Archive for the ‘Medicare’ Category

Meaningful Use: Stage 2 Clarifying Tips

09 Oct

Newly published information from the Centers for Medicare and Medicaid Services (CMS) that specifies the Stage 2 criteria for Meaningful Use is now available for eligible professionals, hospitals, and critical access hospitals. This information includes a tip sheet giving additional details. However, providers should keep in mind that before meeting these requirements, participants must achieve meaningful use under the Stage 1 criteria.

This tip sheet offers professionals a timeline illustrating the progression of meaningful use stages from when a Medicare provider begins participation in the program. While during the first year of participation, providers must demonstrate meaningful use for a 90-day electronic health record reporting period, the subsequent years will require a full year HER reporting period.

This full-year period is defined as an entire fiscal year for hospitals or an entire calendar year for EPs, except in 2014. Providers participating only in Medicaid HER Incentive Programs are not required to demonstrate meaningful use in consecutive years. However, their movement through the stages would follow the same structure of two years meeting the criteria of each stage, including a 90-day HER reporting period during the first year. 

As stated above, the reporting rules for 2014 differ from prior years. In 2014, all providers, regardless of their stage of meaningful use, are only required to demonstrate meaningful use for a three-month reporting period. CMS will be offering this one-time three-month reporting period in order to enable providers who must upgrade to 2014 Certified HER Technology to have time to implement their new Certified HER systems. This three-month period will be restricted for Medicare providers to the quarter of either the fiscal or calendar year. Medicaid providers who are only eligible for Medicaid EGR incentives will not be restricted to a fixed reporting period, since providers do not have the same alignment needs. 

The tip sheet explains that Stage 2 retains the core and menu structure for meaningful use objectives from Stage 1. While some Stage 1 objectives were eliminated, the majority of them are core objectives under Stage 2 and the threshold that providers must prove has simply been raised. This threshold includes demonstrating meaningful use of Certified HER Technology to a larger portion of their patient populations. 

At the core of the tip sheet are two Stage 2 criteria:

  • EPs must meet 3 menu objectives and 17 core objectives selected from a total list of 6, creating a total of 20 core objectives.
  • Hospitals that are eligible and CAHs must meet 3 menu objectives and 16 core objectives selected from a list of 6, for a total of 19 core objectives.

The tip sheet concludes with a complete list of the Stage 2 core and menu objectives for all participants, including a downloadable table. 

With the next stage of meaningful use now available, health care providers have ample resources from CMS to make sure that they meet guidelines and reap the benefits.


Overview of Health Information Exchanges

08 Oct

In keeping with the current Meaningful Use legislation, agencies across the country are developing health information exchange programs. Health Information Exchanges allow for the streamlined transmission of health-related data and patient information between health care providers and ensure this exchange is secure and up-to-date.

UC-David Health System has launched a state-wide data sharing program in California. This initiative — the California Health eQuality Program — will link hospitals, emergency departments, and physicians by 2014. In addition to a four-year, $38.8 million grant through the federal economic stimulus package, officials are seeking other funding sources to expand the program past 2014.

The initiative, as described by Kenneth Kizer, Director of the Institute for Population Health Improvement, will allow health information to “flow safely and quickly between and among health care providers…”

When will the Pacific Northwest hop on the wagon? We already have. The state of Oregon launched its statewide health information exchange, called CareAccord, in May 2012. The system will improve provider communication, reduce duplicate orders and help health care providers meet the requirements for Meaningful Use, which will allow them to qualify for Medicaid and Medicare incentive programs instituted by the Obama administration beginning in 2009.

Harris Healthcare Solutions will implement Oregon’s health information exchange and Oregon Health Authority will administer the program. Harris will employ a Direct Secure Messaging System to exchange information through any internet-enabled device, meaning that patient data will be available to practitioners on everything from laptops to mobile phones.

Other additions to the data exchange in the next phase may include:

  • Data exchange between EHR systems.
  • Record search through Master Patient Index Record Locator services.
  • Connection to federal systems, including those managed by the Department of Veterans Affairs and the Social Security Administration.

Similarly, Washington State has instituted their version of Health Exchange, One Health Port Health Information Exchange (OHP HIE). According to, “This integrated physician/hospital partnership provides patients the highest quality care through a sustainable healthcare delivery system made up of over 17 partnering clinics. This relationship effectively and efficiently meets the healthcare needs of the Greater Yakima Valley region and its people.”

Participating physicians and clinics, or trading partners, will be updated regularly and posted to the One Health Port website in the Practitioner Level Provider Directory.

In addition, to ensure the availability of data transactions, OHP HIE will include a Washington State HIE Entity Level Provider Directory. This directory will list any organization wishing to post the HIE or HIO they participate through, what transactions they are prepared to send and receive, as well as routing addresses and technical contact information for each entity.

With Meaningful Use providing benefits to health care professionals across the country, an increase in state-specific data-exchange programs like those above is likely to continue and will alter the way health care information is transmitted and processed.

No Comments

Posted in Medicare


How Patients Can Help ACOs Save Money

16 Aug

There are many ways ACOs can save money in the healthcare industry from an administrative perspective. But some of that savings will depend on patients being faithful to their medications, according to a new report.

For example, the report found that if more diabetics took their medication, a Medicare ACO with 10,000 seniors could save $1.1 million on emergency room and hospital visits every year. While thay may not sound like a lot on the national level, that’s only one example. And when you look at it on a national level, the study conservatively estimates $4.7 billion savings a year overall and $2.2 billion to Medicare. The estimates are deemed conservative because the study only included the savings from the cost of hospital stays and emergency room visits, not outpatient care.
While it’s ideal to hope that people will do this independently, there has to be an outside catalyst, if patients do not keep up with their medications already armed with the basic knowledge that it will improve or maintain their health. The researchers did n’t estimate the cost of interventions to boost drug adherence.
“As accountable care organizations and other similar entities form and take greater responsibility for the health and spending of an entire population, focusing on better adherence may be a high-yield activity,” wrote the authors in their report.
The study, published in the journal Health Affairs, examined how closely patients follow their prescriptions. The researchers did so by analyzing three years of data for 135,640 diabetes patients. They tracked changes in prescription use during the first two years (2006 and 2007) and examined hospital and emergency room visits in the third year (2008). They also took into account that some patients could be more ill than others. 
For those patients who didn’t follow their prescriptions during the first year, but who properly took medications in year two, the likelihood of a hospital or emergency room visit dropped 13 percent. The average cost per emergency room visit and hospital stay were $1,502 and $11,575 respectively.
Those patients who started on the right foot and took their medication correctly, but did not continue to do so, the likelihood of a hospital or emergency room visit jumped 15 percent. 
As for how to improve adherence to prescriptions, unfortunately the study did not go down that road.

Tighter Controls on Diabetic Supply Claims

19 Jul

Providers and suppliers will be under greater scrutiny when submitting claims for large numbers of test strips and lancets, thanks to an Office of Inspector General (OIG) June 2012 report. The OIG report estimates contractors overpaid as much as $271 million for these types of claims in 2007. In response to the report, contractors say they have made appropriate changes, or plans to do so.

Home blood-glucose test strip and lancet supplies are covered by Medicare Part B for physicians who prescribe them for their diabetic patients.
While the National Coverage Determination (NCD) does not specify utilization guidelines and documentation requirements, Local Coverage Determinations (LCDs) for the four related contractors reviewed by the report (NHIC, Corp., National Government Services, CIGNA Government Services, and Noridian Administrative Services) – state that Medicare covers up to 100 test strips and 100 lancets each month for insulin-treated diabetics, and 100 test strips and 100 lancets every three months for non-insulin-treated diabetics.
Medicare considers 50 test strips as one unit and 100 lancets as one unit. This means a standard claim for a patient’s monthly (or three-month) allotment of these supplies would be two units of A4253 blood glucose test or reagent strips for home blood glucose monitor, per 50 strips and 1 unit of A4259 Lancets, per box of 100.
To be reimbursed for a claim that exceeds these guidelines, there must be documentation that supports the reason for additional supplies and documentation in the physician’s or supplier’s records that supports the frequency of testing. The doctor must also have seen the patient and evaluated their diabetic control within six months prior to ordering the excess supplies.
No Comments

Posted in Medicare


Medicare and Insurer Revenue Growth Jumps

03 Jul

According to the Standard & Poor’s Healthcare Economic Indices, healthcare professionals and hospitals saw accelerated per capita growth in revenue from Medicare and commercial insurers in the past 12 months ending in April. S&P’s healthcare composite index for that 12-month period jumped by 6.14 percent as compared to a 5.65 percent increase for the 12 months ending in March.

Breaking revenue changes down into public and private sources, Medicare fee-for-service revenue for hospitals and healthcare professionals were up by 2.6 percent in the 12 months ending last April. Commercial revenue saw a more dramatic change with an 8.46 percent increase.

“There is a clear upward trend across all annual growth rates, which began around October 2011, and we have now reached close to the top of the range of price changes established over the last few years,” said David Blitzer, index committee chairman for Standard & Poor’s Indices, in a news release. “The April increase in the composite’s annual growth rate was largely driven by a substantial jump in commercial plans.”

According to Standard & Poor’s, one of the primary purposes of their Healthcare Economic Indices is to help medical professionals and the public as a whole better understand the costs associated with healthcare. Over the last 10 years, trends of annual cost increases have varied from mid-single digits to mid-teens.

1 Comment

Posted in Medicare


Medicare Coverage Problems Arise with More Observation Stays

13 Jun


Hospitals all over the U.S. are labeling their patients as outpatients under observation. According to a new study, that is causing problems for people who are being covered by Medicare.
Over the last 10 years, the Center for Medicare & Medicaid Services (CMS) has put a greater emphasis on detecting Medicare fraud and curbing costs via hospital audits, which includes audits of short hospitalizations. 
According to research from a Brown University study (and maybe some good old fashioned common sense), this has lead to an increase in patient observation stays (different from a hospitalization), since hospitals can avoid an audit if they do so. The researchers found a 34 percent increase in the ratio of observation stays to inpatient hospitalizations among Medicare beneficiaries between 2007 and 2009. Also during that timespan, there was an 88 percent jump in Medicare patients held for observation stays for 72 hours or more.
Trying to reduce the number of inpatient hospitalizations may have the good intention of reducing fraudulent or medically unnecessary healthcare expenditures, patient advocates say this leaves Medicare recipients in the lurch with large and unexpected expenses.
Hospitals walk a difficult tightrope between criticism on the patient advocacy front when they appear to increase observation stays at the expense of patients and auditor with the CMS if they don’t.
The California Hospital Association states on their website that hospitals “face criticism from patients and CMS over the perceived use of observation status as a substitute for inpatient admissions, but risk penalties from CMS auditors and prosecutors when auditing admissions of short inpatient stays.”

CMS Proposes 2013 Pay Rate Hike for Hospitals

30 Apr


The Centers for Medicare & Medicaid Services (CMS) just issued a proposed rule to update 2013 Medicare, which includes a payment rate increase of 2.3 percent for inpatient stays at general acute care hospitals. The increase would raise total Medicare spending for inpatient hospital care by about $175 million.
According to a CMS statement: “The rate increase, together with other policies in the proposed rule and projected utilization of inpatient services, would increase Medicare’s operating payments to acute care hospitals by approximately 0.9% in fiscal year 2013.”
However, there is also a provision to reduce payments by two percentage points beginning in fiscal 2013 for hospitals that have excess readmissions for MI, heart failure, and pneumonia.
CMS is also proposing medical coding additions to the existing Vascular Catheter-associated Infection HAC category, ICD-9:
– 999.32 Bloodstream infection due to central venous catheter
– 999.33 Local infection due to central venous catheter
Those LTCHs that fail to meet the quality measures will see payment rates cut starting in 2016.
The proposed rule would also include a one-year extension of the existing moratorium on the “25 percent threshold” policy, pending results of an ongoing research initiative to redefine the role of LTCHs in the Medicare program. Currently, the legislative moratorium expires at the end of 2012.
The American Hospital Association (AHA) responded by saying: “While we commend CMS for delaying the full implementation of the 25 percent rule for long-term care hospitals (LTCHs), we are troubled that the delay does not fully apply to all LTCHs this year. Leaving the proposal as is could arbitrarily prohibit some patients from receiving needed long-term care.”
A final version of the proposal is expected to arrive on August 1. CMS will accept comments on the proposed rules until June 25.

CMS Picks First Medicare Shared Savings Program ACOs

19 Apr


The first 27 accountable care organizations (ACOs) to fall under the Medicare Shared Savings Program have been chosen by the Centers for Medicare & Medicaid Services (CMS). Accountable care organizations are one of the more talked about items in healthcare reform. They are being created to bring about financial incentives for doctors, hospitals, and other healthcare providers to better coordinate care, lower their costs, and improve the health of Medicare beneficiaries.
Among the 27 healthcare entities in 18 states are more than 10,000 physicians, 10 hospitals, and 13 smaller physician-led entities. They are estimated to serve more than 375,000 beneficiaries. According to the CMS, this most recent ACO announcement increases the number of Medicare beneficiaries participating in various shared-savings initiatives to 1.1 million. In January, the modified Pioneer Model ACOs (32 healthcare groups) and six Physician Group Practice Transition Demonstration organizations were launched.
“There were some people who feared that the only entities that would participate would be hospital-dominated systems,” said Jonathan Blum, Director of the Center for Medicare at the CMS. “That has not happened.”
It was announced by the CMS last summer that 7 out of 10 physician groups that participated in the their Physician Group Practice Demonstration achieved benchmarks on all 32 performance measures in the fifth year of the project. However, a January Congressional Budget Office report on 10 ACOs and disease management initiatives found insufficient savings to offset cost.
Blum expects the new ACOs to have more success controlling healthcare costs than similar payment and delivery reform pilot projects previously authorized within Medicare. 
“We are encouraged by this strong start and confident that by the end of this year, we will have a robust program in place, benefitting millions of seniors and people with disabilities across the country,” said acting CMS administrator Marilyn Tavenner in a written statement.
No Comments

Posted in Medicare


CMS Proposes 2012 Changes to Payment Policy and Rates

02 Jan

The Centers for Medicare & Medicaid Services (CMS) has made public their proposed rules that will affect doctors, hospital outpatient departments (HOPD), ambulatory surgical centers (ASC), and suppliers of renal dialysis services in 2012.

Highlights from the proposed rule changes include updates to payment policies and rates for 2012 and measures being taken to continue to implement the provisions of the Affordable Care Act meant to improve the quality of care, but also reduce government spending.

Under the law as it is today, Medicare payment rates for physician services face a 29.5 percent reduction in 2012 based on the Sustainable Growth Rate (SGR) formula. Along with other advocates, CMS is against this reduction, which means it is unlikely that physicians will receive such a drastic pay cut.

“Today, the Centers for Medicare & Medicaid Services (CMS) issued proposed rules that spell out how this cut is calculated and warned that if Congress does not act in time, doctor fees will be slashed come January 1. We cannot – and will not – let this happen,” wrote CMS Administrator Donald Berwick, MD on

The Medicare Physician Fee Schedule rule proposed for next year would also update a number of physician incentive programs, including the Physician Quality Reporting System, the e-Prescribing Incentive Program, and the Electronic Health Records Incentive Program.

You can view the proposed changes to these physician incentive programs over at the
Centers for Medicare & Medicaid Services website. Some of the highlights include:

– Expansion of its multiple procedure payment reduction to the professional interpretation of advance imaging services to recognize the overlapping activities that go into valuing these services

– Revision of the criteria for a health risk assessment (HRA) to be used in conjunction with annual wellness visits (AWVs)

– Expanding of the list of services that can be furnished through Telehealth to include smoking cessation servicesRevisions to the quality and cost measures that would be used in establishing a new value-based modifier that would reward physicians for providing higher quality and more efficient care.

1 Comment

Posted in Medicare


2012 HCPCS II Now Available, More Than 430 Changes

16 Nov

The Centers for Medicare & Medicaid Services (CMS) recently released the HCPCS Level II codes that go into effect January 1, 2012. Among the changes are 285 code additions (plus one new modifier), 48 revisions, and 75 deletions. Another 18 codes were added and eight deleted throughout 2011.

The policy requires hospitals to combine the charges and appropriate codes for any outpatient diagnostic and “related” non-diagnostic services, not including ambulance and maintenance renal dialysis, provided within the three-day period immediately preceding an inpatient admission.

Many C and Q codes have been deleted and replaced by new J codes, including C9272 being replaced by J0897 Injection, denosumab, 1 mg; Q2040 replaced by J0588 Injection, incobotulinumtoxin A, 1 unit; and Q2042 replaced by J1725 Injection, hydroxyprogesterone caproate, 1 mg.

There have been a few C codes added for 2012, including C9287 for the lymphoma drug brentuximab vedotin and C9366 for the membrane/skin allograft EpiFix®. Similarly, there are fewer than a dozen new drug/supply Q codes for 2012. Among them are Q0162 for the anti-nausea drug ondansetron, Q2043 for sipuleucel-T, a therapeutic vaccine for prostate cancer, and nine new codes (Q4122-Q4130) for skin substitutes such as Dermacell®, Alloskin™ RT, and Talymed™.

  • A series of new E codes (E0988, E2358-E2359, and E2626-E2633) describe various accessories (e.g., batteries, arm supports) for manual and power wheelchairs.


  • Four new K codes (K0743-K0746) have been added for home suction pumps and supplies for wound healing (i.e., negative wound pressure therapy).


  • G codes for telehealth consultations (G0425-G0427) have been revised to apply both to initial and emergency department services.

The largest number of changes (209 additions, 27 revisions, and 28 deletions) affects G codes used to report quality indicators for the Physician Quality Reporting System (PQRS). Eligible professionals (EPs) who successfully report on quality measures in the PQRS are eligible for a 0.5 percent Medicare payment incentive for years 2012-2014. In 2015, EPs and groups that don’t report quality data successfully will face a 1.5 percent payment reduction in Medicare payments, and a two percent reduction for 2016.