Section: CME Category: Practice Management

Medicare Update Part 2

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. Report and understand the new CMS updates
  2. List the auditing tools that CMS initiated to potentially take money back from providers
  3. Recognize the Medicare Carrier’s expectations of clinician’s documentation
  4. Review potential new services that can enhance, ethically, clinician’s office income
  5. Review the sources available to accurate coding for services rendered to patients
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    Gabriel Halperin has nothing to disclose.

  • Lecture Transcript

  • MALE SPEAKER 1: I’m going to introduce our next speaker, lecturer for Medicare Update part 2. Pretty much a no-name young podiatrist who you’ve probably never heard of. But we invite him back because he likes making fun of Jack Morgan. So, without further ado, we’re going to have Gabriel Halperin give his next talk.

    GABRIEL HALPERIN: Thank you. Well, I’m back. I have a couple of things to say about yesterday’s talk before we get started. First off, regarding the 29581, the Unna Boot, and the multiple layer. I went back and did a little homework. The lymphedema still stands. Though you can’t use it for lymphedema. But that code is being used by the national trainers for sports leagues when they go have… when they have a clinic and they’re able to bill Medicare for whatever they do, they use the three… the multi-level compression for sports activities. So, I’m really upset about this, but Jack Morgan was right. So… don’t hit him too…


    GABRIEL HALPERIN: [Laughs] You can still be nice to him because of the time that he dropped on his head though.


    GABRIEL HALPERIN: Hey, he doesn’t have any burns when we set him on fire on the steps of the State Capital.

    So, regarding that, just don’t use the diagnosis of lymphedema because it’s a separate identifiable problem. It is not the… the disease is not payable under Medicare for whatever reason Medicare determined. So, use edema as well as… in fact, we would use edema, plus…


    GABRIEL HALPERIN: ... thank you. Plus, the trauma. Next, you should all know that starting this year, I think, for continuation of our services with managed care companies, we need to have a Medi-Cal contract. [00:02:05:05] So, even though you don’t see Medi-Cal patients and you’re now forced to see Medi-Cal patients, get the contract. Get the… does anybody here not have a contract with Medi-Cal? Yeah, get the contract to continue. They don’t talk about it, but it’s out there.


    GABRIEL HALPERIN: Secondly or thirdly, I had to say it again, I’m not retired.


    GABRIEL HALPERIN: I sold my practice, but I’m still practicing in the practice as a drone and I still have my… the wound care practice. So, please don’t think that I’m not suffering just like you guys. We’re all suffering together under, you know, under Medicare. Also, remember, the things I’m talking about are Medicare and not private insurance. So, a lot of the things that are pertaining to Medicare really don’t pertain to private insurance.

    And the last thing is… let’s see. This is the reason why I ask Dr. Kesmon to be here because he gets into so much debt that I wouldn’t be able to do. Plus, I actually ripped off his lecturers to give to you. So, this is much easier.

    Now, if you see an error… let’s say you identified an error in practice; you were billing for orthotics, whatever, what Paul talked about, and if you don’t go back into the records and identify the number of times that you have had that problem and then rectify it by volunteering the money back to Medicare and then making a note in your Medicare Compliance Manual, if they come out and they audit and they, by chance, find it, they will get that money back and they will take $22,000 per occurrence. Per occurrence. So, that will put us out of business assuming you did something.

    A way to get around it, we found out… I found out about this. [00:04:01:01] Most of us found out about it was through a discussion last year at the National CAC Meeting in Baltimore and one of our attorneys had brought it up. It’s been in the law… it’s been the law for years, but it was never really pushed and it seems to be some pushing for the… for this problem. So, I came up with an idea and I ran up to those attorneys and they seem to think that it has credibility. That is, obtain voluntarily an audit of your charts, but do it through your attorney. Don’t do it with a private coder. Do it through your attorney. Have them go ahead and ask for 40 charts or 80 charts or whatever it is, send it to them, have them do a chart review. Simple as heck. And then, deal with it.

    Let’s say that everything is fine, let’s say you didn’t find anything, and let’s say you got audited and they find that thing about the orthotics. When the attorney sits down with them, and he will, that attorney is going to say that you fulfilled your fiduciary responsibility by having a chart review which could lower the impact of that audit for you. And I am doing this. I am doing this. In fact, I called Greer, okay, Keith Greer and he’s doing a chart review for our office and he mentioned, I think I talked about this last year, that he’d be willing to set up like a small company and do that for everybody if you wish. But choose your attorney, whatever attorney you want. Make sure he’s a healthcare attorney and make sure that attorney is going to be there for you when you need it.

    Let’s see, Rio, Ipinema, I’m going on vacation in two days, I think we got it all. Okay, let’s go on. Does these things work? Yes? [00:06:00:02]


    GABRIEL HALPERIN: These third-party people?


    GABRIEL HALPERIN: When you get audited by the health plan, there are two reasons; one is you might be an over utilizer and they’re trying to figure it out, but the most common reason is because they are looking for additional diagnosis, because if they can find at risk diagnoses in your chart, they will get paid more by Medicare.

    Medicare has a carve-out for more co-morbidities.


    GABRIEL HALPERIN: Oh, for Medicare? No, it’s not Medicare patients, fee for service, we’re talking about fee for service, sorry, you still have to pay it. Okay, I wanted to go over another thing that was a little confusing and that is options for the covered routine foot services.

    Let’s get this very, very straight. There are two conditions, one is painful conditions, which were worked on by myself and Harry Goldsmith and Tony Poggio over 25 years ago or more, and at risk condition, which is outlined in the National Carrier Decision, basically written into the national register.

    Under painful conditions, painful conditions, we have debridement of painful mycotic dystrophic nail. We have the debridement of the painful callus and corns. What’s not built into it is trimming of nails. So if the patient has … if you’re trimming nails, they’re long, but there is no painful … it’s painful, but there is no at-risk condition, that’s not payable. [00:08:03] Do something … pay cash, do something.

    If you’re wedging a nail because if it’s incurvated or if there is an infection … I’m not talking about surgery, I’m just talking about avulsion, which is just wedging it out. You could charge an EM code. But make sure you put down, as part of your diagnosis, paronychia. Paronychia is not an infection, it’s inflammation. So you can use a paronychia code with pain.

    It is not a painful condition, it’s an EM code. So under pain, it’s either debridement of the painful, dystrophic mycotic nails or debridement of painful callus or corns.

    Now, personally, I stay away from mycosis. I stay away from the diagnosis. It’s been a problem for years for our profession. I use dystrophic. I don’t why, but that simple change has never triggered any type of audit or question. But truly, a mycotic nail is pretty dystrophic, am I correct? So therefore, I use dystrophic and just save yourself the hassle.

    At-risk conditions, again, we’re good for everything. We’re good for the debridement of the ugly dystrophic nail, we’re good for the callus and corns, and we’re good for trimming of the normal nail. So therefore, the trimming, which is cutting straight across, is the G code or the 11719 code. Either is fine, but use the one that pays more, obviously, so use the G code, and of course, that will be a 50%.

    Does it makes sense? Okay. So nobody ask me this afterwards, please.

    MALE SPEAKER: Can you recommend that everybody get – if it shows that they just have mycotic nail rather than they’re just saying it’s mycotic nail?

    GABRIEL HALPERIN: That’s not within the LCD. You don’t have to do a fungus culture. If you want to do a fungus culture, do a fungus culture, but I’m not going to stand up here and tell you to do it. It doesn’t have to have, and no one’s been brought on the carpet for not having to do a fungus culture. [00:10:05] In California, in Wisconsin, and with other areas, yes, they have, but not here.

    Is someone raising their hand in the back? Yes?

    FEMALE SPEAKER: I was asking really about 11720 and she have a …


    GABRIEL HALPERIN: For at-risk? I think it’s the same diagnosis. You could use the same diagnosis. I don’t know.

    Status? Do you need a separate diagnosis for the G code?

    MALE SPEAKER: The same.

    GABRIEL HALPERIN: Same code. That’s my coder. If we’re wrong, blame Jack Morrigan.

    Okay, I want to get over this stuff.

    I want to bring something else up. Let’s see. Where are we?

    I wish I had a computer up here. Okay. Everybody is cool on the three-layer compression bandages, right? It’s … and I made mistake, I should have said lymphedema is that, but it’s not. Don’t mention ever lymphedema under Medicare. Private insurance, go for it, just not Medicare.

    Okay. Under CMA … CMS policies, they had a raised concern about the structure and evaluation of EM codes, and of course, they did something about it because next year, they are going to change it.

    Now, this year, in 2019, they changed up some things. Documentation of changes since last visit or pertinent items rather than full review of systems. In other words, don’t document negatives, just document the positives on the review of systems. [0:12:00]

    Staff for beneficiaries, documentation of chief complaint is allowed rather than practitioner themselves. I absolutely never knew that I was supposed to do it myself and I’ve had my MAs do it for like 38 years, so now I’m legal. I don’t look good in orange. Jack might pull it off, because he wore yellow yesterday, but I don’t know.

    Okay. Now, consolidation, again, let’s go over this because this is really important for us. Consolidation of level two, three, four EM codes for new and established patients, I put it in yellow. level five is maintained separately. Overall impact, the estimation is that we’ll go up by 10%. According to Frank, it was 12%, but I actually ripped this off of the person who told us, so I think it really is 10%. But if it’s 12%, God bless us. But we’ll be making more money.

    And the reason why we’re making more money is because we’re leading to a level two visit. You’ll document a level two visit. But that level two visit documentation is going to be paid for level two, three and four. So do your little documentation and get paid the same as the guy that is documenting the hell out of it for a level four.

    Now, if you want to get to a level five, that’s fine, that’s going to be separate. And they’ll come up with the coding guidelines during the year. However, they did say that it’s going to be … I don’t think it’s here … it’s going to be either 1997, 1995, or it’s going to be a medical decision-making as a guide for the medical records.

    Future policies, global periods, everybody knows global, right? Do surgery, 90 days global, 10 days global. Well, they don’t like it. Medicare doesn’t like it. They declared war on it. And the reason why is because they did their statistics and they found that … let me see … here, only 4% of 10-day global services were reported with one or more post-operative visits. [0:14:02] 67% of 90-day global services reported with one or more post-operative visits. 66% of podiatrist reported any post-operative visit. And rose plus reporters, those of us that see the patient often, reported post-operative visits on 87% of a 90-day global, but only 16% of the 10-day global.

    So Medicare, in their divine wisdom, decided, “Well, they’re going to seek input on how to encourage reporting because they’ll implement an enforcement mechanism.” So we’ll go to jail if we don’t see our post-ops in the 90-day period.

    What they’re getting to, is they want to eliminate the global. They want to pay us less because our global does include post-operative visit, the cost of post-operative visit. So they’re going to pay us all less, so you’ll be paid, like, I don’t know, maybe 25 bucks for a bunionectomy. And you’re about ... and then you see the patient daily for their post-ops. [Laughs] But there won’t be any more global. I don’t know when it will happen but they’re going towards that right now.

    There’s going to be some … final policies include some virtual check-in, which is when the patient gets on Twitter or on Instagram, contacts you to find out if they really should come in. And if you do come in, because you have to be followed with a… with an office visit, they get… you’ll get paid on their virtual check-in. Same thing with remote evaluation, they’ll do the same thing, but you have to see that patient within 24 hours.

    So if it’s really bad and you say you have to come in because it’s really bad, you’ll get paid on that remote evaluation and the visit, EM code. And there’s inter-professional internet consultation services which means that you’re going to message your favorite internist who’s going to ask you your opinion and you can get paid for it.

    There are six separate codes, but I don’t know what they look like, I think Jeff Lehrman might talk about that. He’s going to talk about that. [00:16:01]

    What we did this year was we cut my lectures into pieces and we had people come out to give those lectures. So Dr. Jeffrey Lehrman who’s a specialist and works with the APMA, health policy committees, is talking about the new changes, the new coding for 2019. He’ll also be talking to you about the routine foot care that we have been talking about, because I didn’t go into specifics. He’ll talk to you how… how to do it and how to make it easy. [Audience sneezes] God bless you.

    And let’s see, going on, release memo. We have in our possession, release memo that shows that MACRA, that’s MIPS, was actually a Russian plant and should be abolished. It was intended to force out doctors to Canada because they have a physician shortage. And the FBI is investigating and like they normally do, they’ll put it into text. Does anybody take that seriously? Please raise your hands. Okay.

    This is the 2018 CAC information in California. The national error rate is 8%, California is 6.7%. I was up here about four or five years ago and I told you, our error rate was like, 10% and that’s the reason why they fired the previous… the previous carrier, well it looks like with Noridian forever, because it went down to a tremendous low.

    We are Jurisdiction E, everybody E, us, Nevada, Hawaii, Guam, and the other Pacific Islands. The rest of the country, not really, but the rest… a lot more of the country is F, and you could see the state. And there, well, you could see the error rates, Arizona is 13.6% and Montana, all four doctors are 16.4%. [00:18:00]

    Next, California error, top provider types. Do you see us in there? No, we’re not. The medical director, Dr. Lervy says that we are good people, quote. So clinical labs are the highest… clinical labs are the highest not because they are cracks, although some are. Clinical labs are there because we make errors, and as a result, they get the third errors because we don’t give them proper information to ascertain the medical necessity or the signatures for the labs that we send over there.

    Ambulatory surgical centers are separate problem. I’ll talk about that in a second. Ambulatory surgical centers actually are a problem…going to be a problem for us, be prepared because they are missing supportive documentation, preoperative notes, conservative measures, history of conditions before the surgeries. What the hell? We go there for surgery, they don’t have to know everything. But it looks like we have to give them some of our records, maybe our initial consults, or the consult where we decide on surgery, send them the records, so they can send it in to Medicare with their billing information.

    Internal medicine is because they have lousy supportive documentation. Their EM codes are uploaded like everybody a five, and missing physician orders for services. One of the biggest down codes is primary care, orthopedic surgery, neurosurgery, and a couple of others.

    Top errors, all of us, insufficient documentation, supportive documentation. Dr. Lervy says, don’t write a thesis. Just give me an outline, four words that describe it, but put it in there, missing physician intent, missing in… or eligible signature, we talked about that, right? Having your signature on a signature logs so that everybody can know that it was your signature. Incorrect coding, down coding is most of the time because we don’t have enough documentation to show the down code. [00:20:02] Will that be a problem in the future? No. If we live through 2019 and 2020, we will… that won’t be a problem anymore, if you can document to a second… to a 2-0 level. We can document to a 2-0 level, right? 2-0 level means the patient was breathing and walked in to your office. Okay.

    Preventive actions. Document orders and intent, legibly signed your records, code and bill for the level of service, collaborate with the ordering physicians to ensure your practice has necessary records, supply ostentations and signature logs for an eligible signatures, and authenticate certifications or writ certifications. Okay, you’re going to read these.

    The CERT website. CERT is an audit that will… that is auditing the carrier to make sure that they took care of you correctly. So when you fail an assert, it doesn’t necessarily go against you, it goes against the carrier. The carrier wants you to pass the CERT, self-preservation. So they set-up all these things, a task force, I wish they do that for the rest of us. A task force to help you pass the CERT, so be in touch with them because they’ll tell you. They’ll look at your documentation and say if not efficient, write additional information, not in the original note, and to try to pass the CERT.

    They will also, if you go get a CERT, they will appeal like… appeal it, and they will help. And this is their information. And that’s the CERT contact information. I’m going to go faster now. I’m going to go after some edits.

    These are from 2018, not 2019, but I’m afraid that some people didn’t quite get it. So I’m going to go over really quick. Just to show you 28234 is a column 2 code to CPT 28285. [00:22:04] So, what I did was I looked up 28285, I pressed the CERT button and about 100 codes came down, and I looked for the 28234 and it was on that type 2… the column 2. What I did was I attached the 59 modifier, because that’s CCI, to the 28234 which is on column 2.

    Sequestration, we know it’s still in effect. Surgery, they did some revisions, if you didn’t get it. Proud flesh cauterization has been revised, 64550 has been revised, and 64565 was deleted. More importantly, fluoroscopy, was revised, you can read that.

    On medicine, the follow-up management and training, prosthetic training has been revised, and there was another… there was a check-out that was deleted.

    Shock wave is not… shock wave, amazingly, was being used for wound care. I don’t know how the heck someone came up with that, but it was being paid for by Medicare and they’re no longer paying for it as they should.

    On x-ray, does everybody have the old analog still in the practice? Anybody still have the old analog? If you have the analog, you have to use or modify your come up to for… with a 20% reduction of your services. Does everybody… anybody have the computerized technology? Not the digital, but the computerized x-ray in your office where you take the picture, you open the cassette, you take what’s in the set and you put it through the machine? That’s a 7% reduction because that’s old technology, you old people, so you have to upgrade. It’ll only be $50,000. And get a new digital system. My wife got one for my birthday.

    So, analog, 2017, 20%. [00:24:01] Copy… computerized radiography is… was reduced 7% in 2018. They’re talking about 10% in 2023. They’re actually talking about a lot more at that point. And digital radiography, there’s none. So, what you’d have to do is use the consent and… I think right here, we got the consent… okay, this is computerized. You have to use right and then FY. Yeah. What happens if you don’t use the FY? What happens? Tell me what happens. Nothing. Except, one day, they’re going to visit.

    I got a visit for a non-invasive arterial machine I was using a couple of years ago. They came out to look at the damn device. So, they wanted to make sure that it was real. So, they have the technology and they have the people to come out and they have people just hanging around. When I go to the CPT… the Medicare plate, there are people in the hallway sitting cross-legged. So, I’m sure they have enough people to come to the office and see this stuff. So, if they see your old machine and you’re not using the FY, that’s $22,000 per… so, you don’t want that. So, use the code.

    And I think these are the codes. TC, Technical… 20 dash… 26 is professional. We all use both. We just don’t… we don’t use those components, but we do use FY if you have the computerized. Okay.

    Someone talked to me today. They gave a neuroma injection and they got denied because they were using 64450. It is not 64450. Neuroma is 64455. And the other injection, a nerve block or whatever, is 64450. Got it? Okay.

    Now, are you going to use diabetes, diabetic peripheral neuropathy for your diagnosis? Anybody? Give me a yell. One person. Yes? One… thank god. Okay. Nobody is going to use the diabetic peripheral neuropathy, okay? Also, don’t use that for the neuroma either. A neuroma is a neuroma. It has nothing to do with diabetic peripheral neuropathy. [00:26:00] And I believe that peripheral nerve entrapment or impairment is appropriate.

    Tony disagrees, but that’s a profession… that’s a gentleman’s disagreement. I don’t think we put a hit out on each other yet. And pain control versus therapeutic management versus diagnostic testing. I do it for diagnostic testing to see whether if the pain went away with the posterior tibial nerve block, then there’s a good chance that the posterior tibial nerve was the solo participant in that peripheral neuropathy or that peripheral nerve pain the patient was coming in with.

    Global surgery, we talked about that already. Peripheral nerve stimulator. This is where you’re going to find more information about the PNS versus PNFS. Do not use PNFS. If they come to you and they want you to use their services, it is not payable under Medicare. I don’t know about the privates. PNS is payable and you have two way… there are four things. You have it… you have the trial, you have the permanent implementation that’s both cutaneous or open surgery and these are the codes for it. You have a limit of two times in a year. And if it’s less than 50%, you may be audited for repayment, for picking inappropriate patient subjects.

    These are the diagnoses I gave you for that PNS. Again, it’s in the lecture. You can download it. I talked about the 50% modifier, the 50 modifier. Everybody comfortable with that like on an Unna boot? It’s... incorrect... to do the 29580 left, 2859 right, and diagnosis edema, the correct is one code, 29580-50. One unit. One unit. The fee. Put in double. Who the hell cares? They’re going to pay you 150% anyway and diagnose as edema. Does that make sense? [00:28:00:05]

    How do you know which is a bilateral code? How do you know it’s either… what CPT is going to be bilateral? You don’t. You go to APMA Resource Coding. Or if you want to, you could download an app. There’s an app fromm the AMA called, I think it’s iCoder. It costs about $95 and you could look that up on your phone and you can get the same information, too. It’s not as sophisticated as Coding Resource, but for looking for a bilateral. It has bilateral. Yes or no? So, it’s a lot easier. Could it be wrong? I don’t know.


    GABRIEL HALPERIN: Injections are also bilateral. Okay, someone came to me also asking about arthrocentesis... arthro is the injection, the aspiration code the same for the injection code, and it is.

    So it’s arthrocentesis, aspiration, and or injections of a small joint, burst, or a ganglion, and then you also you have for the medium joint. Intermediate joint is an ankle, hip is large, knee is large. Now ankle used to be two joints.

    Used to be... the subtalar joint, it was part of the ankle joint. It was a dual joint system, kind of separated in semantics. So if you do a subtalar joint injection, that is an intermediate joint, it’s part of the ankle joint. So make sure you don’t – make sure you use the appropriate code.

    Got it? Does anybody know about the new disposable, the disposable negative pressure devices? Have you all been involved with that? Okay, they have a separate coding. This is coding for the non-disposable, the durable devices, if you want to put it on in your office, and these are the codes for the disposable devices, again, from 2018.

    59 modifier, you all know about that, I’m going to go pass that so I can go to the next piece, come on, and they are taking the 59 modifier still, but technically, technically, they split the 59 modifier into… for other modifiers, and, but what you… but they’re still the 59. [00:30:10:01]

    So keep using the 59 until we’re… until they’re forcing us to, and they would let us know first. You know about ABNs, and, let’s see, office based wound care, biologics, okay. I wanted to talk about biologics for a moment. It seems that it is … there’s something called … is it called ASP?

    There are two types of biologics you can then put on in your office. One is labeled ASP and the others are not. The ones that are not, Medicare is paying only invoice for those devices. However, if the biologic you’re using is ASP, ASP will continue to pay what they have been paying with that profit built in. However, on box 19, you still put in the invoice price, but they won’t hold it against you. But put the invoice price into box 19 and continue putting in what you would normally bill for the biologic in units.

    Makes sense? And just ask them if they have … are they ASP or not. I can’t tell you which ones because I’m not allowed to talk about brands.

    Cue codes, I don’t care about. Well, I do care about it, but I don’t care about it in hospitals.

    Total for office placement … okay, objective. Okay. The Western United States Office of CMS sends their greetings. Lolita is our … is the person that corresponds to the physicians, and she’s very nice. And she comes to our CAC meetings, and she has her little blurbs. [00:32:02]

    So they wanted to know that they have an objective update of the opioid initiative, behavioral health telemedicine support, update on patients over paperwork. Patients over paperwork, it’s patients over paperwork. It’s too much work so they’re trying to reduce the paperwork.

    Answer that. The opioid crisis, they’re trying … there are goals. It’s all words. They don’t mean … they’re not doing anything yet. Not that I know of.

    Jeff, are they doing anything? Jeff is gone. I don’t know.


    MALE SPEAKER: The United States has required to register with a clearly state prescription laundry program.

    GABRIEL HALPERIN: We are all. It’s by state law. So we are all … we’re all peers, correct? And we talked about that as the measure that we’d be using. So that’s good. Other than that, it’s all words and plans. Basically, they’re just making … they’re trying to reduce the overdoses.

    Opioid epidemic, CMS efforts. It’s a long-term roadmap, which means that there’s nothing in this year. But you know that they’re writing PowerPoints about it.

    Okay, let’s get through this. Virtual care is the electronic that we spoke about. We want to know…However, they are hearing from us. This is what the provider feedback is. Requirements are excessive, documentation are too hard to find, and providers are afraid of audits.

    Do you agree? Yeah, they heard us. They’re not doing anything about it, but … okay. Oh, yeah, they are doing things about it. What they’re doing is they’re putting up more requirements.

    Okay. And Dr. Lurvey says hello as well, like I’d said yesterday.

    So these are Medicare coverage articles that I was able to obtain for you. It’s in your resources that I put up, that I put on the website. [00:34:01] I want to let you know that the Medicare portal, NMP is really good. And they are offering claim denial details for just about everything, including date of death denials.

    I don’t know if they’re denying that someone died or they’re denying your services because the patient died supposedly before you rendered your services.

    Does anybody do zombie care?

    So anyway, but all of these are covered. All of these are covered in the portal.

    MALE SPEAKER: Half-price?


    MALE SPEAKER: Half-price?

    GABRIEL HALPERIN: Half-price? Because they’re dead? Okay, good. That’s Les Levy, no sense of humor.

    Okay. Physician orders for deep most, they have it up there as well. Targeted probe and education … I know I’m going over a little bit, but targeted probe and education is absolutely necessary. This is my opinion, it’s based on a pervasive thought in CMS that the entire medical community is lazy, doesn’t read the bulletins or is ignorant, with a couple of crooks, and that we needed a gentler, parental figure to guide us into following the documentation rules. And that’s why they made targeted probe and education.

    Does that sound like alien abduction and probing? Hmmm. Okay. When you get your probe call me and let me know.

    Most providers are going to have only one to two repetitions of this probe. Personally, if it’s a probe, I’d rather have just one. They keep probing until you get it right. And they will give you the answers. They’re going to give you the answers. They’re going to give the answers, they’re going to tell what words to use, they’re going to tell you what the diagnosis codes are. So number four, you’re really, seriously stupid or a crook if you keep screwing this up. And if there’s no change, they’re going to refer it to a fraud and abuse, so really, we really got to get it right. [00:36:00] And they expect most ops will be the first or the second repetition. Not the first time of doing it, the first repetition after they tell you what to do and then they ask for another 30 or 40 charts.

    You can find more information about TPE on the Noridian website, under anal probe. [Laughs]

    And this is how it works. Basically, if you’re chosen, for whatever, however, you’re going to get a letter. The MAC is going to review 20 to 40 charts, and they’re going to send a complaint. You’re going to be reviewed again. If you’re good … now, how they’re going to do it is person-to-person. They’re going to sit with you. They’re going to, either electronically or in person, and they’re going to sit with you and go over the problems that you have in your charts.

    No arrest. You’ll probably have to pay something back on the, you know, on the charts. They’re not going to go through a universe against you and give you a large payback. But what they will do is tell you exactly what you’re doing wrong, how you have to correct it.

    Seriously, all of you should … if you have this happen ton you, it should be one. I’d like to hear about it. If any of you do get a TPE, let me know, because I’m going to bring it back to the CAC. And if it’s something that’s not right, I’m going … we will … the CAC will embarrass the medical director and the people there, including the nurses or the doctors that are doing the review.

    This is the same thing that Paul put up, and it’s scary. This is the letter you’re going to get or, God forbid, you may get, and it’s a notice of targeted probe and education. Okay? Again, each round 20 to 40, after each round, you’re going to get a one-on-one education by medical review, by face-to-face, teleconference, electronic visits, letters, or provided report cards. [00:38:00]

    Providers are allowed 68 weeks between each education to get it right. And then they can discontinue or they can ask for the next probe, and they can do that. By the third, they relay some problems.

    This is the new Medicare card design. Have any of you seen it yet? The new numbers? Okay. Keep the old numbers, because a lot of times they’re just not cross walking correctly. So you may need to use the old number, which is the Medicare number plus the suffix.



    MALE SPEAKER: Are they going back when they do like a second round or whatever round? Are they looking at charts since your interview or whatever?

    GABRIEL HALPERIN: Yes. Yeah, they’ll ask for an additional 20 to 40 charts.

    MALE SPEAKER: Since that last interview?

    GABRIEL HALPERIN: A whole new one, a whole new one. They’ll keep doing that until you …

    MALE SPEAKER: I kind of go back a little further back into the chart for…


    GABRIEL HALPERIN: Technically not, because they’re going by education. So education means that they’re going to give you the information, and then they’re going to check how you did it. So that stands to reason.

    If they do go back further, I need to know about it. I really do, because that goes to the medical director and that’s not what he is saying. Okay. Somebody … remember, you have a big organization, not everybody talks to each other, left hand, right hand, so they could be doing things that management don’t know about.

    Okay. We determined the … okay, remember, there’s a re-opening, re-determination, reconsideration and then ALJ. ALJ stands for administrative law judge. I was told I have to have a dictionary for my acronyms. So ALJ, administrative law judge, not an employee of the carrier.

    So Medicare, the re-determination notices are not going to be mailed to you anymore. Don’t … you’ll have to go online to get it. So get really familiar with that online, because that’s where you’re going to get your ALBs, and that’s where you’re going to get all the other stuff that you need to deal with.

    There’s something called a print suppression policy, which means that it’s all self-service. Go online, get whatever you need. They’re going to… you’re going to stop … they’re going to stop sending you a lot of mail that you’d have been … that you’ve been getting for years. [00:40:05] And they started that two years ago, but they are only getting into it at this point.

    This is what – this is what I have to sit through. This is what I have to sit through on a quarterly basis. Draft LCDs for discussion, multimode MOL Dx and I just called it MOLD. And these are gene oppressions or a gene expression test. So how many? I’m sitting through each one of them, right? This is where I do my – last time, there were about 40 of these. This is where I do my email, and I play solitaire. Talk to the guy next to me, radiology.

    Okay. This is the – this is Dr. Lurvey’s own notes. This is the way he types it. Everybody hates his notes. He talks about electronic records that must be up to date for any visit, concurrent, the illnesses, just make sure that everything is on the chart.

    Talk about the comorbidities. We don’t do that. If the patient comes in with, let’s say, a pain corn, we don’t talk about – and we should – we say painful corn, periostitis, PAD maybe, diabetes mellitus. We don’t say post CVA. We don’t say muscle weakness. We don’t say gout. We don’t say all the other things that are in our chart, but we need to put it in the diagnoses list. Remember, they can – you can print – you could put up to eight diagnoses in a diagnoses list. This is what they want. They want you to be a whole doctor that’s treating a foot condition.

    Chronic care management, this is talking about the primary care docs. They could buy … they could charge additionally for chronic care management of the diabetic or the PAD or the others. There’s a Medicare Diabetes Prevention Program, which we’re not invited on either. [00:42:00] But neither are dermatologists or rheumatologists, so I feel, like, we’re not being segregated.

    Read new resources are available on Medicare Diabetes Prevention Program. I don’t care because I’m not getting paid.

    And TPE, he talked about. This is clinical reviews. This is something we should know about. These clinical reviews are given to them by CMS. CMS will tell them, we want you to review these things. So you’ll notice that they’re reviewing physical therapy codes, and they’re reviewing hyperbaric oxygen codes. Not the physician, the wound care center. They’re reviewing application of multi-layer compression systems, okay? 29581. They’re going to be reviewing those systems. That code is going to be looked at. But that is under Part A, not Part B now, because they are being used in a hospital.

    Part B, that’s where reviewing us. The injection code, 6450, debridement of nails, six or more, therapeutic physicians, procedures one to four areas, those … that’s physical therapy.

    They’re going to be reviewing high level EM codes, prolonged EM codes, biopsy codes, the 11000 series codes. And the proposals in 2019 are documentations, simplification of CMS, changes in EMM coding, changes in the NCD and LCDs, changes in the CAC meetings because they’re reducing our CAC meeting of frequency, and virtual groups, which are individual doctors banding together for their MIPS contribution.

    He wants us to get online, to see our healthcare ratings. I did, and then I shut the computer off. I said, “I’m old. I don’t care.”

    These are upcoming trends you should know about, various store, in-store clinics clinics being tried and tested. Healthcare systems are trying virtual visit systems. [00:44:00] Walgreens, and MD Live are having phone services because they’re going to be charging for that virtual consultation. Telemedicine, he asks an employee in large companies and insurance, or storing in work places. NPN physician telehealth visit is about $15. Social media blogs, medical practices in the internet, you have … we all should have blogs, should we?

    I don’t want a blog. I’ll hire somebody. Anybody here want to do my blog?

    And alternative medicine increasing in usages, and direct-to-patient marketing. This is a big deal. Direct-to-patient marketing, all those advertisements that you see on television are made to have patients tell their doctors what to prescribe, and they’re all expensive. And they don’t want the alternatives. And they’re trying to deal with it.

    I just have two more slides. The first is, this is a picture of the Noridian website. You’ll see Jurisdiction E, and Jurisdiction F. California is blue. Of course, we are blue, right? And Jurisdiction E, we’re Jurisdiction E. So if you go to F, you’ll have a completely different paperwork.

    Same thing, when you go down, you’ll see Jurisdiction A and D for Demerk. We’re not Jurisdiction A. We’re or Jurisdiction D, so make sure that you click the right one.

    And I think that’s it. I’m done.

    TAPE ENDS [00:45:39]