar year with variable reporting periods
• Nine (9) different options for reporting
• Claims submission or clinical registry
• Individual or group measures
©Copyright 2009 NeuStrategy All rights reserved.
Source: Federal Register, November 19, 2008
Section 01, MPFS
Physician Quality Reporting Initiative (PQRI)
“Stroke Related” Measures
10. CT or MRI of brain within 24 hrs of hospital admission
11. Carotid Imaging Reports with reference to stenosis
measurements
31. DVT prophylaxis received by end of hospital day two
32. Discharged on Antiplatelet Therapy
33. Anticoagulant Therapy Prescribed for Atrial
Fibrillation at Discharge
34. Tissue Plasminogen Activator (t-PA) Considered (<3 hrs)
35. Screening for Dysphagia
36. Consideration of rehabilitation services is documented
114. Inquiry Regarding Tobacco Use
115. Advising Smokers to Quit
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/pqri/
www.qualitynet.org
Physician Quality Reporting Initiative (PQRI)
• Outcome™ PQRI Partner Program
• CMS-qualified web-based registry
• Allow hospitals to leverage data already collected for
physicians
• ~100 practices using it
• A few Get-With-The-Guidelines hospitals using it to
provide physicians with their patient’s data
• Anticipate more neurologist will be interested
• Consider it as an alignment strategy with your
neurologists
©Copyright 2009 NeuStrategy All rights reserved.
Refer to www.outcome.com/pqri.htm for more
information
Physician Quality Reporting Initiative (PQRI)
• CY 2010 – New Elements
• Still voluntary
• Last year for Bonus Payment
• Group practices can qualify for
incentive payment
Number of Measures Available
200
150
100
50
153
175
Proposed
CY 09
CY 10
119
74
0
CY 07
CY 08
• Names of physicians and groups
satisfactorily reporting will be on CMS website
• A number of reporting options and report periods available
• Data captured through registries due in 2011
• Adds an electronic medical record (EHR)-based
reporting mechanism
©Copyright 2009 NeuStrategy All rights reserved.
Source: Federal Register July 13, , 2009 and August
5, 2009 Proposed Rule Section 02 MPFS
Pay for Performance
Hospital Quality Reporting Initiative
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/hospitalqualityinit
www.qualitynet.org
Hospital Quality Reporting Initiative (PQRI)
• 2004 – Reporting Hospital Quality Data for Annual
Payment Update (RHQDAPU) established
• Financial incentive to report data on quality
measures
• Voluntary but….must report designated quality
measures to get full inflation-adjusted MS-DRG
rates for the next year
• Non-reporting hospitals get 2% reduction in
annual inflation adjustment
• Quality measures are publically reported
• www.hospitalcompare.hhs.gov
• 2009 – 99% of hospitals participated
97% received full inflation adjustment
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/hospitalqualityinit
www.qualitynet.org
Hospital Quality Reporting Initiative (HQI)
• Quality Measures - Inpatient
• Includes measures for 10 most
common Medicare inpatient
diagnoses
• Heart Attack
• Heart Failure
• Pneumonia
• Also includes
• Surgical (SCIP)
• Mortality
• Patient Experience
Number of Measures Required
70
60
50
40
30
20
10
0
69
Proposed
43
46
30
10
FY 04 FY 08 FY 09 FY 10 FY 11
• Measures are be calculated using claims data and others from
abstracted clinical data, survey data or individually reported
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/hospitalqualityinit
www.qualitynet.org
Hospital Quality Reporting Initiative (HQI)
• Quality Measures – Outpatient
• Includes
• 5 Emergency Department measures
• 2 Perioperative care measures
• Also includes 4 imaging efficiency measures
• Some measures will be calculated using claims data and others
from abstracted clinical data
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/hospitalqualityinit
www.qualitynet.org
Hospital Quality Reporting Initiative (HQI)
• CMS FY 2009 – Proposed Stroke Quality Measures
• STK-1
• STK-2
• STK-3
• STK-5
• STK-7
DVT Prophylaxis
Discharged on Antithrombotic Therapy
Patients with Afib Receiving Anticoagulation Therapy
Antithrombotic Medication by End of Day Two
Dysphagia Screening
• Included measures must be endorsed by National Quality
Forum (NQF)
• Due to lack of endorsement by NQF at the time of
release of the final CMS inpatient rules, stroke
quality measures were not adopted
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/hospitalqualityinit
www.qualitynet.org
Hospital Quality Reporting Initiative (HQI)
• CMS FY 2010– Stroke “Measure” Adopted
• Participation in a systemic clinical data registry for stroke care
• Considered a “structural” measure
• Applicable to all hospitals
• Report once annually, submit via web-based tool
(www.qualitynet.org)
• Effective 1/1/2010
• Participation in a registry is not required
• Report whether you participate
• If so, report, which registry
• AHA/ASA Get-With-The–Guidelines Registry is
referenced
©Copyright 2009 NeuStrategy All rights reserved.
Source: Federal Register / August, 27, 2009,
Changes to the Hospital Inpatient Prospective Payment Systems
Hospital Quality Reporting Initiative (HQI)
• CMS FY 2011– Future Outlook
• Eight (8) NQF endorsed stroke measures referenced
• A stroke mortality measure
• Anticipate EHR-based submission (piloting as early as 7/1/09)
• CMS FY 2012
• Focus on improving reliability and quality of the process
• CMS will randomly select 800 hospitals annually
and will validate 12 medical records on a quarterly
basis
©Copyright 2009 NeuStrategy All rights reserved.
Source: Federal Register / August, 27, 2009,
Changes to the Hospital Inpatient Prospective Payment Systems
Pay for Performance
Premier Hospital Quality Incentive
Demonstration
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/hospitalqualityinit
Premier Hospital Quality Incentive Demonstration
• CMS Hospital Quality Initiative - 3 Year
Demonstration Project (beginning in 2006)
• Pay for “results”
• Selected hospitals paid a bonus for their performance on
quality measures
•Heart attack, heart failure, pneumonia, CABG, hip and knee replacement
• Scored on quality measures related to each condition
• Hospitals in the top 20% will be recognized and
given a financial bonus
• By year 3 underperforming hospitals in lower 20%
could receive lower payments
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/hospitalqualityinet
Premier Hospital Quality Incentive Demonstration
• Demonstration Project was extended through 2009
• Purpose
• Test new payment models
• Test new ways to measure quality
• Test methods to provide information to support
designing value-based purchasing models
©Copyright 2009 NeuStrategy All rights reserved.
Source: www.cms.hhs.gov/hospitalqualityinit
Discussion
Questions
©Copyright 2009 NeuStrategy All rights reserved.
• Presentation is available at
www.neustrategy.com
Thank you
Please Note: Coding and reimbursement information provided is gathered from sources referenced on each slide and is presented for
informative and illustrative purposes only. By making this information available, neither the author nor NeuStrategy, Inc. make
representation or warranty regarding its completeness, accuracy, timeliness, or applicability for a particular patient case. This
information does not constitute reimbursement or legal advice. Laws, regulations and payer policies concerning reimbursement are
complex and change frequently. Providers are responsible for making appropriate decisions relating to coding and reimbursement
submissions. Accordingly, the author and NeuStrategy, Inc. recommend that you consult with your payers, reimbursement specialist
and/or legal counsel regarding coding, coverage and reimbursement matters.
©Copyright 2009 NeuStrategy All rights reserved.
NEUROLOGY
AND STROKE
CALL
SURVEY
RESULTS AVAILABLE
Save-the-Date
Webinar
December 10, 2009
60 Minutes
2 pm ET / 1 pm CT
12 pm MT / 11 am PT