More from February 2013 Vol. 32 No. 02
Levi G. Ledgerwood, MD
A recent focus in global health is to address the portion of global burden of disease with a surgical cure. Cleft lip and palate, and congenital deformities represent a large portion of this burden, and require a level of expertise not routinely found in many locations worldwide. Nowhere is this more true than in Zimbabwe.
Operation of Hope is a non-profit organization that for 20 years has provided life-changing surgeries to people with cleft lip and palate deformities. Travis T. Tollefson, MD, MPH, and I recently had an opportunity to travel to Harare, Zimbabwe, as part of a seven-year-old project to foster a multidisciplinary team to provide support and education on surgical repair of these congenital deformities.
Our trip to Harare included 10 days of surgery at the Harare Central Hospital, a tertiary care center that serves the poorer portion of the population of Harare and smaller neighboring cities. More than 200 children with various congenital malformations, many of whom had traveled several days to attend our screening clinic, greeted us. During our stay, the team performed more than 50 primary cleft lip and palate repairs, along with many other minor surgical procedures. The look on parents’ faces when they saw their child for the first time after a cleft lip repair highlighted the profound personal affect of these surgeries for the patients and their families. However, the team is striving to improve upon the traditional vertical surgical mission paradigm. The collaborative team includes nurses, anesthesiologists, and others who contribute with lectures, supplies, and funding. The project also includes ongoing collection of surgical outcomes and determining a geospatial distribution of the congenital facial deformities in Zimbabwe.
This mission also enabled us to work with and train several local surgeons in cleft lip and palate repair. In collaboration with host country maxillofacial surgeons and residents, we have developed relationships for the ongoing care of these children. Such continuity is paramount to the success of any ongoing project, since so much of the care of these children takes place after the two-week project.
Overall, this experience was a powerful reminder of the stark contrast between medical care in the United States and developing nations. Operation of Hope has developed connections with the local government and community to obtain equipment and supplies for the mission, and continues to contribute to the medical community in Harare despite the political turmoil in the country. This important project in Harare has left an obvious mark on the community—one that can be seen in the smiles of all the children we have had the honor help there. Eric D. Wirtz, MD
David Healy, MD
Scott Roofe, MD
Department of Otolaryngology
Tripler Army Medical Center, Hawaii
Operation Sight, Sound, and Smile, a program comprised of otolaryngology and ophthalmology, was developed at Tripler Army Medical Center in 2004. It was created with the goal of partnering with surgeons throughout Asia in caring for their local, underserved population. Our goal is to not only provide direct patient care, but also to collaborate with the local surgeons to build capacity and advance their capabilities to create a sustainable impact. Since its origin, Sight, Sound, and Smile has partnered with fellow surgeons throughout Asia in countries as diverse as Bangladesh, Sri Lanka, and Malaysia.
Birendra Army Hospital in Kathmandu, a city of nearly 1 million people in the center of Nepal, was the site of our most recent mission from September 18-26, 2011. Three otolaryngologists, Scott B. Roofe, MD, David Y. Healy Jr., MD, and Eric D. Wirtz, MD, two anesthesia providers, two surgical technicians, and a circulator participated.
During our four surgical days, we performed more than 30 operative cases. The majority of these were tympanoplasties for near total perforations. In addition, we performed several tympanomastoidectomies for cholesteatoma and functional endoscopic sinus surgery for chronic rhinosinusitis with polyposis.
The Nepal trip proved to not only be a beneficial experience due to the patients who received surgical treatment for their chronic disease, but also due to the partnering that occurred between the Nepalese surgeons and our team. This partnership will continue to be fostered as there are plans to bring the Nepalese surgeons to Tripler Army Medical Center for continued collaboration. Tentative plans are set to return to Nepal in 2013 to further strengthen the partnership that has been created. James D. Smith, MD
Since separating from the Soviet Union in the early 1990s, Kazakhstan, a country with a population of about 15 million, has moved from an agrarian society to an economic one fueled by oil discoveries and other natural resources. As in most mid-level world economies, the wealth is not evenly distributed.
In October 2012, I was privileged to join a team giving a conference in Almaty, Kazakhstan, on pediatric neurodevelopment disabilities, specifically autism, cerebral palsy, and developmental delay. Almaty, Kazakhstan’s former capital, has beautiful scenery surrounded by 12,000-15,000-foot snow-capped mountains.
The team consisted of a developmental pediatrician; a pediatric neurologist from Astana, Kazakhstan’s current capital, who helped with translation; a speech therapist specializing in working with autistic children; an occupational therapist; a teacher of special needs children; an intern who has her PhD in neurobiology; and myself.
Two years ago, we started doing this type of conference at a pediatric hospital in Nairobi, Kenya. It turns out that in many countries children with these disabilities are kept hidden at home, basically receiving few or no services for diagnosis, treatment, or education. In Kenya, on our second visit we were told that the average age of referral for children with disabilities had gone from eight years of age to three. This is a significant change with improved hope for treating these children.
After a short visit to Almaty in 2011, Tracy Buckendorf, CCC-SLP, speech pathologist, was invited to return with this team for a week’s conference on pediatric neurodevelopmental disabilities. The initiation and organization came from a parent with a child with autism.
Although attempts were made to make the conference known in the medical community, there were only three or four physicians present. Of the nearly 90 attendees, about one-third were parents, one-third special needs teachers, and the rest were speech therapists, physical therapists, psychologists, and psychiatrists.
It turns out that the diagnosis and treatment of autism was the biggest draw. We found out that, by law, psychiatrists can only diagnose, but not treat, autism in many former Soviet Union countries. To further complicate early diagnosis and treatment, psychiatrists do not see children younger than four years of age. This means that the early critical period for training these children is missed.
In Kazakhstan, we learned that there were fewer than 200 children diagnosed with autism. To further complicate their care, the autism diagnosis is changed to schizophrenia at age 16. Parents become frustrated as they recognize something is wrong, but the pediatricians tell them nothing is wrong. From the Internet they are suspicious that their child has autism, but they have nowhere to turn for help.
The feedback from the audience was overwhelmingly positive. Attendees from a neighboring country asked for a team to do the same training next year. Invitations also came from Tajikistan and Azerbaijan when they heard about the conference.
What did I learn from this trip? The satisfaction of working with a team of other specialties and other professionals to help educate parents, teachers, and other professionals in an area they were eager to learn more and they saw as a need.
I realized first, how fortunate we are to have services for children with disabilities, which in many countries are hidden from society; second, how short-term teams, which provide education and training, can make as much difference in lives as direct patient care. Finally, I realized that sharing with others can be a life-changing activity. 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 one contains elements that make up the breadth of the education opportunities available through the Academy.
In this article we will explore the two live events offered by the Foundation: the Annual Meeting & OTO EXPOSM and the Coding and Reimbursement Workshops. Both of these provide opportunities for interaction with experts and networking with colleagues from around the world. Both also provide continuing education credit for participants.
Annual Meeting & OTO EXPOSM
As you know, the Annual Meeting & OTO EXPOSM is the world’s best gathering of otolaryngologists, together with the world’s largest collection of products and services for the specialty. Tailored specifically for practicing otolaryngologist–head and neck surgeons and associates, researchers in otolaryngology, senior academic professors and department chairs, leaders of international societies, fellows-in-training, and residents. The 2013 Annual Meeting & OTO EXPOSM will take place September 29–October 2 in Vancouver, BC, Canada.
The education component of each annual meeting is composed of instruction courses, miniseminars, guest lectures, scientific oral presentations, and posters. Instruction courses address current diagnostic, therapeutic, and practice management topics. Miniseminars are presentations, case studies, and interactive discussions that provide an in-depth, state-of-the-art look at new research in a clinical area. Oral presentations present findings on scientific research, surgical procedures, practices, and approaches to practicing physicians, residents, and medical students. Posters contain innovative information on original scientific research conducted by young investigators.
While numerous education options are available, the OTO EXPOSM itself is a focal point of networking and career enriching opportunities. Here the attendees are able to visit with representatives from more than 300 companies that cater to every aspect of otolaryngology practice, including device manufacturers, pharmaceutical companies, and practice management service providers.
Participants at the 2012 Annual Meeting & OTO EXPO praised both the excellent education content and the expansive exhibit hall.
“Excellent conference with outstanding panels and speakers.”
“Excellent. I was amazed at the new technology presented by exhibitors.”
“Very insightful presentations all around; great display of newer technologies and surgical techniques.”
Coding and Reimbursement Workshops
The Coding and Reimbursement Workshops are regional two-day events that enhance the business side of clinical practice and assist with the most current coding challenges. Day One of these workshops is designed to provide an overview of practice and reimbursement management and appropriate metrics and measurements for ENT practices. Day Two addresses coding office procedures, ancillary service coding, and surgical coding procedures.
The workshops are offered in conjunction with Karen Zupko and Associates (KZA) and take place eight times a year in select cities. The Academy’s Health Policy staff works with KZA to design new content for each year’s workshops. The Core Otolaryngology and Practice Management Education Committee (COPMEC), under Brendan C. Stack, MD, ensures its overall quality and success.
This year’s workshop themes are “Take Your Practice to the Next Level” and “Mastering ENT Coding.” Taken together, these two programs will show participants how to optimize their entire revenue cycle, and demonstrate how using the right processes speed payments and reimbursements.
“We know you have many options when it comes to coding courses. But we guarantee you’ll find that these workshops are an exceptional educational experience that is head and shoulders above the rest,” said Karen Zupko. Rahul K. Shah, MD
George Washington University School of Medicine,
and Children’s National Medical Center, Washington, DC
It has been more than a decade since the Institute of Medicine’s sentinel report on errors in healthcare, which outlined ways to systematically improve the quality of care in our country. There have been tremendous technological improvements during the past decade. For example, there is now broad reporting and acceptance of macro-level data, which allows trends to become apparent that can affect outcomes for our patients. Certainly, technology can be credited for helping to move the patient safety and quality improvement agenda forward in a dramatic fashion during the past decade.
However, there is one issue that persists and at times eludes the healthcare profession: enhancing communication. We function in an antiquated communication paradigm where we see a patient in the office, dictate a letter, and then mail the letter to our referring physician. Usually by the time the physician receives our letter, we have operated on the patient and they are seeing us for post-operative visits. I am sure you can think of many similar examples. Other industries have similar communication issues, but have been able to embrace technology and use it to greatly enhance communication and service (think of Wall Street two decades ago versus now vis-à-vis trading equities).
Of course, the electronic medical record is a giant leap forward in documentation and record keeping internally for practices and healthcare systems. However, at my last count there were hundreds of electronic medical record (EMR) companies out there—even one with free EMR. The problem with EMRs, however, is with inter-practice communication and within in a healthcare system. There is no doubt that we can and should track patient records; however, the EMRs do not address the communication void.
It has been noted that more than a quarter of adverse events and medical errors involve communication breakdowns. This is not too hard to fathom because for a medical error to occur there are usually multiple breakdowns in the system that allow an issue to persist and manifest as an error.
I often wonder with enhanced, rapid, or real-time communication if medical errors would be markedly reduced. The data seem to indicate so. There are certainly emerging platforms that exist to help change the manner in which we communicate in healthcare. I would posit that at present we can adopt low-technology solutions while awaiting broad acceptance of technologically more sophisticated alternative communication modalities.
Simply, we can all attempt to over-communicate. I cannot fathom an instance where over-communication would be detrimental to patient care. Indeed, the military and other industries use refined communication tools, such as the Situation, Background, Assessment, Recommendation (S-B-A-R) technique to ensure proper communication. How about the drive through at fast food establishments? They often invoke the read back and verify rule with your order. They want to ensure your order is correct. Perhaps in healthcare we can do similarly to ensure the medication we dispense or order we give is correct.
One of the constraints we have faced is the burden of regulations. HIPAA does place limits on how we can communicate, especially with electronic protected health information (e-PHI), which has come under tremendous scrutiny. Certainly there are technologies that are being developed for substantial cost, and some for free, that will improve healthcare communication. I implore Academy members to contemplate low-technology solutions for communication and seek platforms that are designed to enhance technology communication. The end goal being a reduction of adverse events and medical errors by improving the manner in which we communicate healthcare information.
We encourage members to write us with any topic of interest and we will try to research and discuss the issue. Members’ names are published only after they have been contacted directly by Academy staff and have given consent to the use of their names. Please email the Academy at firstname.lastname@example.org to engage us in a patient safety and quality discussion that is pertinent to your practice. Experts agree that correct coding may be the single most important area for surgical practice improvement. However, keeping up with the constant changes in claims coding and billing rules can be costly and time consuming. Therefore, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS)—as a part of its ongoing endeavor to support members—has several resources available for members, as highlighted below.
AAO-HNS CPT for ENT Articles
These articles provide specific, coding guidance from the AAO-HNS Physician Payment Policy (3P) workgroup and AAO-HNS CPT team, on common coding inquiries received from Members, or key coding changes impacting Otolaryngology-Head and Neck Surgery. They can be found online at: http://www.entnet.org/Practice/cptENT.cfm.
New for 2013: Academy Coding Corner
Beginning for 2013, the Academy will include critical updates and coding changes to Members via multiple mechanisms, including the Bulletin and the HP update. Stay tuned for more information.
AAO-HNS 2013 Coding Workshops
The Academy, in partnership with Karen Zupko & Associates, provides members with the opportunity to enhance the business side of their clinical practice. Held eight times a year, these two day workshops enhance the business side of clinical practice and assist with the most current coding challenges. Visit www.entnet.org/coding for more information.
AAO-HNS Coding Assistance
As an Academy member, you receive several complimentary coding guidance consultations to help with your more complex coding questions. To access a coding specialist, call 1-800-584-7773, 9 am-6pm ET. If you would like to provide feedback on guidance provided by the coding specialist, please contact the Health Policy department at HealthPolicy@entnet.org.
Additional Coding Resources
We urge physicians to reserve the use the AAO-HNS Coding Hotline for complicated coding questions. For more general education and guidance, we strongly recommend that you and/or your office billing claims staff annually attend the AAO-HNS Coding workshops as well as some or all of the following coding educational workshops and/or visit the websites noted for coding reference materials:
Medicare Learning Network offers 17 web-based programs. Details are on the CMS website: http://www.cms.hhs.gov/MLNProducts (click on the link to web-based training modules at the bottom of the page).
American Medical Association offers many resources including: CPT/RVU search; 2013 Code Changes book and workshop, CPT Assistant, webinars, CPT/RBRVS Annual Symposium, articles, etc. See: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-products-services.page?
Coding & Reimbursement Workshops for Otolaryngology
Enhance the business side of your clinical practice by attending the regional workshops conducted by Karen Zupko & Associates. The course sessions, held Friday and Saturday, are designed to help you to run a better business and ensure that you are coding correctly:
Profitable Practice Management Mastering ENT Coding
The second day of each workshop is approved for AMA PRA Category 1 Credit™ for physicians.
Workshop location and dates for 2013:
Wyndham Grand Orlando, Bonnet Creek
Las Vegas, NV
Encore at Wynn Las Vegas
The Drake Hotel
Loews Vanderbilt Hotel
Radisson Blu Mall of America
Las Vegas, NV
The Westin Las Vegas
Hyatt Chicago Magnificent Mile
Register at www.karenzupko.com or call 312-642-8310.
For more information, visit www.entnet.org. In October 2012, the Office of Inspector General (OIG) issued its Annual Work Plan for the next fiscal year, which stipulates the areas of the Medicare and Medicaid programs that the OIG (Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General) will monitor and investigate to promote efficiency and eliminate incorrect billing, waste, fraud, and abuse in these programs. The OIG releases the details of its findings in reports that outline its methodology for determining payment or billing errors and recommendations to the Centers for Medicare & Medicaid Services (CMS) to recoup erroneous payments. In addition, the Medicare Recovery Audit Contractors (RAC) will monitor the improper payment trends that the OIG indentifies in these reports to guide its selection of new areas to audit in Medicare Part A and Part B programs.
The OIG plans to focus on Medicare Part A and Part B claims billed in various settings, including hospitals, acute care hospitals, hospital outpatient setting, physician offices, and ambulatory surgical centers. Notably, in addition to continuing its oversight of the Recovery Act and the Affordable Care Act (ACA), the OIG will also review CMS’ documentation of its contracts with Medicare Administrative Contractors (MACs) and CMS’ ongoing monitoring and assessment of MAC performance.
We have reviewed the 2013 work plan and believe the following new and ongoing OIG initiatives could affect otolaryngologist–head and neck surgeons. Members should also remember that several initiatives instituted in previous years are still ongoing.
Some of the new areas that OIG will review in 2013 include:
OIG will analyze claims data to determine how much CMS potentially could save if it bundled outpatient services delivered up to 14 days prior to an inpatient hospital admission into the diagnosis related group (DRG) payment. Currently, Medicare bundles all outpatient services delivered three days prior to an inpatient hospital admission.
OIG will review Medicare payments made to hospitals for beneficiary discharges that should be coded as transfers and determine whether these claims were appropriately processed and paid.
Providers may use GA or GZ modifiers on claims they expect Medicare to deny as not reasonable and necessary. After a recent OIG review showed that CMS paid for 72 percent of pressure-reducing support surface claims with GA or GZ modifiers resulting in $4 million in inappropriate payments, OIG will determine the extent to which Medicare improperly paid claims from 2002 to 2011 in which providers entered GA, GX, GY, or GZ service code modifiers.
Since OIG suspects that hospitals may be acquiring Ambulatory Surgical Centers (ASCs) and providing outpatient surgical services in that setting, for 2013 OIG will be reviewing the extent to which hospitals acquire ASCs and convert them to hospital outpatient departments. OIG plans on also determining the effect of such acquisitions on Medicare payments and beneficiary cost sharing.
After recent Government Accountability Office (GAO) reports have revealed pervasive deficiencies in CMS’ internal control and contract management, OIG will review the number, types, and dollar amount of active CMS contracts and examine how CMS maintains all of its contract information. In addition, OIG will assess CMS’ monitoring and performance of MACs and assess MACs implementation of Part A and Part B system edits.
OIG will determine the extent to which Medicare’s supply replacement schedules for supplies related to continuous positive airway pressure (CPAP) machines vary from those of Medicaid, Department of Veterans Affairs (VA), and Federal Employees Health Benefits programs.
After recent drug shortages, OIG will attempt to determine the extent to which providers of select Part B-covered drugs in short supply report difficulty acquiring those drugs. OIG will ask providers to describe their behavior when facing a drug shortage and any effect on pricing, quality of care, and market availability.
In addition to its new initiatives, the OIG will continue previously launched initiatives by continuing to review:
Hospitals’ controls for ensuring the accuracy and validity of data related to quality of care that they submit to CMS for Medicare reimbursement. Hospitals must report quality measures in order to avoid penalties to their Medicare payments.
Medicare: Hospital claims with high or excessive payments.
Medicare payments for Part B Imaging Services.
Medicare Part B paid claims and medical records for interpretations and reports of diagnostic radiology services (X-rays, CT, and MRIs) performed in emergency hospital settings.
Off-label use of Medicare Part B prescription drugs and medical necessity of reimbursement.
Medicare payments for observation services provided during outpatient visits.
Medicare claims for same day hospital readmissions.
Medicare Part B claims and appropriate report of place-of-service codes.
The appropriateness of the process for devising ambulatory surgical center (ASC) reimbursement rates under the revised ASC payment system.
Safety and quality levels of surgeries performed in an ASC setting.
Place of service coding errors for services performed in an ASC and hospital outpatient departments.
E/M services reimbursed as part of the global surgery fee in effort to determine if practices have changed since institution of the concept in 1992.
Electronic Health Record E/M Claims with identical documentation across services.
Medicare/Medicaid Incentive Payments for provider adoption of Electronic Medical Records.
Appropriateness of Medicare payments for sleep studies and sleep test procedures.
Medical necessity of high-cost diagnostic tests billed to Medicare.
Medicare Outpatient Hospital Claims for the Replacement of Medical Devices: OIG will determine whether hospitals submitted outpatient claims that included procedures for the insertion of replacement medical devices in compliance with Medicare regulations.
The extent to which providers comply with assignment rules (for participating and non-participating providers).
Physician billing for incident-to services so OIG can see if the error rate is higher than non-incident-to services.
Physician billing of unusually high cumulative part B payments made to an individual physician or supplier, or on behalf of an individual beneficiary, during a specified period.
Medicare Part A and B claims submitted by top error-prone providers.
Since the work plan primarily focuses on providers’ compliance with Medicare requirements, it is vital that members adhere to documentation requirements, particularly given the transition to electronic health records and requirements for meaningful use. As such, we encourage members to access Academy resources and tools designed to assist with compliance prior to submitting your claims:
The Academy’s Coding Hotline: 1-800-584-7773.
Correct Coding Initiative Edits assists with modifier usage: https://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage.
Ensure you are aware of maximum units you can report for a service on the same patient on the same date of service (Medically Unlikely Edits (MUEs) https://www.cms.gov/NationalCorrectCodInitEd/08_MUE.asp#TopOfPage.
Be mindful of global periods for procedures when submitting claims.
Access the Academy’s website for updated coding resources (http://www.entnet.org/practice/Guidelines.cfm) prior to submitting your claims. Please email Healthpolicy@entnet.org for further details.
2013 OIG Work Plan: https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf; Accessed December 2012.