MALE SPEAKER 1: Iâm going to introduce our next speaker, lecturer for Medicare Update part 2. Pretty much a no-name young podiatrist who youâve probably never heard of. But we invite him back because he likes making fun of Jack Morgan. So, without further ado, weâre going to have Gabriel Halperin give his next talk.
GABRIEL HALPERIN: Thank you. Well, Iâm back. I have a couple of things to say about yesterdayâs 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 canât 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 theyâre able to bill Medicare for whatever they do, they use the three⦠the multi-level compression for sports activities. So, Iâm really upset about this, but Jack Morgan was right. So⦠donât hit him tooâ¦
[OFF-MIC]
GABRIEL HALPERIN: [Laughs] You can still be nice to him because of the time that he dropped on his head though.
[OFF-MIC]
GABRIEL HALPERIN: Hey, he doesnât have any burns when we set him on fire on the steps of the State Capital.
So, regarding that, just donât use the diagnosis of lymphedema because itâs 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, plusâ¦
[OFF-MIC]
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 donât see Medi-Cal patients and youâre 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 donât talk about it, but itâs out there.
[OFF-MIC]
GABRIEL HALPERIN: Secondly or thirdly, I had to say it again, Iâm not retired.
[OFF-MIC]
GABRIEL HALPERIN: I sold my practice, but Iâm still practicing in the practice as a drone and I still have my⦠the wound care practice. So, please donât think that Iâm not suffering just like you guys. Weâre all suffering together under, you know, under Medicare. Also, remember, the things Iâm talking about are Medicare and not private insurance. So, a lot of the things that are pertaining to Medicare really donât pertain to private insurance.
And the last thing is⦠letâs see. This is the reason why I ask Dr. Kesmon to be here because he gets into so much debt that I wouldnât 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⦠letâs say you identified an error in practice; you were billing for orthotics, whatever, what Paul talked about, and if you donât 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. Itâs been in the law⦠itâs 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. Donât 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.
Letâs say that everything is fine, letâs say you didnât find anything, and letâs 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 heâs doing a chart review for our office and he mentioned, I think I talked about this last year, that heâd 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 heâs a healthcare attorney and make sure that attorney is going to be there for you when you need it.
Letâs see, Rio, Ipinema, Iâm going on vacation in two days, I think we got it all. Okay, letâs go on. Does these things work? Yes? [00:06:00:02]
[OFF-MIC]
GABRIEL HALPERIN: These third-party people?
[OFF-MIC]
GABRIEL HALPERIN: When you get audited by the health plan, there are two reasons; one is you might be an over utilizer and theyâre 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.
[OFF-MIC]
GABRIEL HALPERIN: Oh, for Medicare? No, itâs not Medicare patients, fee for service, weâre 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.
Letâs 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. Whatâs not built into it is trimming of nails. So if the patient has ⦠if youâre trimming nails, theyâre long, but there is no painful ⦠itâs painful, but there is no at-risk condition, thatâs not payable. [00:08:03] Do something ⦠pay cash, do something.
If youâre wedging a nail because if itâs incurvated or if there is an infection ⦠Iâm not talking about surgery, Iâm 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, itâs inflammation. So you can use a paronychia code with pain.
It is not a painful condition, itâs an EM code. So under pain, itâs 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. Itâs been a problem for years for our profession. I use dystrophic. I donât 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, weâre good for everything. Weâre good for the debridement of the ugly dystrophic nail, weâre good for the callus and corns, and weâre 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 â if it shows that they just have mycotic nail rather than theyâre just saying itâs mycotic nail?
GABRIEL HALPERIN: Thatâs not within the LCD. You donât have to do a fungus culture. If you want to do a fungus culture, do a fungus culture, but Iâm not going to stand up here and tell you to do it. It doesnât have to have, and no oneâs 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 â¦
[OFF-MIC]
GABRIEL HALPERIN: For at-risk? I think itâs the same diagnosis. You could use the same diagnosis. I donât know.
Status? Do you need a separate diagnosis for the G code?
MALE SPEAKER: The same.
GABRIEL HALPERIN: Same code. Thatâs my coder. If weâre wrong, blame Jack Morrigan.
Okay, I want to get over this stuff.
I want to bring something else up. Letâs see. Where are we?
I wish I had a computer up here. Okay. Everybody is cool on the three-layer compression bandages, right? Itâs ⦠and I made mistake, I should have said lymphedema is that, but itâs not. Donât 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, donât 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 Iâve had my MAs do it for like 38 years, so now Iâm legal. I donât look good in orange. Jack might pull it off, because he wore yellow yesterday, but I donât know.
Okay. Now, consolidation, again, letâs 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 weâll 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 itâs 12%, God bless us. But weâll be making more money.
And the reason why weâre making more money is because weâre leading to a level two visit. Youâll 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, thatâs fine, thatâs going to be separate. And theyâll come up with the coding guidelines during the year. However, they did say that itâs going to be ⦠I donât think itâs here ⦠itâs going to be either 1997, 1995, or itâs 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 donât like it. Medicare doesnât 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, âWell, theyâre going to seek input on how to encourage reporting because theyâll implement an enforcement mechanism.â So weâll go to jail if we donât see our post-ops in the 90-day period.
What theyâre 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 theyâre going to pay us all less, so youâll be paid, like, I donât know, maybe 25 bucks for a bunionectomy. And youâre about ... and then you see the patient daily for their post-ops. [Laughs] But there wonât be any more global. I donât know when it will happen but theyâre going towards that right now.
Thereâs 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⦠youâll get paid on their virtual check-in. Same thing with remote evaluation, theyâll do the same thing, but you have to see that patient within 24 hours.
So if itâs really bad and you say you have to come in because itâs really bad, youâll get paid on that remote evaluation and the visit, EM code. And thereâs inter-professional internet consultation services which means that youâre going to message your favorite internist whoâs going to ask you your opinion and you can get paid for it.
There are six separate codes, but I donât know what they look like, I think Jeff Lehrman might talk about that. Heâs 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 whoâs a specialist and works with the APMA, health policy committees, is talking about the new changes, the new coding for 2019. Heâll also be talking to you about the routine foot care that we have been talking about, because I didnât go into specifics. Heâll talk to you how⦠how to do it and how to make it easy. [Audience sneezes] God bless you.
And letâs see, going on, release memo. We have in our possession, release memo that shows that MACRA, thatâs 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, theyâll 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 thatâs 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, weâre 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 donât 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. Iâll talk about that in a second. Ambulatory surgical centers actually are a problemâ¦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 donât 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, donât 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 donât 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 wonât 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, youâre 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 doesnât 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 theyâll tell you. Theyâll 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 thatâs the CERT contact information. Iâm going to go faster now. Iâm going to go after some edits.
These are from 2018, not 2019, but Iâm afraid that some people didnât quite get it. So Iâm 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 thatâs CCI, to the 28234 which is on column 2.
Sequestration, we know itâs still in effect. Surgery, they did some revisions, if you didnât 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 donât know how the heck someone came up with that, but it was being paid for by Medicare and theyâre 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 whatâs in the set and you put it through the machine? Thatâs a 7% reduction because thatâs old technology, you old people, so you have to upgrade. Itâll 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. Theyâre talking about 10% in 2023. Theyâre actually talking about a lot more at that point. And digital radiography, thereâs none. So, what youâd 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 donât use the FY? What happens? Tell me what happens. Nothing. Except, one day, theyâre 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, Iâm sure they have enough people to come to the office and see this stuff. So, if they see your old machine and youâre not using the FY, thatâs $22,000 per⦠so, you donât 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 donât⦠we donât 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, donât 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 thatâs a profession⦠thatâs a gentlemanâs disagreement. I donât 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 thereâs 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 youâre 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 donât 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 thatâs both cutaneous or open surgery and these are the codes for it. You have a limit of two times in a year. And if itâs 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, itâs 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? Itâs... 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? Theyâre 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 itâs either⦠what CPT is going to be bilateral? You donât. You go to APMA Resource Coding. Or if you want to, you could download an app. Thereâs an app fromm the AMA called, I think itâs iCoder. It costs about $95 and you could look that up on your phone and you can get the same information, too. Itâs not as sophisticated as Coding Resource, but for looking for a bilateral. It has bilateral. Yes or no? So, itâs a lot easier. Could it be wrong? I donât know.
[OFF-MIC]
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 itâs 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, itâs part of the ankle joint. So make sure you donât â 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, Iâm 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 theyâre still the 59. [00:30:10:01]
So keep using the 59 until weâre⦠until theyâre forcing us to, and they would let us know first. You know about ABNs, and, letâs see, office based wound care, biologics, okay. I wanted to talk about biologics for a moment. It seems that it is ⦠thereâs 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 youâre 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 wonât 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 canât tell you which ones because Iâm not allowed to talk about brands.
Cue codes, I donât care about. Well, I do care about it, but I donât 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 sheâs 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, itâs patients over paperwork. Itâs too much work so theyâre trying to reduce the paperwork.
Answer that. The opioid crisis, theyâre trying ⦠there are goals. Itâs all words. They donât mean ⦠theyâre not doing anything yet. Not that I know of.
Jeff, are they doing anything? Jeff is gone. I donât know.
[OFF-MIC]
MALE SPEAKER: The United States has required to register with a clearly state prescription laundry program.
GABRIEL HALPERIN: We are all. Itâs by state law. So we are all ⦠weâre all peers, correct? And we talked about that as the measure that weâd be using. So thatâs good. Other than that, itâs all words and plans. Basically, theyâre just making ⦠theyâre trying to reduce the overdoses.
Opioid epidemic, CMS efforts. Itâs a long-term roadmap, which means that thereâs nothing in this year. But you know that theyâre writing PowerPoints about it.
Okay, letâs get through this. Virtual care is the electronic that we spoke about. We want to knowâ¦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. Theyâre not doing anything about it, but ⦠okay. Oh, yeah, they are doing things about it. What theyâre doing is theyâre putting up more requirements.
Okay. And Dr. Lurvey says hello as well, like Iâd said yesterday.
So these are Medicare coverage articles that I was able to obtain for you. Itâs 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 donât know if theyâre denying that someone died or theyâre 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?
GABRIEL HALPERIN: Huh?
MALE SPEAKER: Half-price?
GABRIEL HALPERIN: Half-price? Because theyâre dead? Okay, good. Thatâs 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 Iâm going over a little bit, but targeted probe and education is absolutely necessary. This is my opinion, itâs based on a pervasive thought in CMS that the entire medical community is lazy, doesnât 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 thatâs 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 itâs a probe, Iâd rather have just one. They keep probing until you get it right. And they will give you the answers. Theyâre going to give you the answers. Theyâre going to give the answers, theyâre going to tell what words to use, theyâre going to tell you what the diagnosis codes are. So number four, youâre really, seriously stupid or a crook if you keep screwing this up. And if thereâs no change, theyâre 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 youâre chosen, for whatever, however, youâre going to get a letter. The MAC is going to review 20 to 40 charts, and theyâre going to send a complaint. Youâre going to be reviewed again. If youâre good ⦠now, how theyâre going to do it is person-to-person. Theyâre going to sit with you. Theyâre going to, either electronically or in person, and theyâre going to sit with you and go over the problems that you have in your charts.
No arrest. Youâll probably have to pay something back on the, you know, on the charts. Theyâre 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 youâre doing wrong, how you have to correct it.
Seriously, all of you should ⦠if you have this happen ton you, it should be one. Iâd like to hear about it. If any of you do get a TPE, let me know, because Iâm going to bring it back to the CAC. And if itâs something thatâs not right, Iâm 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 itâs scary. This is the letter youâre going to get or, God forbid, you may get, and itâs a notice of targeted probe and education. Okay? Again, each round 20 to 40, after each round, youâre 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 theyâre just not cross walking correctly. So you may need to use the old number, which is the Medicare number plus the suffix.
MALE SPEAKER: Gabe?
GABRIEL HALPERIN: Yes.
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, theyâll ask for an additional 20 to 40 charts.
MALE SPEAKER: Since that last interview?
GABRIEL HALPERIN: A whole new one, a whole new one. Theyâll keep doing that until you â¦
MALE SPEAKER: I kind of go back a little further back into the chart forâ¦
[OFF-MIC]
GABRIEL HALPERIN: Technically not, because theyâre going by education. So education means that theyâre going to give you the information, and then theyâre 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 thatâs 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 donât know about.
Okay. We determined the ⦠okay, remember, thereâs 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. Donât ⦠youâll have to go online to get it. So get really familiar with that online, because thatâs where youâre going to get your ALBs, and thatâs where youâre going to get all the other stuff that you need to deal with.
Thereâs something called a print suppression policy, which means that itâs all self-service. Go online, get whatever you need. Theyâre going to⦠youâre going to stop ⦠theyâre going to stop sending you a lot of mail that youâd have been ⦠that youâve 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 â 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? Iâm sitting through each one of them, right? This is where I do my â 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 â this is Dr. Lurveyâs 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 donât do that. If the patient comes in with, letâs say, a pain corn, we donât talk about â and we should â we say painful corn, periostitis, PAD maybe, diabetes mellitus. We donât say post CVA. We donât say muscle weakness. We donât say gout. We donât say all the other things that are in our chart, but we need to put it in the diagnoses list. Remember, they can â you can print â you could put up to eight diagnoses in a diagnoses list. This is what they want. They want you to be a whole doctor thatâs 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. Thereâs a Medicare Diabetes Prevention Program, which weâre not invited on either. [00:42:00] But neither are dermatologists or rheumatologists, so I feel, like, weâre not being segregated.
Read new resources are available on Medicare Diabetes Prevention Program. I donât care because Iâm 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 youâll notice that theyâre reviewing physical therapy codes, and theyâre reviewing hyperbaric oxygen codes. Not the physician, the wound care center. Theyâre reviewing application of multi-layer compression systems, okay? 29581. Theyâre 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, thatâs where reviewing us. The injection code, 6450, debridement of nails, six or more, therapeutic physicians, procedures one to four areas, those ⦠thatâs physical therapy.
Theyâre 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 theyâre 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, âIâm old. I donât care.â
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 theyâre 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 donât want a blog. Iâll 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 theyâre all expensive. And they donât want the alternatives. And theyâre trying to deal with it.
I just have two more slides. The first is, this is a picture of the Noridian website. Youâll see Jurisdiction E, and Jurisdiction F. California is blue. Of course, we are blue, right? And Jurisdiction E, weâre Jurisdiction E. So if you go to F, youâll have a completely different paperwork.
Same thing, when you go down, youâll see Jurisdiction A and D for Demerk. Weâre not Jurisdiction A. Weâre or Jurisdiction D, so make sure that you click the right one.
And I think thatâs it. Iâm done.
TAPE ENDS [00:45:39]