Despite being rural and relatively small, Duncan (OK) Regional Hospital has been a leader in health IT for years, first installing Meditech financial and clinical systems for acute care nearly 20 years ago. The latest IT project for the 167-bed facility in southwestern Oklahoma is to improve workflow and quality in the emergency department and better coordinate emergency care with care delivered elsewhere. This summer, Duncan Regional is deploying T SystemEV Stat, an upgrade to an earlier management system from Dallas-based health IT vendor T-System, because the hospital has had problems managing paper records that came from other providers. The hospital also has been experiencing a steep increase in ED volume, according to Roger Neal, Duncan Regional's VP and CIO.
It's no surprise that the state of the HIPAA 5010 transition is something of a mess. The potential for slowed or even stopped claims reimbursements is understood. And the inevitable ripple effects on health IT are not so clear. What with that increasingly louder clock ticking in the back of the healthcare industry's collective head, a question: As the Jan. 1, 2012 compliance deadline approaches, should providers and the federal government devise contingency plans for HIPAA 5010? "As much as I like deadlines and people being held accountable, I think it would be a dereliction of duty for (the Centers for Medicare & Medicaid Services) to not come up with some sort of contingency plan for HIPAA 5010," said Steve Sisko, an analyst and technology consultant focused on payers and ICD-10. Sisko is hardly alone in thinking that a backup plan will be necessary. Testifying late last month before the National Committee on Vital Health Statistics, the Medical Group Management Association said that "as of early June, very few practices have instituted external testing, and this could lead to a backlog of test requests in the last few months of the year."
Halifax Health CEO Jeff Feasel received a 9.5% raise in June that bumped his salary up $50,000 to $575,000 a year. The CEO of the public hospital system hasn't had a raise since 2008, and his pay was reduced by 5% in 2009 and 2010 as part of belt-tightening. A consultant's salary study recently found Feasel earned 26% less than the median base salary of CEOs at similarly sized hospitals. Still, Feasel is the highest paid official of any entity in the area that is supported by local property taxes. The $30,000 consultant study also reviewed salaries for other Halifax executives and recommended eight other executives receive pay increases totaling $282,080.
The HITECH Act and meaningful use aim to promote -- and fund -- the building of a health IT infrastructure in which patient data fires across a national health information exchange. State IT leaders discussed the trials of building this national network at the 2011 State Healthcare IT Connect Summit in Washington, DC. The main hurdle they must overcome? Health data interoperability. "At its worst, meaningful use can appear a bureaucratic hodgepodge of hoops to jump through," said national health IT coordinator Farzad Mostashari, MD, in his keynote address, in which he confirmed that proposed Stage 2 meaningful use criteria are on schedule to be released later this year and finalized by mid-2012. "As hard as [achieving electronic health record] adoption is, exchange is that much harder because of technical reasons, because the services you need aren't there yet, because policies need to be articulated -- particularly around privacy and money." Gregory Franklin, deputy health IT director for the state of California's Technology Agency, framed the complexity of the health data interoperability challenge in a panel discussion following Mostashari's address.
Home births increased 20% from 2004 to 2008, accounting for 28,357 of 4.2 million U.S. births, according to a study from the Centers for Disease Control and Prevention released in May. White women led the drive, with 1 in 98 having babies at home in 2008, compared to 1 in 357 black women and 1 in 500 Hispanic women. Sherry Hopkins, a Las Vegas midwife, said the women whose home births she's attended include a pediatrician, an emergency room doctor and nurses. "We're definitely seeing well-educated and well-informed people who want to give birth at home," she said. Robbie Davis-Floyd, a medical anthropologist at the University of Texas at Austin and researcher on global trends in childbirth, obstetrics and midwifery, said "at first, in the 1970s, it was largely a hippie, countercultural thing to give birth outside of the hospital. Over the years, as the formerly 'lay' midwives have become far more sophisticated, so has their clientele."
The Centers for Medicare & Medicaid Services (CMS) released the 2012 OPPS proposed rule late Friday afternoon, on the eve of the July 4th holiday weekend. The proposed rule does not contain many substantive operational changes. However, CMS does propose changes to some much discussed areas, including payment for combined CPT® codes for CT of the abdomen and pelvis and determining required levels of physician supervision.
“I was pleasantly surprised by several aspects of the rule,” says Jugna Shah, MPH, president of Nimitt Consulting Inc. based in Washington, DC. “First, I can’t recall the last time we had a file to read that was less than 1,000 pages. Second, CMS really listened to comments it received during the last year from many organizations on its rate-setting methodology for the ’new’ combined CT code for CT of the abdomen and CT of the pelvis.”
In 2011, the CPT editorial panel created three new codes for computed tomography (CT) of abdominal and pelvis:
Code 74176, Computed tomography, abdomen and pelvis; without contrast material
Code 74177, Computed tomography, abdomen and pelvis; with contrast material(s)
Code 74178, Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions
CMS assigned those new CPT codes to existing APCs with payment rates that many felt were far too low to cover the costs of providing combined (two services).
Many organizations have been working hard to convince CMS that these new codes are just that, new codes but not new services. They argued that CMS should use its historical claims data to set appropriate payment rates for the single and combined CT services, Shah says.
“CMS has listened based on its proposal for 2012 and this is a huge win for the provider community given that we’ll see more appropriate payment, and significantly higher payment rates for these services if CMS’ proposal for 2012 is finalized. Moreover, since we expect to see more and more combination codes being released by the AMA, this change on CMS’ part is critical to ensure adequate future payments.”
CMS proposes to create two new APCs to assign the CPT codes for combined abdominal and pelvis CT services:
APC 0331 (combined abdominal and pelvis CT without contrast) for CPT code 74176
APC 0334 (combined abdominal and pelvis CT with contrast) for CPT codes 74177 and 74178
CMS proposed no changes to E/M visit coding guidelines nor did it discuss drug administration at all. This doesn’t mean that hospitals won’t see payment rates changes for these important and high volume services, says Shah. “That is the one thing we can count on every year – individual APC payment rate fluctuations so take a few minutes now to review the proposed payment rates compared to current rates for your most frequently billed services either by volume or percent of charges.”
Conversion factor update/ increase
Under the 2012 OPPS proposed rule, CMS is projecting a market basket update of 1.5%. However, that amount will likely decrease to 1.1% after CMS factors in all adjustments.
One such adjustment is related to a special payment provision proposed for 11 cancer hospitals. CMS proposed changes on how these cancer hospitals would be reimbursed due to the fact that its internal studies have shown that these hospitals have a much lower payment-to-cost ratio (PCR) compared to all other hospitals. CMS’ proposal is intended to create some payment parity between the hospitals.
CMS proposes that if the PCR for these cancer hospitals is below the weighted average PCR for all other OPPS hospitals, then it will increase the payment to these cancer hospitals on a hospital-specific basis.
The increase would be equal to percentage difference between the cancer hospital’s individual PCR and the weighted average PCR of other OPPS hospitals. This must be done in a budget neutral manner according to the Affordable Care Act. Therefore CMS indicates in the proposed rule that this provision will cause a 0.6% reduction to the payment rates for non-cancer OPPS hospitals.
Another payment adjustment that will impact final payment rates is due to CMS’ proposal to complete its transition to using full community mental health centers (CMHC) data to set the CMHC partial hospitalization program (PHP) APC per diem payment rates. However, if finalized, this proposal will result in a 0.2% payment increase for all other hospitals. These are two examples of adjustments to the final conversion factor that impact it going up and down.
Payment for partial hospitalization services
CMS proposed to continue with its methodology for creating separate APCs for partial hospitalization when provided in the hospital setting vs. in a CMHC despite the lawsuit that was brought against the agency earlier this year. CMS has proposed to update the existing four CMHC PHP APC payment rates—two for freestanding community mental health center (CMHC) PHPs, and two for hospital-based PHPs. Under the proposal, CMS would pay:
$97.78 for APC 0172 (level 1 partial hospitalization for CMHC)
$113.62 for APC 0173 (level II partial hospitalization CMHC)
$162.34 for APC 0175 (level 1 partial hospitalization for hospital-based PHPs)
$189.87 for APC 0176 (level II Partial Hospitalization for hospital-based PHPs)
Drugs and pharmacy costs
CMS has proposed to increase the drug packaging threshold from $70 today to $80 for CY 2012, which means that more drugs are likely to be packaged.
In addition, CMS has proposed to decrease the payment for all separately payable drugs and biologicals without pass-through status from the current average sales price (ASP)+5%,to ASP + 4%.
The payment reduction is bad enough, says Shah, and may be due in part to the proposal to increase the drug packaging threshold. It could get worse in the final rule as CMS clearly indicates that the final ASP plus percentage could drop by a percentage point when everything is factored in, she adds. “Therefore hospitals need to take a look at this in the proposed rule, provide comments to CMS, and begin preparing their facilities for this potential payment reduction.”
Supervision requirements for outpatient therapeutic services
For CY 2011, CMS finalized a number of changes to physician supervision requirements for hospitals. Most notably, CMS created a new category of nonsurgical extended duration therapeutic services, which require direct supervision at the initiation of the service but can then be followed by general supervision for the remainder of the service. Furthermore, CMS stated its plan to convene a panel to review the supervision level of additional services that might be added to this category of nonsurgical extended duration services as well as other services. Finally, CMS did not enforce the supervision requirements for CAHs in 2011 but indicated that it would do so in the near future.
In the 2012 OPPS proposed rule, CMS has a lengthy discussion about its proposal to use the existing APC Advisory Panel with some modifications, including the addition of panel members from the CAH and rural hospital community, to review the supervision levels of services brought to its attention. CMS outlines the process it proposes along with its plan on handling requests for services to review and other criteria it expects to use. As a result, CMS also proposes to extend its non-enforcement policy of supervision requirements to CAHs. This means CAHs will be exempt from these requirements for one more year, says Shah.
Hospital Outpatient Quality Reporting Program
CMS proposes adding nine quality measures to the current list of 23 measures that hospital outpatient departments must report. That will bring the total number of measures to be reported for 2013 payment determination to 32. The new measures include:
Six chart abstracted measures
One healthcare associated infection measure to be reported to the National Health Safety Network
One measure about the use of a safe surgery checklist
One measure collecting hospital outpatient department volume for selected surgical procedures
In addition, CMS proposes added one measure—influenza vaccination coverage among healthcare personnel— to the list for reporting for the CY 2015 payment determination.
Comment on the proposals
CMS will accept comments on the proposed rule through August 31, and will issue the final rule by November 1. Visit http://www.regulations.gov to submit electronic comments on this regulation. Follow the instructions under the “More Search Options” tab.
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