Section: CME Category: Practice Management

Medicare Update Part 1

Gabriel Halperin, DPM

Gabriel Halperin, DPM discusses new CMS updates in 2019, new auditing tools initiated by CMS, new expectations by Medicare regarding documentation, as well as reviewing the sources available to accurately code for services in private practice.

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  1. List the auditing tools that CMS initiated to potentially take money back from providers
  2. Report and understand the new CMS updates
  3. Recognize the Medicare Carrier’s expectations of clinicians’ documentation
  4. Review potential new services that can enhance, ethically, clinicians’ office income
  5. Review the sources available to accurate coding for services rendered to patients
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  • Lecture Transcript

  • MALE SPEAKER: Alright. Our next speaker is Dr. Gabriel Halperin and Dr. Halperin is going to be going into Medicare Update part one. Probably a lot more important, too, than what I just shared with you on Lapidus Bunionectomies. He is the Past President of the Los Angeles Podiatric Medical Association and the Los Angeles County Podiatric Medical Society and he is the President and Medical Director of the New Hope Podiatry Group in LA. Please welcome Dr. Gabriel Halperin.

    GABRIEL HALPERIN: Hello. I’m back. The talk today is going to be on Medicare Update. It is 45 minutes today and another 15 minutes to… maybe 30 minutes tomorrow. I have about 30… no, I have about 250 slides. So, I’m going to be sliding by a couple of them. The presentation itself is complete, but I’m going to skip over certain slides because people look at the written material later to get other information. But I’ll be going over the highlights.

    You’ll be able to get the information the… in all these years, we always have the printouts, but we don’t do that anymore. So, it’ll be on the LA County website, LA… and by the way, it’s LA County Podiatric Medical Association because we’re big. So, we’re associated. So, it’s LA County Podiatric Medical… so, lacpma.com. And on that, you would pick… I think it’s a Medicare Update 2019 and you’ll be able to get this, plus source materials like the LCDs, the articles, and some other lectures that we put together in past years on routine footcare and other aspects of billing.

    So, let’s get started. Disclosures. I have to do a disclosure. I, nor my family have no financial relationships to disclose. [00:02:01:09] I don’t think that’s normal English, but I got it in there. These are my disclosures. Hello? There it is. Almost everything I say today is not my opinion. So, find someone else to blame. If I err, I am human. Don’t hurt me. Although I am wearing Kevlar. And I’m still married to a beautiful genius because without my wife as my partner, she’s a CPA, not a podiatrist, I never would have been the success that we have been today.

    To those of you that heard that I sold my practice, I did. I sold my podiatric practice to Dr. Charles Anunyon who’s been my associate for many, many years. Dr. Anunyon has that part of the practice. I am still in practice. So, I am still going to feel all the pain that everybody else is feeling, maybe more so because it’s more wound care and you know how painful that is. However, I still own and practice through a wound care company, so I’m not out of practice. Plus, I continue seeing trauma patients. And the reason why I’m still practicing is because my wife doesn’t want me at home. It makes her nervous.

    Learning objectives. Be aware and understand how new, crazy, and not well-thought out stupid ideas that CMS is bringing on us. Basically, I’m going to discuss today how we are screwed, but how we could survive through it. Understand the auditing tools that CMS brings to take back the income that we work so hard and bringing home to feed our children. Does that mean that we have to feed our children less? Well, if they are overweight, we may consider. We also have to be aware of the Medicare carrier’s expectations for our documentation, introduce potential new services that can enhance ethically our office income, and know what the sources are available to us code correctly for services rendered and we’ll be going over all of it. [00:04:00:09]

    My personal contact information is up here. But I’m going to the next slide, so you can’t copy it. Did you get it already? Okay, good. I am going to the next slide then. Does this thing work? Maybe? Of all the slides, that had to stay up.

    Okay. Manuals, the manuals to keep in your office. Now, this is important because when we get audited, they look for these manuals. The Medicare Compliance Handbook, the HIPAA Handbook, the Employee Handbook, the OSHA Handbook. How many people have thought about OSHA? I mean, I haven’t thought about it in 15 years, but you got to have it, and you need to mention what coding manuals or services that you use, and you have to put it into your Medicare compliance handbook.

    Every one of these is available on the APA member section. These are the old tools of the trade. I kept these and I mentioned it in all of our compliance manuals, the CPT, the hick picks, the ICT 9 code manager.

    I don’t have anything anymore, I don’t have any of it, because I use the … I use the APMA coding resource guide, and although you have to pay for it, it’s worth it. Does everybody here go … have the APMA resource? Hands?

    Okay, there’s a lot of people that don’t, but you benefit from it certainly. So these are my sources where I come up with these stupid lectures. Carrier Advisory Committee, I am your CAC rep, which means I represent our association to Noridian, and I’m part of a team, Dr. Tony Opogio, is Chairman of that committee and he goes to the Northern California, I go to Southern California.

    The Noridian Carrier Meetings that we go to, APMA alerts, APMA health affairs committees, the National Pontiac Medical CAC meetings, it means that all the CAC members from all over the country go to Baltimore and stay at a very sleazy hotel, and they give us no food, and it’s really nasty. [00:06:10] And then we have … and then what we do is meet, and we discuss, and we have speakers come in, like medical directors from other … the other parts of the country come in and talk to us about how to get along with your medical director.

    What they don’t know is that our medical director is actually one of our best friends. He’s looked out for us for years. He’s been our medical director for 20, 30 years with different carriers. He’s also a personal friend of mine and he respects Tony. So we have great relationship and I email him on a regular basis with the problems I hear about you guys, as well as questions and potential problems. By the way, he sends his regards, and he says that podiatrists are not in trouble this year.

    We haven’t been in trouble for a while. It’s a good thing.

    Also, the Noridian bulletins, I actually read all these things because my wife doesn’t let me bring anything else into the bathroom. And PM news.

    Now, here’s the APMA coding resource center. There are no books needed anymore, anymore. It’s online real-time. When you get online, you will be able to get access to your CPTs, your ICT-10s. You could do your … what do you call it? CCI edits. Does everybody know CCI edits? Does anybody know what a CCI edit anymore? One person, oh my … two people. Okay. And it’s Paul. Of course he knows CCI edits.

    CCI edits mean, many years ago, surgeons, not necessarily podiatrists, all surgeons were billing for different parts of the procedures that are being done. Like in appendectomy, they use to charge for the incision, the opening, the identification, the cutting, the suturing, and closing up. [00:08:04] Well, you can’t do that, it’s called bundling. So CCI edits were created to pay for one thing, but the CCI edits went crazy. They call it a black box. We can even identify how they do it. So similar things we do. For instance, you do a bunion on the left foot and a hammer toe on the right foot, they’ll bundle it as one payment, saying that it’s the same procedure.

    Well, that’s stupid. So to get around it, you could use the 59 modifier, and that’s where the 59 modifier came from. Well, unfortunately, you never really know how to use it, and if you have two surgeries, which one do you do the 59 modifier on? You can’t use it on both. So what we … so there are … so, well, there are books, and on the APMA coding resource center, you put in both codes, it’ll come out, and they’ll have columns, column one, column two, like Chinese food.

    Column one is the original code, column two is the 59. Any CPT codes you identify on the second column gets the 59 modifier. So it helps your coding. So this is something that we don’t want any books anymore, we just use the coding resource center. Also the best part, they do automatic updates and they do … and they have all of our LCDs.

    For members, I think that is $249, non-members, I have no idea. To get more information, not just about that but for anything, you go to APMA website, CPMA website. On CPMA, we don’t have … we don’t own CPMA.org, it belongs to an association of building materials so what we … so they have podiatrists.org.

    Now the handouts that will be uploaded for you will be this lecture, my lecture from 2018, Building Pairs for At-Risk and Pain Foot Care for the 59 modifiers. [0:10:05] My MIPS PowerPoint and resources, the EM documentation PowerPoint. If you think evaluation management is not important, boy, I got news for you, it’s going to be even more important, especially since the changes that they’re going to have in Medicare. At-risk routine, foot care, billing encoding PowerPoint, symptomatic keratoma and ulcers lecture and all the LCDs that pertain to us, and articles that Medicare write to clarify the LCDs.

    We also have a grid for routine foot care to where … again, to where … to explain where to put the 59. And I also put in my office template for at-risk and routine foot care for nail debridement. This is important because it’s gone through auditing. It’s been accepted, we’ve never had to pay back, we’ve never had to … we never had a denial of services for that, so it’s something that people like to use.

    I will share with you that I think … I talked about it before that I got audited about four years ago, because it takes that long to go through the process. And they found $300,000 off of my office because I was using my documentation from my wound care, was not … did not match the LCD. I wrote the LCD, so I knew something was really wrong. And we found out that the LCD that they were using was from part A, not part B. No one knew that there was an LCD, somebody found it somewhere under a book or something.

    So I went to the redetermination, reconsideration, no … I lost on those cases. I went to the ALJ. And when I went to the ALJ, I won every cent back with the exception of one chart because the person didn’t fill it out correctly, so I let them have one out of hundreds. And I won all the money back plus interest. [0:12:00]

    So I want to let you know that the ALJ is real, your appeals are real. And if you don’t appeal, then you’re really falling into the … and a lot … if you don’t appeal, the money that you paid back is reported to Congress as fraud and abuse. Not you particularly, I mean, they don’t have your name, but they do… but they will… it will go to the total.

    When you appeal, you are asserting you are right for the money that you are working for. And the ALJ doesn’t work for Medicare, it’s a private judge. And I think the statistic show that almost 85% to 90% of the time, they overturn the denials. So it’s important for you to go back and do your denial… do your appeals. Does everybody appeal on a regular basis? Everybody? No, nobody’s raising their hand. Three people raised their hand.

    Okay, LACPMA website, LA County Podiatric Medical Association, lacpma.com and go to Medicare update 2019 and you’ll also get all the resources that we’re uploading.

    This is my office and the guy on the left is Dr. Ananian, Chuck. The rest, I think they’ve been fired by now. No, they’re all there, they’re all there. The guy on the right is our coder. We have a professional coder who’s here today. And he helped me on the MIPS section because every time I see MIPS, my brain freezes and I can’t think and my blood pressure increases, so he was able to go to work with me on that. We all know that we are an association not a society.

    Okay, let’s go into denials. We wanted to avoid unspecified ICD-10 codes. Why do we use unspecified ICD-10 codes? Because we don’t have to figure out left foot, right foot, new problem, old problem, so we use unspecified. But the problem is that, Medicare is not going to be paying for that. And if they do, eventually, they’re going to find out and they’re going to audit. [0:14:01] So just use specified codes. Use the entire ICD-10.

    Nail and callus are going to be paid, painful and painful, as well as at risk, at risk care will be paid for vascular neurologic immunocompromised and anticoagulation. An ICD-10 uses… those of us that are old and use the ICD-9, ICD-10 crosswalks are still online.

    Never trust the CPT codes, nor the ICD-9 codes given to us by the vendors, either for a new service, or a new device, never, never ever. And the reason why is, they’re wrong most of the time. And as a result, what happens is you can’t say that. When you do your… when you do your PL, you can’t say I was given a wrong information. They don’t care, I mean, the buck stops with us, not the vendors. So it’s important to go ahead and get it corrected, get the correct numbers. Check it out either with the CAK up… me, no, better talk to Tony, and by the sources you have in your office, and contact Noridian for information too. Noridians are really friendly.

    When it comes to audits, and you get a CAK, you know, you get a… you get one of the audits. One of the audits is not auditing you as an individual, it’s auditing Noridian, and as a result, they’re very, very interested in you passing that audit. So they actually will help you. If you talk to them, send them the information, they’ll tell you what you need to do to pass that audit. I mean, don’t make up your stuff but…

    Dual-eligible, we still see dual-eligible patients, does anybody? Dual-eligible. Well, duel-eligible, you may have lost the patients to an HMO that you’re not with, but you have a continuation of your care for six months. You have six months of continuous care. It was written into the policies. So you want to make sure that you continue seeing the patient. [00:16:00] You have to contact the HMO they signed into, and they will send you a card out, a little card of agreement to continue care usually for the same treatment plan, for the same diagnosis. Use that time to spread rumors and have them dis-enroll. Besides we’ll get this enchanted anyway.

    MIPS, does anybody participate with MIPS? Everybody? Anybody? Okay. I don’t want to worry about the potential penalty, well, that’s… I’m saying that wrong. I’m not worried about the potential 7% incentive that will be in two years. I’m worried about the penalty because there’s no way I’m going to get an incentive. So, let’s worry about getting out of MIPS with our skin still attached.

    Now, those of you… does anybody belong to an ACO, an advanced ACO? Okay. I sort of why, I belong to Regal’s ACO. I will tell you that even though you belong to the ACO, you are not immune to MIPS. Because the only persons that will be able to skip MIPS because they belong to the ACO, because this is what people are talking about, are the primary care providers as defined by Medicare. We are not, we are specialty. So we, with the ACOs, the next gen ACOs are preferred providers, but we are not partners. So as a result, even though you do belong to the ACO, you still have to use MIPS.

    On the SNF, just the same thing, nothing’s changed. No standing orders. You can’t be a standing order, it has to be a TO. If you’re going to a nursing home to do debridement, you will need a telephone order on the chart for your services. The standing orders on admission are not accepted by Medicare and they will fail on audit. If you do greater than 12 nail debridements in 24 months, consider a culture even though we really don’t need one with our policy, but consider one. [0:18:03]

    Use EM to describe the pain or danger to the patient, in other words, you’re not going to use an EM on every visit, but you’re going to use it when there’s a separate identifiable problem. So if there… if you are giving… if you’re also dealing with dermatitis or they’re dealing with a small infection, whatever it is, use an M code, but don’t do it on every visit because it will spark an audit.

    How do these spark audits? What they do is they use computers to look at potential abuses. A human doesn’t even look at it until it’s spit out. But the … but they use complex algorithms to identify abnormal usage.

    Most denials are based on eligible notes and eligible signatures. I’ve seen the notes. They are amazing. Like every word is just a straight line or it’s like crayon. Eligible signatures are even worse. I mean, mine, too. So, what you would … I’ll tell you what to do for those.

    All these can be prevented or appealed. Most of the denials include not using the appropriate documentation from the LCD.

    Everybody know what an LCD is? Local carrier decision? It is a roadmap on how to get paid. They tell you what to say, they tell you how to bill it, and they tell you the codes for billing and the diagnosis codes. People still put diagnosis codes that are not in the LCD. It gets denied.

    So the eligible note can be transcribed, right? Someone talked to somebody today. If your note is eligible, just transcribe it, write it out. But don’t put that down as the original because they know better by now. What they do is just say, “Transcribe notes.” Literally, a translation into English. Date and time, and sign the transcribed copy.

    Again, attach the written note. [00:20:00:] When you date and time that piece of paper, date and time it with today’s date, not the date of the treatment.

    We all know the levels of appeal. It’s redetermination, reconsideration, and ALJ. Correct? Plus, they also have a re-opening on the first part of the redetermination if you made an error in the way that you were billing. If you were billing the wrong number, the wrong ICD-10, you don’t have to … you could re-open it by phone and give them the correct code.

    Okay, eligible signature. This is something that goes back to the Medicare Compliance Book. You have a signature page. All you do is just write your signatures, all the ones, all the crappy ones, all the stuff where just was like a loop with a hole in it. Put it all in there because that’s what you can send back with your notes and that will allow your eligible handwriting to be approved by the nurses looking at your notes. And it makes no difference how or where the scribble is.

    Now, they only gave me 45 minutes to talk today. I’ll be finishing it up tomorrow. I only have 35… no, I only have 250 slides. We’re at slide number 26. This doesn’t help. [Laughs] Okay.

    Now, when you get audited, they not may… they may not be looking at you. They may be asking for other reasons. For instance, they may be auditing the hospital, the lab, the pharmacy, and the radiology group, and the physical therapy. So in there, all they want is the reason why you sent the patient for those services. You don’t have to write a thesis, an outline. One word can do it. But they just want some medical necessity to carry out … to pay these other people. They want to make sure that the referral was real. [00:22:02] And believe me, a lot of referrals or not.

    The auditing for diabetic shoes, they were saying the MD needed to perform the foot exam. They were proved wrong. It’s gone back for recalibration, which means they may have shot their nurses and brought some new nurses on board. I don’t know what they do.

    I want to go … I only have a couple of slides of this. I don’t know how many people do routine foot care in their offices. But if you don’t, you’re missing a tremendous amount of money and … as a revenue.

    At-risk routine foot care. If you’re going to do that, don’t use the 11719, use the G0127. I check every year and this is what they pay now. So the G code pays 2787, the 11719, 1641, these are trimming codes. Trimming codes. I never use trimming codes by themselves, but I’ll show you how we do use them. And only one nail trimmed, which is kind of a normal nail or a dystrophic nail, when you cut it straight across, allows the use of that code. Only one nail. And I use the G code along with the 1172, and I charge 50% for it.

    If you’re going to take pictures, make sure you get my best side.

    Okay. Now these are the new fees. The fees for covered foot care, 99212 is 5091. Anyway, I’m not going to go through all of them, but I will happily tell you that the debridement codes of the calluses went up almost $10 each, which is pretty good.

    Overall, I’ll share with you, with the new price on the physician payment schedule, podiatrists went up to 2%. We got 2% increase. [00:24:00] Because of the … what do you call it? The 2% they take away every year? Sequestration? So we got nothing.

    Okay. But remember this, options for routine foot care services, it either is painful or at risk. If it’s painful, it’s a debridement of painful mycotic dystrophic nails, debridement of painful calluses or corns, and you have codes for that based on the LCDs. If you have to debride or wedge resection a painful, normal nail, there is no code for that. You can’t use a nail code, but you could use an EM code.

    If you use an EM quote to describe the cutting of nails routinely on, let’s say, an at-risk patient, technically, when you get audited, if you get audited, they’re going to ask for the money back because you didn’t use the correct coding. Not only that, it was stupid, because you get more money for the debridement codes than you would for the EM quote.

    And at-risk conditions, you use the debridement of mycotic dystrophic nails, trimming of normal nails, and debridement of calluses and corns. So everything you do will get paid, and you could charge for everything. So for instance, on this particular patient, they charged a third level office visit, $82. The debridement of one corn, debridement of, let’s say, one dystrophic or mycotic nail, and trimming of the others nails brings you $97.38.

    Which one would you rather have? Any hands?

    Now, documentation is super easy on the debridement code. But if you get audited on the visit, you have to have all the bullet points that support the visit, a third-level visit. Do you really want to have to do that? Although, if you electronic medical records, you might be able to, but then, you know, there’s always cloning and those problems with it. So this is a whole lot easier. And I gave you a form that you could use in your office or modify to make it super easy for yourself. [00:26:01]

    Potential … let’s say, the 98597 code for the debridement of an ulcer, which is $104 this year, plus one callus, plus one nail, abnormal, plus one normal nail was $174.94, or you could get 50 bucks for a level two visit. And you get audited on the level two visit, which is totally unfair.

    If you noticed, I’ve never used … well, I put it in here, though I don’t use it, the 11721 code, that $51, it’s not worth it. 11721 is on the hit list from OIG this year, for sure, and it’s also on the hit list for Medicare. Medicare and Noridian, and all the others, are looking at that. Just don’t use 11721 on more than a few percentage of your patients, maybe 10%, 20% of your patients. Try not to do it. I would rather down code with the 11720 and then use and up code a little with the G code, and I’m going to get almost the same amount.

    MALE SPEAKER: Even with vascular?

    GABRIEL HALPERIN: I’m sorry?

    MALE SPEAKER: Even with vascular?

    GABRIEL HALPERIN: Even with vascular?

    MALE SPEAKER: Yeah.

    GABRIEL HALPERIN: Well, either with the … each vascular … either at-risk or pain, either way, I’m going to do good.

    California is one of the few states that pays for pain. The rest of the country doesn’t. However, they have been coming … they’ve been changing to what we’ve been doing. So now, the rest of Noridian, which are, you know, they’re half the country, will probably come on board as well.

    Okay, Medicare policy updates. This is the good stuff. Podiatry EM codes. You didn’t know this but Medicare was toying with the idea of taking us away from the EM codes and give our … giving them … giving our profession our own EM codes, where they can then downgrade it because they’re going to separate us from our brothers and sisters in the medical community. So there was an uproar, a complete uproar, the American Medical Association, our state associations, everybody fought it and they relented, so that we stay … we’re staying with the same EM codes. [0:28:10]

    The bad part is that Medicare is taking away the EM codes. [Laughs] They’re converting it. The level two, three and four are going to be eliminated to one code, and the five code would be adjudicated separately. With that, everybody says, “Well, what’s going to be in the documentation?” And it looks like if you document to a level two code, you have met the requirements of the two, three and four.

    Now, because of that, it sounds terrible, doesn’t it? But our APMA money people, a number of people got together and they found out that our association, Podiatrists, will have an average of a 10% increase …

    MALE SPEAKER: 12%.

    GABRIEL HALPERIN: 10, I checked it, 10. 10% … because I copied their lecture. [Laughs] When you rip it off, yeah. 10% increase in the EM codes. So we’re bound to do better. We’re going to do better regardless. So I just want to let you know that if there’s bad news later, because it is in the works for 2020 that they’re going to be doing this, we’re still protected.

    However, how you document now is being discussed, whether it be a medical decision-making, whether it be … do you remember the ’95 and the ’97 techniques of documentation? Does anybody? Us old people, we know that. Anyway, we are … I didn’t need to call you old, you’re younger than I am, but …

    FEMALE SPEAKER: I know.

    GABRIEL HALPERIN: So …

    MALE SPEAKER: God is younger than you.

    GABRIEL HALPERIN: God is younger than I am? [Laughs] Yes, I taught him everything he knows. [0:30:00]

    It will be out there. One of my … one of the lectures in the source is documentation for ’97, so you’ll have that.

    So what I’m saying is that, we may need to change the way we document, we may need to change the way that your electronic medical record is documented, so… but to let you know, we’ll be on it.

    The impact of the conversion factor, as I told you, it’s 2% for podiatrist in 2019. And this is the consolidation, so effective in 2020, effecting the initial and established visits, level five will be handed… will be separate. They have put together the two, three and four level codes initial and follow-up. And we’ll have alternative documentation rules, they’ll be coming out. And… but I know for a fact that ’97 is more favorable bullets. It’s a more favorable to us so I suggest that you study the ’97 documentation and there is a lecture on that documentation in your resources and there’ll be more information. And again the estimation that this will be affecting podiatry is either 10% or 12%. Thank you.

    Merit based and incentive payment system, final rules. They continue to transition to a full MIPS, by this time, we are in full MIPS, which means like, full heart attack. It continues to seek opportunities to reduce burdens, this is all propaganda. And they use meaningful measures which we know are not meaningful, but they have included un-meaningful, stupid things for opioid use as well. And they changed… do you
    remember ACI last year, for computer… for the computer part? They changed it to interoperability, and they made a new word. And that is still… that computers will be able to talk to each other. So are our computers talking to each other at all? [0:32:01] No, so it’s non-interoperability.

    The definition of the eligible conditions has expanded to physical therapist, occupational therapist, and other people. As far as the low threshold, the covered part B professional services, 200 services or less will bring you… will bring it to a point we don’t have to participate in MIPS, it’s for new practitioners. And also, there’s an optimum capability that of those three low volume thresholds, if you do… if you have two but not three, you can opt in to MIPS. And the reason for that is because in MIPS later on, they’re going to judge the doctors, will have a star system like the nursing homes. So as a result of that, you’ll be in a good boys list or a bad boys list, or a good girls list. So as a result, some people who can’t get to that volume of patients, where they have to do MIPS are… will volunteer to be in MIPS.

    Virtual groups, not well understood but individuals, individuals are in small groups can get together, and create a virtual group. They’re not practicing together but they get their data and put them in together. I’ve seen no reason for it, but it’s in there.

    And finally, the facility based measurements for quality and cost based on the point of sys… the point of practice on in-patient, emergency, and on campus. It means that if you are teaching, if you are teaching, or you are based on a hospital, they have finally have the ability for you to participate in MIPS.

    Nursing homes, part of our practice is the wound care, the wound care company that goes to nursing homes, that’s the part that I still, I still have. That one… every doctor participating participates in MIPS. So even a nursing home, they could still participate.

    The performance category, quality is going down, well, quality is going down. [0:34:00] Quality is going down from 50% to 45% because it went to cost. Cost is increased now to 15%, not 10% a movement that… improvement of activities are still 15%.

    Do you remember last year? I told you to get to the lower threshold of MIPS, where you won’t be given… they won’t make… take money away, all you did after… all you had to do is get to the 15%, and you could do that with one high… was it one high rated performance, new performance. In my office, we chose the performance of 24/7 records, in other words, we always have people on call, and we have access to the patient’s medical records, which we all do because of VMR. So we got all of the performance points which goes to 15%, which meant that we didn’t have to do anything else.

    My office also got a waiver for ACI because we’re small group. Small groups get waivers for the advancing information or now called interoperability. It means that my computer system was not being rated. I didn’t have to enter that.

    We also got a, not a waiver, but we entered in small groups, small groups, individuals or group can double the weight of the improvement. In other words, the maximum improvement is about… I think the maximum improvement is 20 points in the improvement section of MIPS. But if you are a small group, it’s doubled, it’s 40 points. Forty points means that you can take the entire section. So what I did was… this shows you the 30-point performance and that will going to take 7 point… 75 points as now. That used to be 70 points. If you got more than 70 MIPS points, you are able to get more money. You will get that 7% plus. [0:36:00]

    Now, it’s 75%, they’re getting more difficult for you to get that plus 7%. I don’t care about the 7% because I know I’m not going to be able to reach it. I just don’t want to give away the 7%, so I want to reach the minimum, which is 30 points, 30 points, not 15. So last year, the 15 MIPS points performance was achieved, exception for ACI for small practices, we did, the 15 MIPS points obtained from quality improvement, we did, but you need a written exemption for small groups to allow two times points in the quality improvement activity. We decided to use the 24/7 access to medical records, we got all 40 points, that translated to 15 points on MIPS, and that’s all you had to do. We passed MIPS.

    Did everybody... we talked about this last year. Did anybody do that? Hello? Good, two people. Thank you. My day is done.

    So you have to make sure you get a high measure, a measure that’s weighted highly, double, due to being a small group, 40 points, and again, this year, it’s 30 points, so you can’t do it with one... you can’t do it with performance, you have to do with something else also. So only few changes, except that 30 point threshold. So we’re getting the exemption for the ACI to get that out, we’re applying for the same exemptions as a small practice, the improvement is still 15%, so we’re still going to do the same improvement quality for the 24/7, and the... but I have to use quality measures to make up the difference. So am I talking over everybody’s head, or is everybody pretty much okay with this? Okay.

    Last year, we used the 24/7 access, but another one that you could use, because we all have to do CURES, is everybody... does everybody have CURES? [00:38:02:03] Hello? Yeah? Okay. So if you have CURES, you’ve already gotten another activity disruption which is CURES... annual registration which we do, and consultation of the monitoring program. You can’t write for an opioid without looking at it. You’ve just consulted. So therefore, you could use that one as well, they’re both weighted high, you could use either. If you don’t have any MR that you have 24/7 access to, use that one, because we, all in California, have met that.

    In 2018, these were the six performance category, quality performance categories that I used, I used DM, diabetic foot care, peripheral neuropathy, I used the ulcer prevention, I used BMI screening, I used at risk assessment, at risk full assessment, false... plan of care, and then I used preventative care and screening for tobacco use. Those are the ones that I use.

    Now, this year, because we have to get a high... we had to get a high a weighted activity, we took out the screening of the tobacco, and we added controlling high blood pressure, and you’re all saying, “How the hell am I going to control high blood pressure?” You don’t have to. By taking blood pressure in your office, and identifying that patient has hypertension, either because they’re not taking medicine, because medicine is not effective, whatever, you are now controlling high blood pressure. So just take a BP, which actually is good for your documentation anyway.

    I’m not talking about these because we don’t have enough time. And besides, it’s all BS.

    Most important, March 2019, the MIPS claims data submission is due. [00:40:02] So you have some time, not much, to get all your MIPS information in for 2018. Very, very important. Got it? Okay. There, I’m almost at the end of the speech here.

    I didn’t understand anything I read here. I had to call Stanus, our coder, and he went over for me. He also gave me a bottle of milk.

    Okay, LCDs. These are your LCDs. This is what we practiced with. Not all of them pertain to us personally. For instance, benign skin lesion removal, of course, that pertains. Injections to tendon, ligament and ganglion, that pertains. Nerve blockade for treatment of chronic pain, that pertains. Nerve conduction study in EMG, not really. But when you ask for it and they don’t want to do it, you’ll have to understand why. You need to read the LCD to make sure that the patients that you are referring for nerve conduction velocity studies will be seen by the neurologist or the physiologist.

    Non-invasive peripheral arterial studies, peripheral nerve stimulation. Does anybody know about peripheral nerve stimulation? Have you been visited by the vendors?

    Okay, there are two types. There is peripheral nerve stimulation, which is real and is even recommended for mononeuropathies, it’s recommended for CRPS type 2 when it’s a mononeuropathy. Then there is peripheral nerve field stimulation. That is not real and that’s not payable under Medicare. So just to remember, if it’s field stimulation, don’t do it. If it’s pure PNS, then it’s real and it’s reimbursable. And this is one of the things that you can do in your practice to make more money, besides marrying a rich person.

    Treatment of ulcers and symptomatic keratosis, treatment of varicose veins, and trigger point injections. How many people give trigger point injections? [00:42:00] How many people know what a trigger point injection is?

    The trigger point injection is not the heel spur. A trigger point injection is to a point of irritation in a particular muscle. And we don’t do that, but the patients come in and they’re saying they have pain in the gastrocs, they have pain, you know, in other muscle areas and muscle bellies. You can inject it. You can inject it with saline. You can inject it saline, you can inject it lidocaine, you can inject it with anything. You put a little steroid in it, but it’s payable. And that LCD has all the documentation, which is not very much, and has the CPT codes and has the ICD-10 codes. Use it and make more money, and make the patients feel better.

    I should have said that first. Anyway.

    This is the … this is it, the 2% cut that I can never pronounce. Okay, they have digital articles that nobody ever reads. Nobody. And they have a lot to do with what we do, with those CPT … with those LCDs. So I took them, I actually read them, I had some extra time, and I have slides on that that I’d like to give to you. But all of these are on the resources that you’ll find online.

    Compression bandages. I didn’t know this but the three-layer compression bandage systems, the high compression, the systems that we purchase are not going to be paid. And if they are, they’re going to ask for the money back, so be prepared. So you can’t use 29581.

    What Jack … I know that’s not what Jack Morgan said. I really apologize for that.

    But ever since Jack’s accident where he thrown his head, he just hasn’t been the same. Is Jack here? He was here before? [00:44:00] Let him know... be good to him because of that accident. I think he has a plate. Huh? Oh, okay, whatever it is, use the Unna boot code, Unna boot code.

    And if the patient is home, and you put it on like two or three times at home to show the family how to put it on and they’re going to pay for it, you might get paid. But anything more, like a definitive treatment plan, you’re not going to get paid, and they will look to get the money back, that’s the recent article.

    If you do it in a surgery center or you do it in a wound center, you don’t care… oh, you do care because you’re going to use that code. So use that Unna boot code, please.

    The Medicare podiatry services manual that they have, it’s a tiny… it’s a little book. It outlines the basic services for foot and ankle, it outlined the routine foot care and coverage and specifically list the non-coverage services.

    Peripheral nerve blocks. Please don’t give a peripheral nerve block for diabetes diagnosis. If you’re diabetic, you can get a carpal tunnel, correct? And you could have a surgery for the carpal tunnel, correct? Well, for some reason, we don’t do that for the leg. If they have a peripheral neuropathy… diabetic peripheral neuropathy unilaterally, they also have a compression of the posterior tibial nerve, you can inject, but that will be your diagnosis. Keep diabetes out of it, unless the only way you’re going to get paid.

    The stimulator I retold you about, the peripheral nerve field stimulation is non-payable. It has no document… no good documentation, no good studies, and basically it’s… it just can’t pass master with CMS.

    The posterior tibial nerve stimulator, don’t use it because it’s for urinary incontinence. Got it? Now, if the patient hurts and they’re peeing a lot, maybe, but only urologist have the ability to use it. [00:46:02]

    I’m at minus 15 seconds, okay, let me just go through this for a second. Non-covered… there’s a non-coverage for testing for non-coverage surgical procedures and what can I say? You’re not going to get paid, they’re not going to cover services to work up to a non-coverage surgery. The patient will have to come up with that on her own.

    Vein ablation, nothing to do with us, but just to let you know that there is a correct coding correction because the doctors would give them the wrong CPT and let you know also topical HBO is non-payable. Topical HBO is non payable.

    An amniotic membrane derives skin substitutes are being used for other diabetic foot ulcers and venous leg ulcers. That is just letting you know they are not going to pay for anything, but those two... those two problems. If you’re using it for anything else, people are using it for pressure ulcers or for rheumatoid arthritis, immune… associated ulcerations, they would not get paid. It has to be either diabetic or venous.

    That’s it for now, and I’ll be back tomorrow.


    END OF CLIP
    00:47:27