Published: October 17, 2013

Simplicity

Dymista

AAO-HNSF 2013 Annual Meeting & OTO EXPOSM

Subscription Products Offer In-Depth Study and Interactive Learning

AcademyU®, the Foundation’s otolaryngology education source, offers five types of learning formats that include knowledge resources, subscriptions, live events, eBooks, and online education. Each contains elements that make up the breadth of the education opportunities available through the Academy. In this third article in the series we will explore the two subscription products published through AcademyU®: the Home Study Course (HSC) and Patient Management Perspectives in Otolaryngology (PMP). The Home Study Course is the longest running education product produced by the Foundation, having first been published in 1940. It is also the second most popular education resource with more than 3,000 subscribers annually. More than 1,000 otolaryngology-head and neck surgery residents in more than 100 residency programs subscribe to it, as well as 2,000 practicing physicians. In a two-year period, eight sections of HSC are published covering specific topics that reflect the breadth of the specialty. Two-year subscriptions are encouraged so subscribers will have access to all eight specialty areas. Registration for the 2013-2014 HSC year begins this month. Please see the registration form included in this Bulletin or visit www.entnet.org/HSC. Each HSC “Red Book” provides a compendium of research articles pertaining to one of the eight subspecialties within otolaryngology-head and neck surgery. For example, the 2013-2014 course year offers articles on congenital and pediatric problems; clinical competency issues; trauma and critical care medicine; and plastic and reconstructive problems. Each compendium is accompanied by an extensive bibliography and a self-assessment examination with a symposium discussion. Each section is designated for 40 AMA PRA Category 1 credits™. In addition to helping earn continuing education credit, HSC is a valuable resource for board exam preparation, certification and recertification, and CT Imaging accreditation. Work groups within each of the eight education committees develop the courses. These hard-working volunteers serve for six years and produce three sections during that time. Patient Management Perspectives in Otolaryngology PMP is an interactive electronic or print series that simulates real-life clinical decision-making. Each issue includes a clinical case study, visual materials, detailed patient management summary, references for further study, and a self-assessment post-test. A PMP volume consists of eight issues published annually with topics covering the eight otolaryngology subspecialties. PMP is under the editorship of Daniel J. Kirse, MD, working with volunteer authors from the education committees. Topics to be addressed in the 2013 volume include: Pharyngitis The Dizzy Patient Paragangliomas CSF Rhinorrhea Ear Deformity Child with Hoarseness Epiphora Interactions among Physicians and Physician Extenders. PMP offers subscribers the opportunity to hone decision-making skills through full management of an individual patient from presentation to discharge and follow-up; an interactive question and answer format, with immediate feedback on each choice made; lab studies and imaging, surgery and possible complications, medical therapy, postoperative care and follow-up; opportunities to explore different options and pathways in patient management; visuals including x-rays, scans, surgical photographs, diagrams, and animated full-color graphics; and a thorough, fully referenced discussion of the patient case, presenting both the author’s viewpoint and the broader background in the literature. Subscribers can earn eight AMA PRA Category 1 credits™ with each issue of PMP for a total of 64 credits available in an entire volume. “As the editor of PMP, I appreciate the hard work and dedication of the faculty who produce these highly interactive and practical learning resources,” said Dr. Kirse. “I recommend physicians at all phases in their career subscribe to PMP. Not only can they earn up to 64 continuing education credits annually, but they will also gain new skills that can be immediately applied to their practice.” To subscribe to either of these valuable education resources, visit www.entnet.org/HSC or www.entnet.org/PMP. To view all of the Foundation’s education and knowledge resources please visit www.entnet.org/academyu.

Advocating for Truth in Advertising across the Nation

Because of the increasing ambiguity of healthcare provider terms used in advertisements and marketing, patients often lack information and are confused about the wide diversity of professionals who work in healthcare settings. Many patients mistakenly believe they are being treated by medical doctors (MDs or DOs) when they are actually seeing non-physician providers. Recent studies confirm America’s patients prefer a physician-led approach to healthcare and need accurate information about the level of training and education of their healthcare providers—including physicians, technicians, nurses, physician assistants, and other allied providers. To address this issue, the AAO-HNS and others in the healthcare community continue to advocate for effective state and federal legislation that would require all healthcare providers to fully disclose their credentials and/or level of training in all patient communications. The AAO-HNS, in collaboration with other specialty groups, has worked to perfect the language used in the American Medical Association’s model bill concerning truth in advertising and the use of “board certification” by healthcare professionals. Across the nation, there have been numerous state legislative proposals introduced in the past several years, with more states adopting and implementing transparency legislation each year. Prior to this year’s state legislative sessions, truth-in-advertising legislation had been enacted in Arizona, California, Connecticut, Florida, Illinois, Oklahoma, Oregon, Pennsylvania, Tennessee, and Utah. In 2013, there have been truth-in-advertising bills—both good and bad—introduced in Arkansas, California, Florida, Idaho, Illinois, Maryland, Massachusetts, Nebraska, New Jersey, North Dakota, Vermont, Washington, and West Virginia. In addition, a bipartisan, truth-in-advertising bill (H.R. 1427) was introduced in the U.S. Congress recently. To learn more about the Academy’s advocacy efforts on truth in advertising, visit the AAO-HNS Legislative and Political Affairs webpage at www.entnet.org/advocacy or email the Government Affairs team at govtaffairs@entnet.org.

SGR Repeal Gains Momentum in U.S. House of Representatives

The Sustainable Growth Rate (SGR) formula, the flawed mechanism used to calculate payments to physicians within the Medicare program, has been the proverbial “thorn-in-the-foot” issue for the physician community for more than a decade. Created by the Balanced Budget Act of 1997, the SGR formula was intended to control growth in Medicare payments for physician services by basing payments on per capita growth in the gross domestic product (GDP). Under the SGR formula, physician payments are reduced when growth in Medicare patients’ use of physician services exceeds the universal spending target set by the SGR formula. By faulty design, a weak economy could trigger a decrease in target spending even if use of physician services remained high. As a result, physicians have annually faced steep cuts to their payment rate, forcing Congress to take action almost every year to avert massive cuts in the Medicare system. Since the trend toward negative annual payment updates began, the AAO-HNS and others in the physician community have continually urged Congress to repeal the flawed formula and replace it with a payment framework that would provide stability for physicians practicing within the Medicare program and ensure critical access to care for the nation’s senior population. In this case, however, Congress’ annual actions to avert the payment cuts have acted as a double-edged sword. The good? Steep payment cuts for physicians have been avoided. The bad? In most cases, Congress failed to identify appropriate “pay fors” to fund the elimination of each year’s scheduled cuts. As a result, the Congressional Budget Office (CBO) estimated the cumulative debt associated with the SGR had grown to more than $300 billion by the end of 2012. Despite wide conceptual support by both Democrats and Republicans for repealing the flawed SGR formula, the immense cost associated with such action has proved prohibitive. However, based on early Congressional attention and an updated cost analysis by CBO, it seems 2013 may be the year that the stars align and Congress finally takes action to fully repeal the SGR formula. A Rare Opportunity The first piece of good news for this year came in the form of a Congressional hearing. In February, the Health Subcommittee of the House Energy and Commerce Committee gathered to discuss and evaluate key components for developing a new Medicare physician payment model. While hearings on this topic are not particularly out of the ordinary, its scheduling so early in the 113th Congress signaled that SGR reform was a front-burner issue for many Members of Congress. Soon thereafter, staff from the House Ways and Means Committee invited various physician specialty groups, including the AAO-HNS, to participate in a briefing session on the Committee’s development of a proposal to repeal the SGR and put in place a framework for a Medicare physician payment system designed to incentivize the delivery of efficient, high-quality healthcare. During the meeting, Committee staff emphasized their need for input from the physician community and made a request for official written comments from all the groups in attendance. Given the rare opportunity to take part in the infancy stages of developing a potential new payment model, the AAO-HNS Government Affairs and Health Policy teams, in conjunction with the Academy’s Physician Payment Policy (3P) and Ad Hoc Payment Workgroup, began drafting comments specific to otolaryngology-head and neck surgery. In the past, most legislative proposals regarding the SGR have attempted to move the Medicare physician payment system to a one-size-fits-all approach. However, this year’s initial proposal shows that Members of Congress have begun to understand that, given the dynamic nature of modern healthcare delivery, any payment model must also provide options to accommodate providers across the continuum of care. The AAO-HNS has emphasized that in any sort of payment mechanism, each specialty must be afforded the opportunity to drive the metrics and/or standards by which they are measured. Given the complexity of developing a new payment system and the time required to adapt and test the functionality of new programs, the AAO-HNS also underscored the need for providing a stable payment period for all physicians within the Medicare program following the initial repeal of the SGR. The Academy’s official comments, dated February 26, 2013, are available at www.entnet.org/advocacy. While no one will argue about Washington’s love of a wonky policy scheme, even the best intended proposal could become moot if costs remain prohibitive, right? Here lies the last bit of encouraging news regarding the possibility of SGR repeal in 2013. Also in February, the CBO announced a massive reduction (to $138 billion) in the estimated cost of repealing the SGR. Following the announcement, a seemingly dead-end issue has been revived in earnest and the chairs of the House Ways and Means and Energy and Commerce Committees have heralded SGR repeal as one of their top priorities. Although no hard timeline had been established at the writing of this article, several Members of Congress are urging leaders to address the SGR issue prior to the August recess. However, it must also be said that despite all of this year’s positive activity, ongoing negotiations to reach a compromise regarding an overall deficit reduction plan pose a serious risk of derailing efforts to address the SGR and many other legislative issues. Nevertheless, the AAO-HNS remains hopeful that 2013 marks the year that the infamous SGR is finally laid to rest. And as many agree, repeal of the SGR is now on sale and Congress should act fast before the CBO changes its mind. For more information about AAO-HNS legislative priorities in the 113th Congress, email legfederal@entnet.org.

Congressional House Calls

The Transition to ICD-10: Will You Be Ready?

Robert R. Lorenz, MD Lee D. Eisenberg, MD After years of delay, the Centers for Medicare & Medicaid Services (CMS) has reiterated that on October 1, 2014, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. This means providers should be preparing now to meet the 2014 deadline for transition. The change does not affect CPT coding for physician services or outpatient procedures. Why ICD-10? The rationale for the transition is based on the fact that ICD-9 cannot be expanded to encompass necessary changes as it has only five numeric characters, whereas ICD-10 will have seven alphanumeric characters. Not only will the total number of diagnostic codes (ICD-10 clinical modification [CM]) be expanded from the current 14,000 to 68,000 codes, but the methodology of coding will be altered, too. This mandated change will have a major effect on documentation and billing in the office and hospital. ICD-9 dates back to 1977, and many changes have occurred in technology and disease processes that are not reflected in the current code set. Due to the lack of detail and specificity in the current ICD-9 code sets, significantly different disease processes are being referred to by a single code, making it difficult to capture detailed diagnostic information and the specificity for accurate billing and reimbursement, especially as it relates to severity and complexity. As members are aware, one of CMS’ primary goals in recent years has been to improve quality of care. Therefore, the lack of precision within the ICD-9 code set, which does not allow for the accurate measurement of quality, has been identified as an area requiring improvement by the agency. Further, since most developed countries converted to ICD-10 in the 1990s, international benchmarking of disease outside the U.S. will be facilitated by our domestic implementation of the ICD-10 code set. In addition to the ICD-10-CM coding system changes, the transition to ICD-10-procedural coding system (PCS) will occur concurrently, but applies only to inpatient procedural coding and will largely affect facility-based coders. Physicians will be largely unaffected by ICD-10-PCS changes and will continue to use the CPT coding methodology to report their medical services. Where Do I Stand? When one examines the scope of changes that the ICD-9 to ICD-10 transformation entails, it is easy to become overwhelmed considering the effects on payers, suppliers, clearinghouses, administrators, schedulers, databases, quality measures, and research registries. By starting with your daily workflow as a physician, your focus should be concentrated on two areas: documentation and provider-based coding. Regarding documentation, we can summarize by stating that the increased level of granularity contained within the diagnosis code will continue to need accurate and sufficient documentation to justify the use of that particular code. The use of the diagnostic code should not be the first time an auditor comes into contact with data describing the pathophysiology, but rather, the detail should be contained within the documentation produced by the provider. Therefore, the specificity requirements in your documentation will be predicated on the new, more specific, diagnostic codes you will be entering. More Specific? In regard to provider-based coding, it is easy to state that the new ICD-10 code set will be more “specific,” but many members have asked what that really means. The new code set contains increased granularity around diseases and will include new information such as, but not limited to, the following: Laterality Specific disease pathophysiology Combination codes Common clinical guidance scales and staging Timing of encounters Increased granularity of disease manifestations Alcohol and drug dependence effects of use Increase in injury codes Sequelae What Does This Coding Change Mean for You? The implication to your coding depends on how your practice is structured and what disease sets you commonly see. One place to start is determining whether you’ll be using an electronic medical record (EMR) by October of 2014. Most EMRs are updating their disease-selection technology (pick-list) to conform to ICD-10 requirements. While this may not automatically convert the code from the ICD-9 to the ICD-10 version for existing patients, choosing a new, more specific ICD-10 code using this technology is not much more onerous than today’s practice. Providers who are using paper-based documentation and billing will experience a significantly more difficult conversion to the new coding system, especially if they are using the actual tabular, numerical code, rather than the alphabetic, disease description, as the new numerical system bears little resemblance to the previous methodology. The administrative burden for converting different categories of diseases will vary according to disease. Some codes will map from one ICD-9 code to merely two or three ICD-10 codes while others may map from one ICD-9 code to 12 ICD-10 codes. The most obvious examples of mapping “one-to-many” (in other words, one ICD-9 code being able to be converted to many potential ICD-10 codes) include orthopedics and obstetrics. But even for our standard “382.01: Acute suppurative otitis media with spontaneous rupture of ear drum” ICD-9 code, we will have to include a side and a timing when converting to “H66.014: Acute suppurative otitis media with spontaneous rupture of eardrum, recurrent, right ear” in ICD-10. To assist with the conversion, CMS has developed a tool called General Equivalence Mapping, or GEM, which aids in the conversion from a code in ICD-9 to ICD-10, and is available online. This can be a straightforward, one-to-one conversion, or a more complicated one-to-many mapping. GEMs have been created for both a forward mapping ICD-9 to ICD-10 conversion, or a backward mapping ICD-10 to ICD-9 conversion. What Will This Cost My Practice? Potential costs of the conversion can vary widely, depending on your IT and administrative support. Providers should plan for an initial decrement in their productivity of five percent to 10 percent during coding functions. If your coding is done for you in your office or the hospital, estimates suggest a decrease in coder efficiency of 20 to 50 percent initially, depending on the site. Most large EMR systems have a robust plan for administrating the ICD-10 conversion, but for providers with practice-specific technology, or worse yet, homegrown systems; a full IT overhaul may be required due to the dependencies with systems that interact with the EMR. Training for physicians and staff will be costly and time consuming. The Medical Group Management Association (MGMA) estimates it will cost $84,000 for a three-physician practice to transition to ICD-10 and up to $3 million for large practices. There are multiple educational vendors with prepared materials for your office staff, billers, and us as providers, to review the changes that are specific to your area of expertise. Providers should plan on four to six hours of physician education in order to learn the content. What Steps Should I Be Taking Now? Providers should communicate with their office manager or financial support personnel to ask for a risk assessment of their practice. This should include questions such as: What will your coding process entail when you are utilizing ICD-10? How much additional documentation will be required, if any, to substantiate the use of the more granular code? Do you have preference lists that can be updated ahead of time to mitigate the disruption to your practice? We also recommend that practices contact their payers and ask what type of infrastructure they are creating to assist with the conversion and whether there will be billing implications for the use of generic or unsubstantiated codes. Providers should also ask what percentage of their practice these codes and payers represent, and what they can do ahead of time to decrease revenue disruption. Remember, improving documentation accuracy to levels required for ICD-10 can begin now, even if your coding remains in the ICD-9 system. Other implementation and planning strategies could include the creation of a pilot with your office staff of dual coding to test the systems you’ve put into place or asking a payer to partner with you on a dual coding project ahead of the October 1, 2014, deadline in an effort to work out their own transition complications. Academy Resources for Transition In an ongoing effort to prepare and educate members regarding the looming transition to the use of ICD-10 diagnostic codes, the Academy has developed a series of educational articles and a dedicated webpage on www.entnet.org as resources for members. In addition, we are working toward an ongoing initiative to develop new resources for members, which will be rolled out during the remainder of 2013 and the first half of 2014. A miniseminar will take place at the 2013 Annual Meeting & OTO EXPOSM in Vancouver, Canada, which will include presentations by ICD-10 experts. Currently available Academy ICD-10 resources include: What’s New: http://www.entnet.org/Practice/International-Classification-of-Diseases-ICD.cfm General Information: http://www.entnet.org/Practice/International-Classification-of-Diseases-ICD.cfm ICD-9 to ICD-10 Crosswalk for Top 200 ENT Codes: http://www.entnet.org/Practice/loader.cfm?csModule=security/getfile&PageID=156407 ICD-9 Coding to the highest level of specificity: http://www.entnet.org/practice/resources/upload/Coordinating%20ICD.pdf Previous Academy Bulletin Articles include: Conforming Your Otolaryngology Documentation to ICD-10: http://bulletin.entnet.org/highlight.aspx?id=2904&p=271 ICD-10: What it Means for Your Practice: http://bulletin.entnet.org/highlight.aspx?id=3516&p=310 Preparing for ICD-10: http://bulletin.entnet.org/highlight.aspx?id=3925&p=333 Other materials that may be useful to members seeking additional information include: CMS PowerPoint on ICD 10 Transition: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/CMSICD-10Overview.pdf CMS Implementation Guide: http://www.cms.gov/Medicare/Coding/ICD10/downloads/ICD10SmallandMediumPractices508.pdf CMS Proposed Timelines for Small, Medium, and Large Practices: http://www.cms.gov/medicare/coding/ICD10/Downloads AMA ICD Transition White Papers: http://www.ama-assn.org/ama/no-index/about-ama/icd10-white-paper-confirmation.page AAPC PowerPoint on Transition: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/AAPCICD-10WillChangeEverything.pdf AAPC FAQ: http://www.aapc.com/icd-10/faq.aspx#why Understanding and Preparing for ICD-10: Making the Conversion from ICD-9 to ICD-10 Manageable: http://www.mgma.com/workarea/downloadasset.aspx?id=1368339

CPT for ENT: Coding for Intraoperative Neurophysiology Monitoring

Q: What Is Intraoperative Neurophysiology Monitoring and Can I Bill for It? A: Intraoperative neurophysiology monitoring applies to performing nerve monitoring during complex surgical procedures involving cranial nerves. Another physician (usually a neurologist or physiatrist), or an electrodiagnostic technologist, prepares the patient prior to surgery by attaching fine wires and electrodes on designated areas, such as the face or neck, during a case of facial nerve monitoring. For recurrent nerve monitoring, the electrodes are integrated into the endotracheal tube. These electrodes are connected to electrodiagnostic equipment that monitors specific nerves either through automated monitoring (e.g., an audible alarm), or by the clinician’s interpretation of the monitoring device’s output. Intraoperative neurophysiology monitoring is an “add-on” service, formerly reported with CPT 95920. For 2013, this code has been deleted and replaced with two new codes: CPT +95940: Continuous intraoperative neurophysiology monitoring in the operating room, one-on-one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedures.); and +95941: Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour. Note that in the 2013 final Medicare Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) elected not to accept the CPT Editorial Panel’s addition of CPT +95941, and, instead, created a G code to report monitoring that occurs outside the operating room. Providers should, therefore, report G0453: Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (List in addition to primary procedure.) for monitoring occurring outside the operating room for Medicare beneficiaries. Members should note +95941 may be used for nonmedicare patients. The American Medical Association’s Current Procedural Terminology (CPT®) does not limit CPT codes to any particular specialty. However, the CPT introductory language and AMA coding guidance is clear that in order to bill these codes (+95940, +95941, or G0453) the service must be performed by a monitoring professional who is solely dedicated to performing the intraoperative neurophysiologic monitoring and is available to intervene at all times during the service as necessary. The monitoring professional may not provide any other clinical activities during the same period of time. In the event the monitoring is performed by the surgeon or anesthesiologist, the professional services are included in the primary service code(s) and should not be reported separately. In addition, these codes should not be reported for automated monitoring devices that do not require continuous attendance by a professional qualified to interpret the testing and monitoring. These codes, as with all add-ons, are not billable as standalone codes and are linked to the appropriate neurophysiologic monitoring code. For example, if facial nerve monitoring is performed during a parotidectomy, link CPT code +95940, +95941, or G0453 with the appropriate EMG CPT code (95867—Needle electromyography; cranial nerve supplied muscle(s), unilateral) instead of with the parotidectomy CPT code. If the physician performs only the interpretation and does not own the equipment, he or she should append modifier -26 (professional component) to the code. The provider performing the monitoring must report both the intraoperative findings and record his or her precise level of involvement to obtain reimbursement. It is best to use CPT terminology in the dictation whenever possible. The provider who performs the nerve monitoring should have appropriate credentials to justify reimbursement. In addition, providers should note that there is not currently a code for reporting the use of surface electrode EMG monitoring performed for recurrent laryngeal nerve monitoring during thyroid surgery. Members should also be aware that many carriers consider monitoring with an automated device integral to the surgery performed and will not reimburse for these services separately. Therefore, providers should familiarize themselves with their local Medicare Administrative Contractor (MAC), or private insurer’s medical policies and coding guidelines for these CPT codes prior to reporting these services. Ultimately, it is the discretion of the surgeon to determine the mode and administration of these tests.

Key Dates for CMS Quality Reporting Initiatives

Today, otolaryngologists are subject to multiple quality reporting initiatives that affect their bottom line. Through the Electronic Health Record (EHR) Meaningful Use Incentive Program, the Electronic Prescribing (eRx) Incentive Program, and the Physician Quality Reporting System (PQRS) Incentive Program, physicians may be subject to a nearly five percent payment reduction in 2015 if they do not begin to participate in these programs. Because each of these programs is so complex and has different reporting criteria and timelines, the Academy has put together a timeline showing key dates for each program to help ensure you do not miss another deadline. For more details on the reporting criteria, incentive payments, and associated penalties, visit the Academy’s newly redesigned CMS Quality Reporting initiatives webpage at www.entnet.org/qualityreporting

Ad Hoc Payment Workgroup Evaluates Payment Models

The Ad Hoc Payment Workgroup was formed to provide an avenue for the Academy to evaluate current and future trends in healthcare payment reform and to develop methods for otolaryngologist-head and neck surgeons to actively participate in these new models. The workgroup will supplement the work the Physician Payment Policy Workgroup (3P) and the Academy as a whole are already doing to position us for a future payment system based on quality and efficiency. This includes our work with national quality organizations, such as the American Medical Association convened Physician Consortium for Performance Improvement and the ABIM Foundation’s Choosing Wisely® campaign, which focus on the development of quality metrics and the enhancement of quality care. In addition, we are working closely with our physician leadership to support our members’ participation in quality programs such as Physician Quality Reporting System (PQRS) and the Electronic Health Record (EHR) incentive programs. To support this work, in 2011 we partnered with CECity® to offer PQRIwizardSM, a CMS qualified registry for PQRS reporting. This tool allows the Academy to offer a streamlined method of participation in PQRS to otolaryngologists and builds member participation in the PQRS program. The Academy also continues to develop resources to aid member participation in the EHR Incentive program. The Ad Hoc Payment Workgroup plans to focus initially on three specific areas: 1) clarifying current quality guidance documents available to members, 2) developing a care path for members for the treatment of sinusitis, and 3) evaluation of payment reform trends. Clarifying Academy Guidance Documents Currently, the Academy produces a number of documents to aid members in achieving the highest standards of quality care, including Clinical Practice Guidelines (CPGs), Clinical Indicators (CIs), Clinical Consensus Statements (CCS) and Position Statements. In the last year, the Academy updated nine Clinical Indicators, reaffirmed nine position statements and revised 10, and drafted a new position statement on tongue suspension. Also last year, the AAO-HNSF published an update to our guideline development manual and two CCSs. Two new guidelines will be published this year, two CPGs are currently being updated, and development of a new CPG on tinnitus and a CCS on chronic and recurrent rhinosinusitis in children has begun. Each of these guidance documents has proved valuable for the Academy’s membership. However, the Ad Hoc Payment Workgroup plans to further evaluate the guidance documents and determine how they are best utilized and what differences exist among them. In doing this, they hope to better define each guidance document and improve its applicability to members. Development of the Academy’s First Care Path The Ad Hoc workgroup will also work on the development of the first Care Path, focusing on the diagnosis and treatment of sinusitis. The Academy has developed several resources for our members on the treatment of sinusitis including a clinical practice guideline, performance measures, and a clinical indicator. Therefore, the workgroup will use these existing resources and work to develop a care path for this disease process focusing on the medical management of sinusitis, mapping out the physician decision-making process, treatment, and different options for patients. The workgroup hopes to create other Care Paths designed to help improve quality and efficiency for some of the most costly head and neck diseases with high variability in treatment. Payer Reform Trends Currently, the United States is undergoing a vast transformation of the healthcare system and the Ad Hoc workgroup is working with members, private payers, and patient advocacy groups to best understand, analyze, prepare, and help shape future payment models. Recently, the American Medical Association (AMA) asked the Ad Hoc workgroup to evaluate a draft tool being developed in conjunction with the AMA Federation to evaluate practice readiness for the value-based purchasing payment program. On behalf of the Academy, the Ad Hoc group provided input to assist the AMA and Federation in the development of a tool that is applicable to specialists and their practices. Recently, the Ad Hoc workgroup participated in the development of comments provided to the United States House of Representatives’ Ways and Means Committee’s proposal to replace the Sustainable Growth Rate (SGR). You can read more about this proposal and the Academy’s comments on page 29. Along with this work, the workgroup plans to collaborate with other stakeholders, including the AMA and Surgical Coalition, on the development of new payment models. The Academy also plans to engage private payers to partner in the development of alternative payment methods for otolaryngologist-head and neck surgeons. As James L. Netterville, MD, stated in his President’s column, this is an exciting time in healthcare and the Ad Hoc workgroup is led by a talented group of physicians at the forefront of payment reform and with the expertise needed to develop alternative models of payment. The Academy will continue to work on ways to improve the quality of care for patients and advocate for otolaryngologists. For more information about the Ad Hoc workgroup, email the Health Policy team at healthpolicy@entnet.org.

The Doctors Company Provides Unrivaled Savings, Benefits for AAO-HNS Members

As the nation’s largest medical malpractice insurer, The Doctors Company is on a mission to defend, protect, and reward the practice of good medicine. Since 2003, the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) has exclusively sponsored The Doctors Company. Qualified AAO-HNS members receive extensive benefits, including a program discount of five percent, a claims-free credit of up to 25 percent, the potential for dividends, free trial coverage for qualified members, and industry-leading patient safety tools. The Doctors Company sets the standard for aggressive defense. In the company’s 2012 Member Experience Survey, 94 percent of members agreed that the company relentlessly defended them against frivolous lawsuits. The Doctors Company’s defense includes Litigation Education Retreats, which help members facing claims to master defense tactics, deliver sound testimony, and cope with the emotional stress of a claim. As the acknowledged industry leader in patient safety, The Doctors Company’s innovative programs help AAO-HNS members reduce risk and avoid claims. The recent member survey found that 91 percent of members are pleased with The Doctors Company’s efforts to protect them from potential threats to their reputations and livelihoods. The year 2012 marked the fifth anniversary of the Tribute® Plan, an unrivaled benefit that rewards members for their loyalty and their dedication to superior patient care. Every year, Tribute grows and becomes more popular with The Doctors Company members—the highest award to date is $88,708. The recent survey showed that 92 percent of members agreed that The Doctors Company’s efforts to reward them were unmatched. AAO-HNS members rely on The Doctors Company’s superior strength to provide unrivaled protection. With $4 billion in assets and more than $1 billion in member surplus, the company has the resources to protect you now and in the future. The Doctors Company has the national perspective and local expertise to identify emerging trends and protect physicians with innovative coverage solutions. CyberGuard® protects doctors against cyber liability claims, today’s fastest-growing threat. MediGuard® provides doctors with legal representation for administrative actions. Both products are offered as part of the company’s core medical malpractice policy. We invite you to join your AAO-HNS colleagues and 73,000 doctors nationwide who put their trust in The Doctors Company. Otolaryngology Historical Society Call for Papers If you are interested in presenting at the next OHS meeting in Vancouver, BC, Canada, September 30, 2013, email museum@entnet.org.To join the society or renew your membership, please check the box on your Academy dues invoice or email Catherine R. Lincoln, CAE, MA (Oxon) at clincoln@entnet.org or call 1-703-535-3738.

A History of Otolaryngology through Artists’ Eyes

Emma Cashman, MRCSI for the Otolarynogology Historical Society Art from the Renaissance through the 19th century provides some fascinating insights into historical perceptions of otolaryngology-related disease. For instance, Michelangelo was a perfectionist in his art and enthralled by anatomy. In much of his middle life, he dissected corpses and at one point toyed with the idea of publishing a treatise on anatomy with eminent physician Realdo Colombo, who is credited with distinguishing the thyroid gland as a separate organ. The presence of a goiter in Michelangelo’s Separation of Light from Darkness is well documented. Additionally, the Last Judgment, a masterpiece of Michelangelo’s later years, clearly depicts a woman with the classical signs of exophthalmos. Since the latest restoration in the 1990s, the presence of a small hemorrhage in the lower corner of her eyelid is now clearly visible. Both Rembrandt’s and Van Gogh’s ears have long been the source of speculation. Several lesser known works of art, however, provide an interesting historical insight into medieval perceptions of head and neck pathology. The central figure in Domenico Ghirlandaio’s An Old Man and His Grandson is the gentleman’s nose, which shows evidence of a rhinophyma. Does Piero di Cosimo’s A Satyr Mourning over a Nymph, currently housed in the National Gallery, London, represent the 15th century approach to tracheotomy? Sculpted depictions of facial trauma and, in particular, auricular hematomas, date back to antiquity. More recently, however, Rodin’s bust of fellow-sculptor Jules Dalou in 1889 provides a remarkably accurate portrayal of his subject’s deviated nasal anatomy. Robert C. Hinckley’s depiction of the first successful demonstration of anesthesia in 1846 (The First Operation Under Ether) commemorates an important landmark in surgical history. Hinckley purposely chose a large canvas to emphasize the importance of the event. The work depicts the patient sitting in a chair with his neck exposed for excision of a tumor of his jaw.

Diversity Committee Course Addresses Cultural Concerns

The Diversity Committee’s ongoing endeavors to promote cultural competence and improve patient care across the spectrum of cultures and ethnic backgrounds has been furthered by the release of a recent Patient Management Perspectives in Otolaryngology (PMP) issue. The Volume 42 issue addresses the “Adult for Rhinoplasty Consultation: The Mixed Non-Caucasian Rhinoplasty.” This is the first education activity developed by the Diversity Committee, and it is in the subspecialty of facial plastic surgery. The case is a non-Caucasian woman seeking rhinoplasty, whose aesthetic characteristics show a mix of ethnic backgrounds. She is aware of her ethnic background, and she and her family share pride in this background. These feelings cause her to express specific preferences to the consulting surgeon about the desired result. The preferences expressed may likely result in some confusion on the part of the surgeon, as they may seem to restrict the surgeon from planning a rhinoplasty that he or she might understandably feel would yield an overall pleasing result. This tension is woven into the case that plays out as the case study is read and followed. This course has a number of goals. As a basis, the case guides the participant in the approach to the aesthetic rhinoplasty patient, demonstrating an orderly progression from thoroughly listening to the patient, to formulating and carrying out a surgical plan, and through the postoperative care of the patient. Further, the case challenges the surgeon to listen, accept, and act upon a patient’s desires, even when these desires confuse or even thwart the surgeon in his or her efforts to achieve a result that he or she feels would be reasonably favorable. The case also demonstrates the concept that some patients of mixed ethnic heritage may be knowledgeable and sensitive about the specifics of that heritage, and may wish to preserve some, but not all, of the aesthetic characteristics of some components of that mixture. The influence the patient’s family may have on the aesthetic surgery patient’s feelings about his or her appearance is introduced. Even though it is axiomatic that the patient should be the primary beneficiary of surgical results, the surgeon who ignores the influence of significant surrounding persons on the patient’s self image and acceptance of surgical change does so at his or her peril, particularly when appearance characteristics are clearly ethnic in nature. The management of selected postoperative complications is explored. The concept of deciding against offering an operation to a patient who is clearly desirous of this operation is included, and an ethical manner that might be used to carry out this somewhat unusual decision is suggested. Finally, the course serves as a review of the characteristic rhinologic appearance of a specific non-Caucasian ethnic mix, the Mestizo nose. This review of the approach to, and management of, the Mestizo nose seems itself to be important, because with the increase of Hispanic populations and the increasing mobility of populations in general, the chances of any rhinoplastic surgeon, in any location, encountering a patient with Mestizo characteristics, is growing. Also, because of the specific ethnic mix that comprises the Mestizo nose, it lends itself well to the discussion of the patient with atypical, unexpected, or confusing aesthetic desires, some or all of which may originate in the patient’s ethnic self-image. This exercise also shines a light on the emergence of differing aesthetic ideals other than the generally accepted, Euro-centric, Caucasian/Western ideal of beauty that has long been the norm in aesthetic endeavors. These differing ideals may well grow to take a place beside long-accepted Western ideals, coexisting with them rather than replacing them. So, this course may be seen to address cultivation of the competencies of Patient Care, Medical Knowledge, Interpersonal and Communication Skills, Professionalism, and of course, Practice-Based Learning, in addition to stimulating the development of cultural competence. The interactive nature of the study promises to make it more interesting, and, we hope, more effective than simply presenting didactic material. Participants are invited to visualize themselves in their consulting rooms, actually discussing the patient’s desires and possible management options. The Diversity Committee hopes this PMP issue serves not only to educate participants in the specific aspects of this type of challenge in Facial Plastic Surgery, but also to increase awareness of the ever-broadening scope of patient self-perception, especially as it pertains to the non-Caucasian patient. PMP is an interactive online or print series that simulates real-life clinical decision-making. Each volume consists of eight issues that provides up to 64 AMA PRA Category 1 creditTM . To subscribe, visit www.entnet.org/PMP.

EHR—Meaningful? Useful?

Every president of the United States since George H.W. Bush has touted the electronic health information record (EHR) as the entry point to a new age of healthcare delivery and patient care. The adoption of EHR had been phlegmatic until President Barack Obama initiated and signed into law the American Recovery and Reinvestment Act of 2009. It was this legislation that committed a $20 billion investment in the Health Information Technology for Economic and Clinical Health (HITECH) Act, with the goal of coordinating an informatics infrastructure that would help to eliminate waste and redundancy, enhance quality and safety, allow for improved data collection and analysis, leading to the development of best practices for defined disease entities, i.e., acceptable outcomes for most patients, the most number of times for the least cost. It would therefore result in improved patient care and lower cost, with an anticipated savings of $12 billion over 10 years. In 2010, only 20 percent of physicians and 10 percent of hospitals were using EHR systems.1 The Medicare and Medicaid EHR Incentive Program component of HITECH provided a financial incentive to physicians to buy into the process, with a federally funded “reimbursement” to offset some of the cost of EHR implementation. Of course these funds came with a quid pro quo; physicians had to meet certain criteria in data collection, services and information exchange (Meaningful Use-MU) as a prerequisite for payment. Also, payments to the physicians are staggered over five years, with the criteria for funding not fully developed. Impressively, physicians responded like lemmings jumping off the Norwegian cliffs. The U.S. Department of Health and Human Services boasts that physicians meeting at least five of the core Meaningful Use objectives has increased by at least 66 percent and currently, half of all physicians are meeting nine of the Meaningful Use objectives.2 Two-thirds of physicians have received MU incentives. Now CMS is developing post payment MU audits, using outsourced recovery services, to expose any fraud and abuse. MU will enter Stage 2 in 2014, with a three-month reporting period. The added criteria for Stage 2 were decided upon by identifying the Clinical Quality Measures least reported by current users. The Big Question The biggest frustration of this program is finding the meaning and usefulness of much of the data being collected. Currently, there is no connectivity between practitioners and, other than improved report generation and computer initiated faxing or email, there is no ability to share data. Some federally funded state health information exchange initiatives are being developed, but have been limited to electronic access to laboratory and radiology studies. In the face of this failure to communicate, much of the data collected is moot, with no apparent utility. The next goal of the program is to add PQRS and ICD-10 to our EHR agenda, piling on more administrative strain and another potential roadblock for financial reimbursement from third party payers, including CMS. Where have there been improvements from EHR to date? The ability to send a clinical visit summary to other providers is simplified and expedited. The patients can also be given a written summary of their visit as they exit. Patient healthcare information forms can be developed and personalized, including pre-and post-operative instructions, informed consent, specific disease educational material, and specific therapy material. The added capacity for medication interaction identification and e-prescribing through the Rx component of the EHR enhances patient safety and convenience by eliminating drug interactions and prescribing errors due to handwriting misreads. The next steps should include either a centralization of computer languages or, more likely, super software to allow interconnectivity of all EHR software. Additional services could also be developed. Our Hopes, Our Needs Thomas Goetz, editor of Wired magazine, sponsored and developed an improved clinical laboratory study patient data form, presented on the TEDMED Conference website. He presents a data form that summarizes all normal findings by system, e.g., thyroid, cardiac, and liver all normal. The program then presents abnormal values on a color-coded scale, which explains personal risk to the patient. The program then integrates the lab data with demographics and further develops actions that could be taken for the individual patient. This provides a basis for enhanced patient-doctor interaction, allowing for improved compliance and outcomes. This program costs all of $10,000 for Wired to develop.3 It is time for us, as end-users of EHR, to interact with software companies and the government to put the “meaning” and “useful” into Meaningful Use, put the “quality” into Physician Quality Reporting, and truly improve the quality of patient care. For more information and key dates for CMS Quality Reporting Initiatives, see page 20. Sources Flanders, Adam; “The Real Meaning behind Meaningful Use,” radiographics.rsna.org. US Department of Health and Human Services; “More doctors are adopting EHRs to improve patient care and safety,” HHS.gov/news/press/12/201212b.html. Goetz, Thomas; “It’s time to redesign medical records,” TEDMED, posted 10/11.

Integration Focuses Policy and Action

At the time of this writing, we just completed an interesting week of having a couple of important spotlights on otolaryngology. First, the FDA announced its decision to issue a “box warning” for the use of codeine as an analgesic following tonsillectomy and adenoidectomy in children. Codeine is now contraindicated for this clinical scenario. While we had been communicating this issue to our members for some time, it became official only in February. Because tonsillectomy remains one of the most frequently performed surgeries in the United States, and often involves children, this is a significant announcement. It is beyond the scope of this column to share the details, but the specifics can be found at http://www.FDA.gov/Drugs/DrugSafety/ucm339112.htm. During that same week, the national press conference by the Choosing Wisely® campaign, which included an announcement of the AAO-HNS Foundation’s participation, took place at the Kaiser Family Foundation building in Washington, DC. Our “five things” or tests and treatments otolaryngologists and patients should question about overuse or effectiveness were released to the public. The event was well attended and many news outlets covered the campaign. We received several notices from members who heard the news in their local areas and complimented the Academy on its participation. You can read more atwww.entnet.org/choosing_wisely. While such events are not uncommon, this active week is a further reminder of the integration of the socioeconomic and the clinical. As advocates for our patients, we regard patient safety as paramount. Therefore, with regard to codeine, new data revealing a threat to patient safety is meaningful to us. However, it is challenging to have to abandon a well-established element of care on such short notice. The involvement of the FDA, the flurry of press coverage, and the need to notify doctors, hospitals, pharmacies, allied health providers, and the public demonstrate major advocacy, communications, and health policy challenges. The health policy issue arose from the published scientific and clinical literature combined with the FDA’s own tracking mechanisms for adverse events. Likewise, our participation in the Choosing Wisely® campaign arises from our members’ clinical experience, contributions, and suggestions. A member brought the campaign to our attention. The recommendations were chosen through suggestions from our members, subspecialty societies, Foundation committees, Guidelines Task Force, Patient Safety and Quality Improvement Committee, and others. It is likely that future evidence-based guidelines’ action statements will provide further tests, treatments, or interventions that should be questioned. As future payment models will inevitably be linked to quality improvement, we again see the intersection between advocacy and clinical care. While the Academy/Foundation clinical committees are relatively well known to most of us, the health policy and socioeconomic structure is not. Most of us could sit in on a clinical committee, easily follow the dialogue and discussion, and contribute valued opinion, experience, or judgment. Few of us could attend a RUC (Relative Value Update Committee) or CPT (Current Procedural Terminology) meeting with the same comfort and ability to give relevant input without a lot of coaching, support, and assistance. Most of our members do not know to whom they are indebted for the outstanding manner in which our Physician Payment Policy Work Group (3P) members represent our interests and our specialty in these national venues. This group consists of appointed RUC and CPT representatives and alternates, our Coordinators for Socioeconomic and Practice Affairs, and other members who are engaged in policy in related areas or advancing their skills for future appointment opportunities. Our current Academy structure is designed to better coordinate our efforts for seamless interaction between the socioeconomic and the clinical, research and education, and advocacy. With a single business unit responsible for Health Policy, Regulatory Advocacy, Research, and Quality, we are positioned to anticipate the effect of each element on the other, and to respond more quickly and effectively in advocating for our physician members and their patients’ best interests. Please join me in thanking these tireless individuals who so expertly serve us. CPT Team Bradley F. Marple, MD CPT Advisor Lawrence M. Simon, MD CPT Alternate Advisor RUC Team Charles F. Koopmann, Jr., MD RUC Panel Member Jane T. Dillon, MD RUC Panel Alternate Wayne M. Koch, MD RUC Advisor John T. Lanza, MD RUC Alternate Advisor Pete S. Batra, MD RUC Team Trainee Peter Manes, MD RUC Team Trainee

James L. Netterville, MD AAO-HNS/F President

An Introduction to the Ad Hoc Payment Workgroup

Dear Friends, I’d like to take the opportunity this month to tell you about the important work being undertaken by a group of volunteers on behalf of the Academy. As we begin to move away from a traditional fee-for-service model of payment currently used by our healthcare system today, the Academy has convened an Ad Hoc Payment Workgroup, which serves as a subgroup of the Physician Payment Policy Workgroup (3P), to review current and future payment trends in otolaryngology and other specialties. One of the Ad Hoc group’s goals will be to recommend one new payment model to the executive committee and board of directors in 2013. This is an exciting time for the Academy, as the healthcare community strives to reform and improve, and this key group is led by a talented group of physicians working on your behalf. The Ad Hoc Payment Workgroup comprises 3P Socioeconomic Coordinator, James C. Denneny III, MD; Richard W. Waguespack, MD (Academy President-Elect); John S. Rhee, MD, MPH; Richard M. Rosenfeld, MD, MPH; Emily F. Boss, MD, MPH; Robert R. Lorenz, MD; and J. Pablo Stolovitzky, MD, as well as staff from the Research and Quality and Health Policy teams. Additionally, the workgroup plans to collaborate with other members and Academy leadership who have specialized knowledge of payment models. Focal Points In 2013, the workgroup will focus on several areas that are particularly vital to you as otolaryngologist-head and neck surgeons and members of the Academy, including clarifying current guidance documents available, developing a Care Path for the treatment of sinusitis, and evaluating payment reform trends. This group has already been extremely active in the early months of 2013. For a more in-depth look at the Ad Hoc Payment Workgroup’s specific projects, please read Ad Hoc Payment Workgroup Evaluates Payment Models on page 18.