Thank You To Our Sponsor: Phoenix Ortho

TOA/TOF Annual Meeting: 2012 Ortho Updates and ICD-10 Issues
 

Are you ready for the changes and how it will affect MS Coding in 2013?

In 2012 Current Procedural Terminology (CPT) codes and guidelines changes are significant. Do you know when to use, how to use and what the documentation needs to be?

Is your office documenting in the patients records the 'medical necessity' that your patient needs for Medicare coverage?

Know how to get your claims paid!

Sign Up Today!

Thursday, April 12th, 2012
Houstonian Hotel, Club and Spa
Houston, TX
 

Presented by:
Margie Scalley Vaught, CPC, CPC-H, CCS-P, MCS-P, ACS-EM, ACS-OR
Healthcare Consultant, and one of the nation’s TOP coding instructors!

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Thank You To Our Sponsor: Viztek/Southwest X-Ray

Click on graphic or here to visit their website!

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Concussion Symposium at The 2012 TOA/TOF/TSSM Annual Meeting

Sports Related Concussion and Mild TBI: Developments in Treatment and Management

Are you prepared for Natasha’s Law? The bill, dubbed Natasha's Law, calls for state-mandated education for all parties, the removal from play of suspected concussed athletes and, most importantly, guidelines for return to activity. The Texas Orthopeadic Association (TOA) and the Texas Society of Sports Medicine (TSSM) have partnered with the Methodist Concussion Center to provide this pertinent concussion prevention training. 

This two hour workshop will provide the necessary concussion continuing education and training to coaches, athletic trainers, physicians and other health care providers in compliance with Natasha's Law.

Presented by:
Summer D. Ott, Psy.D, Director
Memorial Hermann Ironman Sports Medicine Institute Concussion Program,
and
Scott E. Rand, MD
Methodist Hospital Neurological Institute Concussion Center

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Thank You To Our Sponsor: Integrity Rehab Group

Click on graphic or here to visit their website!
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RACs, ZPICs and CERTs
 

If you do not know what these acronyms mean, your practice can suffer greatly. The Medicare Administrative Contractors are the organizations that contract with CMS to administer Medicare within the country. Medicare Administrative Contractors (MAC’s) have about eleven different organizations to audit and enforce their policies. Among these are the Recovery Audit Contractors (RACs), Zone Program Integrity Contractors (ZPICs), and Comprehensive Error Rate Testing Program (CERT). In the following few paragraphs, I will try to explain each one of these.

RACs:  Suggested link to monitor Connolly website

This was established in 2006 to identify inappropriate payments and reduce fraud and abuse in the Medicare system. RACs in the past only focused on hospitals, but now physicians in Texas are receiving audit letters. The RACs request patient medical records from physicians. They are limited in the number of records they can request every forty-five days. For example, a practice with six to twenty-four physicians would only have to produce forty-five records, in each forty-five day period. The RACs have been very successful.  In 2008, they recouped over $990 million dollars in overpayments to Medicare providers. For example, in a review of forty-five charts, if a RAC finds an average overpayment of an audit of a claim that amounts to $30 for that claim, they can then extrapolate for all the Medicare patients seen in the last three years. For example, at $30 per claim for 10,000 Medicare patients, the practice would owe $300,000 plus interest, which would be payable in a matter of weeks. The RAC cannot look back more than three years.

RAC audits are appealable!  However, even if the practice appeals the fine, payment has to go to CMS before all the appeals are exhausted. RACs receive a portion of the money that they collect.

ZPICs:  Immediately get an Attorney

This is another government program to eliminate fraud and waste. They again do data mining. They can extrapolate from a few patients to your entire practice. For example, if they requested forty charts covering one or two years and found those charts to not support the charges, they could then extrapolate that number to all patient encounters over those two years. ZPICs do not get a share of the money that they recover. The have a contractual basis and do not get contingency fees. On the other hand, ZPICs have no limit on how far back they can look in your practice. They can go back to the beginning of your practice even if your practice is over thirty years old.

CERTs:

CERTs are used by CMS to improve the quality and accuracy of Medicare claims. Under this program, more than 120,000 randomly selected claims are reviewed each year. CMS then calculates a national paid claim error rate and a contractor specific error rate for services processed in error. CERTs, again, do a randomly selected sample of claims. The RACs and ZPICs may have a targeted sample of claims. CERTs review the claims and medical records to see if the claims comply. 

All three of the above Medicare auditing enforcement agencies have real penalties. These penalties can be fines; interest on those fines, repayment of monies paid to the practice by Medicare, and in some cases a referral for criminal activity or fraud to the attorney general.

Now, like you, I always ask what are the rationale for denial of claims and what documentation is required.

Medicare contractors use what is called a local coverage determination (LCD).  The local coverage determination is used to come up with the new rules on the indications for a total joint such as total hip and total knee. I do not exactly know how Medicare comes up with their local coverage determinations. Medicare looks at inpatient hospital claims, DRG-470, which is joint replacement services. Currently, the medical reviews for joint replacement services are being done in a prospective fashion. They can also be done in a retroactive fashion. They have looked at inpatient hospital claims for DRG-470, which is a joint replacement service. They are now denying some of those claims. Fifty-nine percent of those claims which are denied are denied based on "documentation does not support medical necessity of the procedure." Thirty-five percent are denied based on "insufficient documentation to make a decision." These can also be denied in that services could have been provided as an outpatient, no documentation is submitted for the procedure billed, and no documentation is provided to support changing the elective outpatient procedure to inpatient procedure.

However, as you note above, it is all about documentation. Here is a link that may be helpful.

Most of us are used to having our office records support the reason for a surgical procedure.  RACs and ZPICs are looking only at the information in the hospital chart. Obviously, most of us do not have our medical records in the hospital chart. Often, most of us do not include in our operative report the rationale or documentation to support our surgical procedure. We are simply not trained to do that. This has never been necessary in the past. It has also not been necessary in our history and physical to include all the reasons for a surgical procedure.

Local coverage determinations for lumbar spinal fusion (DRG 460) for instability in degenerative disease include the following:

Indications - Spinal fusion should only be considered as the last step in the treatment of chronic back pain. It is not an indicator for most persons suffering from back pain. Lumbar spinal fusion surgery may be considered medical necessary in coverage for the indications:

I. Lumbar and spinal instability for ANY of the following indications when confirmed by appropriate testing (e.g. radiographic imaging, biopsy, bone aspirate, bone scan, and gallium scan).

1. Acute spinal fracture.

2. Progressive neurological impairment.

3. Neurocompression after spinal fracture.

4. Epidural compression or vertebral destruction from tumor abscess.

5. Spinal tuberculosis.

6. Spinal debridement for infection.

7. Spinal deformity (for example, idiopathic scoliosis over 40 degrees, progressive degenerative scoliosis).

II. Spinal stenosis with associated spondylolisthesis for a single level or other documented evidence of instability (for example, facet joint instability) when ALL the following criteria are met:

1. Back pain with symptoms of neurogenic claudication or radicular pain.

2. Radiographic evidence of spondylolisthesis when applicable.

3. Pain and significant functional impairment despite a history of three months of conservative therapy as clinically appropriate which includes:

1. Anti-inflammatory medication.

2. Analgesics.

3. Daily exercises.

4. Activity lifestyle modification.

5. Weight reduction as appropriate.

6. Supervised physical therapy (activities of daily living diminished despite completing a plan of care).

7. The patient is a non-smoker or has refrained from smoking for at least six weeks prior to planned surgery or has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation if accepted.

III. Spondylolysis with ANY of the following criteria:

1. Confirm progressive deformity.

2. Neurological compromise.

3. Symptomatic high-grade spondylolisthesis demonstrated on plain x-rays.

4. Multi-level spondylolysis.

5. Symptomatic low-grade spondylolisthesis associated with pain and significant functional impairment despite a history of three months of conservative therapy which addresses the following:

1. Anti-inflammatory medications.

2. Analgesics.

3. Daily exercise.

4. Activity lifestyle modification.

5. Weight reduction as appropriate.

6. Supervised PT.

7. Patient is a non-smoker or has refrained from smoking for at least six weeks prior to planned surgery or has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation if accepted.

8. If cognitive behavioral or addiction issues are identified, the documentation should support assessment and treatment prior to surgical management.

IV. Degenerative disease and the absence of instability when ALL the following criteria have been met as clinically appropriate for the patient’s current episode of care.

1. Single level DDD demonstrated on imaging studies (for example, CT scan, MRI or discography) as the likely cause of pain.

2. The case-specific indications for two-level or the rare three, or four or more level planned fusion procedure must be directly addressed in the pre-procedure record with clinical correlation to diagnostic testing results such as disc space narrowing, endplate changes, annular changes.

3. Patient is a non-smoker or has refrained from smoking for at least six weeks prior to any planned surgery or has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation if accepted.

4. If cognitive behavioral or addiction issues are identified, the documentation should support assessment and treatment prior to surgical management.

5. Pain and significant functional impairment despite a history of at least six months of conservative therapy addressing the following issues.

1. Anti-inflammatory medications.

2. Analgesics.

3. Daily exercise.

4. Activity lifestyle modification.

5. Weight reduction as appropriate.

6. Supervised physical therapy.

7. Unsuccessful improvement after completion of intense multi-disciplinary rehabilitation defined as "on-site program that includes supervised PT, cognitive behavior component, and other coordinated interventions by healthcare professionals."

V. Lumbar fusion following prior spinal surgery for the following:

1. Recurrent disc herniation despite clinically appropriate postoperative non-surgical medical management.

2. Adjacent segment degeneration despite clinically appropriate postoperative non-surgical medical management.

3. Associated spondylolisthesis after prior surgery with all the following as clinically appropriate:

1. Recurrent symptoms consistent with neurological compromise.

2. Significant functional impairment.

3. Neurocompression is documented by recent postoperative imaging.

4. Unsuccessful improvement despite three months of clinically appropriate postoperative non-surgical medical management.

5. Instability as documented by appropriate imaging.

6. Patient has some relief of pain and symptoms following the prior spinal surgery.

VI. Treatment of pseudarthrosis (for example non-union of prior fusion) at the same level after twelve months from prior surgery and ALL the following are met:

1. Imaging studies confirm evidence of pseudarthrosis.

2. Unsuccessful improvement despite three months of clinically appropriate postoperative non-surgical medical management.

3. The patient had some relief of pain and symptoms following the prior spinal surgery.

4. Patient is a non-smoker or has refrained from smoking for at least six weeks prior to any planned surgery or has received counseling on the effects of smoking on surgical outcomes and treatment for smoking cessation.

VII. Lumbar spinal fusion for the following condition is not considered medically necessary and is non-covered.

1. When performed with initial primary laminectomy or discectomy for nerve root decompression or spinal stenosis without documented spondylolisthesis or documentation of instability (for example documented intraoperative iatrogenic instability.

2. Lumbar fusions at multilevels (two or more) for pure DDD unless case-specific indications for two level or the rare three or more level planned fusion procedure is directly addressed in the preprocedure record.

Local coverage determination for total knee replacement. MAC will consider total knee replacement surgery medically necessary when ONE OR MORE of the following criteria are meet:

I. Total knee arthroplasty

1. Failure of a previous osteotomy or;

2. Distal femur fracture or;

3. Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues or;

4. Failure of previous unicompartmental knee replacement or;

5. Avascular necrosis of the knee or;

6. Proximal tibial fracture or;

7. Advanced joint disease demonstrated by:

1. Radiographic supported evidence or MRI supported evidence of "subchondral cyst, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis" and;

2. Pain or functional disability from injury due to trauma or arthritis of the joint and;

3. Unsuccessful history of appropriate conservative therapy that is clearly addressed in the preprocedure medical record. Non-surgical medical management is usually implemented for three months or more to assess effectiveness. Conservative treatment as clinically appropriate for the patient’s current episode of care typically include one or more of the following:

1. Anti-inflammatory medications.

2. Analgesics.

3. Flexibility and muscle strengthening exercises.

4. Supervised physical therapy (activities of daily living diminished despite completing a plan of care).

5. Activity restrictions as reasonable.

6. Assistive device use.

7. Weight reduction as appropriate.

8. Therapeutic injection in the knee as appropriate.

The MAC will consider total hip replacement surgery medically necessary when ONE OR MORE of the following criteria are met:

II. Total hip arthroplasty.

1. Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur.

2. Avascular necrosis of the femoral head.

3. Fracture of the femoral neck.

4. Acetabular fracture.

5. Non-union or failure of previous hip fracture surgery.

6. Malunion of acetabular or proximal femur fracture.

7. Advanced joint disease demonstrated by:

1. Radiographic supported evidence of MRI evidence (subchondral cyst, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis) and;

2. Pain or functional disability from injury due to trauma or arthritis of the joint and;

3. Unsuccessful history of appropriate conservative therapy that is clearly addressed in the preprocedure medical record. Non-surgical medical management is usually implemented for three months or more to assess effectiveness. Conservative treatment as clinically appropriate for the patient’s current episode of care typically include one or more of the following:

1. Anti-inflammatory medications.

2. Analgesics.

3. Flexibility and muscle strengthening exercises.

4. Supervised physical therapy (activities of daily living diminished despite completing a plan of care).

5. Activity restrictions as reasonable.

6. Assistive device use.

7. Weight reduction as appropriate.

There are also indications for:

III. Replacement or revision total hip arthroplasty.

1. Instability of one or both components.

2. Fracture or mechanical failure of the implant.

3. Recurrent or irreducible dislocation.

4. Infection.

5. Treatment of a displaced prosthetic fracture.

6. Clinically significant leg length inequality.

7. Progressive or substantial bone loss.

8. Clinically significant audible noise.

9. Adverse local tissue reaction.

The MAC will not consider a total knee replacement or total hip replacement medically necessary when the following contraindications are present:

1. Active infection of the hip or knee joint or active systemic bacteriemia.

2. Active skin infection or open wound with a planned surgical site of the hip or knee.

3. Neuropathic arthritis.

4. Rapidly progressive neurologic disease.

Government auditors are now looking at spinal fusions and joint replacement surgery, specifically hip arthroplasty and total knee arthroplasty. The Texas Orthopaedic Association can help give you information that is local coverage determination for major joint replacements. The Texas Medical Association can give you help if you get a ZPICs RACs or CERTs audit. Please make use of these services. CMS also has websites which explain CERTs, RACs, and ZPICs. Your office manager should have these websites listed on their computer for easy access.

Click here for a CERT: Joint Replacement Documentation
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Thank You To Our Sponsor: Carr, Riggs and Ingram

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Save The Date: 2012 TOA/TOF Annual Meeting April 13-14, 2012

The 2012 TOA/TOF Annual Meeting will be held at the Houstonian Hotel, Club and Spa in Houston, Texas.

We are looking forward to having you join us for a great meeting with exceptional orthopaedic speakers and special events!

April 13-14, 2012

Click here to register NOW!

Reservations:

The Houstonian Hotel, Club and Spa
111 North Post Oak Lane
Houston, Texas 77024
phone 713-680-2626 fax 713-680-2992
Reservations: 1-800-231-2759

Here is a sneak peek at the preliminary program:
 

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