More from January 2013 - Vol. 32 No. 01
Mark C. Royer, MD
My recent surgical outreach trip to Moi University Teaching and Referral Hospital (MTRH) in Eldoret in western Kenya was a continuation of the strong relationship that has developed between the otolaryngology departments at MTRH and Indiana University School of Medicine (IUSM), Indianapolis, IN, as part of the institution-wide partnership, the IU-Kenya Program.
The otolaryngology relationship commenced when Susan R. Cordes, MD, traveled to Eldoret to search for ways the IUSM otolaryngology department could develop an international presence. Since this initial visit, Dr. Cordes and surgeons from our department have taken part in several surgical and teaching trips.
I was fortunate to be included in the February 2012 trip and performed a variety of otolaryngology procedures including pediatric cleft lip and palate repairs, osteosarcoma resection with pectoralis flap reconstruction, endoscopic sinus surgery, and various otologic procedures. The physician team consisted of four from IUSM— Dr. Cordes (residency program director), Taha Z. Shipchandler, MD, (facial plastics and reconstructive surgery), Charles W. Yates, MD (neurotology), and myself (PGY-5), andKimberly Rutherford, MD (PGY-5, University of Connecticut).
In addition to seeing patients in clinic and performing surgeries, Dr. Rutherford and I spent time teaching Moi University medical students. During this trip, I especially enjoyed the camaraderie between the IUSM team and the Kenyan otolaryngologists, meeting patients and their families from all across western Kenya, and developing the requisite problem-solving skills necessary to perform complicated procedures within the limitations of developing world operating rooms.
A highlight of the trip was again seeing and working with my friend, Henry N. Nono, MD, a Moi University otolaryngologist, who was awarded an AAO-HNSF International Visiting Scholarship to attend the AAO-HNSF 2011 Annual Meeting & OTO EXPOSM and spent several weeks with the IUSM otolaryngology department. With our support, Dr. Nono hopes to complete a head and neck fellowship to increase the acuity of care he can provide for patients in western Kenya.
The IUSM-Moi otolaryngology partnership continues to develop the scope and patient care abilities for the future. I look forward to participating in and supporting these efforts for years to come. Many thanks to the AAO-HNSF Humanitarian Efforts Committee and the Alcon Foundation, for their support which made my participation in this trip possible. Eugene N. Myers, MD, FRCS Edin (Hon)
Distinguished Professor and Emeritus Chair
University of Pittsburgh School of Medicine
The XIII Belinov Symposium took place in the Melia Grand Hermitage Hotel, Golden Sands, Varna, Bulgaria, on September 28-30, 2012, sponsored by the Bulgarian National Society of Otorhinolaryngology-Head and Neck Surgery and the Association of Otorhinolaryngologists’ Professor Dr. Stoyan Belinov-Isul.
Thanks to the leadership of Rumen Benchev, MD, PhD, organizing committee chair and president of the Bulgarian National Society, and to the outstanding contribution of Dr. Dilyana Vicheva and Prof. Haruo Takahashi (Japan), the symposium was well organized with 231 delegates including speakers from the U.S., Israel, Germany, and Japan.
Diana Popova, MD, PhD, was chair of the scientific committee and of the Association of Otorhinolaryngologists. Papers were given in both Bulgarian and English with simultaneous translation and the delegates paid a great deal of attention to the academic lectures.
The meeting opened officially with a Plenary Lecture by myself, on “The Changing Role of the Surgeon in the Era of Chemoradiation,” followed by other interesting papers on “Turbinate Surgery, Concepts and Techniques–Conservative Surgical treatment of the Turbinates” by John F. Pallanch, MD, Mayo Clinic; “Pathophysologic Mechanism of Fungi in Chronic Rhinosinusitis” by Dr. Vicheva; “Hearing Improvement Operations in Otosclerosis” by Ivan Tsenev, MD; and “Benefits of Nasal Douches” by Dr. Benchev, all from Bulgaria.
In his informative lecture, Dr. Benchev told of the increasing popularity of nasal douches, stimulated by those who participate in yoga. Other noteworthy lectures were presented by Dan Fliss, MD, (Israel) on “Treatment of Paranasal Sinus Tumors;” Prof. Takahashi on “Pathogenesis and Management of Cholesteatoma from the Viewpoint of Middle Ear Pressure Regulation;” and Prof. Karl Hoermann, MD, on “Challenges of the Frontal Sinus” and “Snoring and OSAS—New Aspects.”
The next two days were primarily dedicated to rhinology sessions in cooperation with the Bulgarian Rhinological Society. In addition, there were plenary sessions on laryngology and otology. The Bulgarian hospitality was superb, including a cocktail reception after the opening session and a splendid gala dinner in the Hotel Admiral, Golden Sands. Eugene N. Myers, MD, FRCS Edin (Hon), Distinguished Professor and Emeritus Chair University of Pittsburgh
Eugene N. Myers, MD, FRCS Edin (Hon), was the guest of honor at the 8th International Conference on Head and Neck Cancer at the Metro Toronto Convention Center in Ontario, Canada, July 21-25, 2012. The conference was a huge success with 1,860 participants attending from more than 70 countries. There were seven keynote speakers, 406 oral presentations, 1,030 posters, and 39 instructional courses, including a full-day ACS hands-on ultrasound course.
Carol R. Bradford, MD, president of the American Head and Neck Society, presided over the meeting. The conference chair, Jeffrey N. Myers, MD, PhD, assembled an astonishingly broad-based and energized meeting and introduced his father, Dr. Eugene N. Myers, as guest of honor.
The program chair was Jonathan Irish, MD, MSc, FRCSC, and other conference leadership was provided by Robert L. Ferris, MD, PhD, chair for proffered papers, Eben L. Rosenthal, MD, poster sessions chair, and Bert W. O’Malley, Jr., MD, fundraising chair. By now, you should have discovered the AcademyU® Education Opportunities catalog that is included with this issue of the Bulletin. The catalog contains a complete description and listing of the education and knowledge resources available to members through the AAO-HNS/F. In total, these resources are a great value for all Academy members, including physicians and physicians-in-training in otolaryngology-head and neck surgery, general practice physicians, physician extenders, and medical students.
In the December Bulletin, we launched the new AcademyU®, Your Otolaryngology Education Source. This single source brings you hundreds of education and knowledge resources covering a variety of topics organized by the eight specialties within otolaryngology-head and neck surgery. Education Opportunities is an easily accessible and comprehensive look at all of these resources.
As described in Education Opportunities, the Foundation’s education and knowledge resources span several learning formats and designs. This diversity should appeal to members’ different education needs, learning styles, and desires whether they are live events, subscriptions, online education, eBooks, or knowledge resources.
Live Events: The Annual Meeting & OTO EXPOSM and the regional Coding and Reimbursement Workshops offer interaction with experts and networking with colleagues and an opportunity to earn continuing education credit.
Subscriptions: Patient Management Perspectives in OtolaryngologySM and Home Study Course are subscription products offering in-depth and comprehensive learning opportunities and continuing education credit.
Online Education: The Foundation offers nearly 200 self-based and interactive online courses, including the Online Lecture Series and COOL cases; most provide continuing education credit for physicians and physician assistants.
eBooks: There are currently five eBooks published by the Foundation that can be used as references and guides in the care of patients. They cover the gamut from geriatric care to trauma. Each is easily accessible and downloadable from the Academy website.
Knowledge Resources: Products that assist with test preparation, applying new skills, resident education, and enhancing presentations include AcademyQ™, ENT Exam Video Series, COCLIASM, and the ImageViewer.
During the course of the next year, we will be taking an in-depth look at each of the elements that fall under these categories. Through these Bulletin articles, you will see that each resource, developed by leading experts, is designed to deliver relevant education and knowledge that is meaningful to your practice.
“AAO-HNSF is dedicated to providing the highest quality education elements to meet member learning needs throughout all phases of your professional career. Please use the 2013 Education Opportunities and take advantage of the exciting education offerings available through the Foundation” emphasized Sonya Malekzadeh, MD, AAO-HNSF Coordinator for Education.
The AAO-HNS Foundation is committed to increasing member awareness and engagement in the education and knowledge resources available from AcademyU®, the Foundation’s otolaryngology education source. Ron B. Mitchell, MD; Heather M. Hussey, MPH; Gavin Setzen, MD; Ian N. Jacobs, MD; Brian Nussenbaum, MD; Cindy Dawson, MSN, RN, CORLN; Calvin A. Brown III, MD; Cheryl Brandt, MSN, ACNS-BC; Kathleen Deakins, RRT-NPS, FAARC; Christopher J. Hartnick, MD; Albert L. Merati, MDTracheostomy
Tracheostomy is one of the oldest and most commonly performed surgical procedures among critically ill patients.1-5 Tracheostomy creates an artificial opening, or stoma, in the trachea to establish an airway through the neck.6 The stoma is usually maintained by inserting a tracheostomy tube through the opening.7,8
Tracheostomy is increasingly performed on adults in intensive care units (ICU) for upper airway obstruction, prolonged endotracheal intubation, and for those requiring bronchial hygiene.9 In adults, the traditional surgical tracheostomy has been accompanied by the emergence of percutaneous dilatational techniques (PDT). Adult tracheostomy can be performed in the operating room or at the bedside in an intensive care unit. In children, other than on rare emergencies, tracheostomy is performed in the operating room with the child intubated under general anesthesia. In children, tracheostomy is most frequently performed in the first year of life due to the increased survival of premature infants requiring prolonged ventilation.10
A review of the literature on the care and management of tracheostomy shows a paucity of both well-controlled studies and high-quality evidence. The majority of publications are book chapters, expert opinion, and small observational studies. There are essentially no controlled studies or peer-reviewed papers to guide care or practice in this field. As evidence-based research is lacking, the current literature does not support the development of a clinical practice guideline, but favors a consensus of expert opinions.
Consensus Statement Development
A consensus panel was therefore convened by the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) to create a clinical consensus statement (CCS). An organized group of multidisciplinary experts was selected to review the literature, synthesize information, and clarify specific areas of controversy or ambiguity regarding the care and management of patients with a tracheostomy. Despite significant differences between pediatric and adult tracheostomy care, the panel concluded there are sufficient similarities to justify a single document for both groups of patients.
The findings of this consensus group are stated as opinions or suggestions, not as recommendations. Clinicians should always act and decide in a way they believe will best serve their patients’ interests and needs, regardless of consensus opinions. They must also operate within their scope of practice and according to their training. The consensus panel made suggestions about a large number of statements that dealt with a variety of subjects including the most appropriate tracheostomy tube type, suctioning, humidification, patient and caregiver education, home care, emergency care, decannulation, tube care (including use of cuffs and sutures), as well as overall clinical airway management. The panel also dropped a number of statements on utility of tracheostomy ties or sutures, cleaning methodology, specific circumstances when the tube should be changed, utility of cuffs, and desired frequency of changing the tube.
This consensus statement was developed using a modified Delphi method, a systematic approach to achieving consensus among a panel of topic experts. Initially designed by the RAND Corporation to better utilize group information in the 1950s, this methodology has been modified to accommodate advances in technology and is used widely to address evidence gaps in medicine and improve patient care without face-to-face interaction.11,12 Figure 1 provides an overview of the consensus process used to create this CCS.
Panel members were asked to complete two surveys utilizing a nine-point Likert scale to measure agreement (see Table 1). An outlier was defined as any rating at least two Likert points away from the mean.
Each survey was followed by a conference call during which results were presented and statements discussed. Statements were categorized as follows:
Consensus: Statements achieving a mean score of 7.00 or higher and have no more than one outlier.
Near consensus: Statements achieving a mean score of 6.50 or higher and have no more than two outliers.
No consensus: Statements that did not meet the criteria of consensus or near consensus.
Key Consensus Statements
Of the 77 statements that achieved consensus, 13 were considered the most important for day-to-day tracheostomy care in adults and children and are presented in Table 2.
Further research is needed in a number of areas highlighted in this document:
To define quality metrics related to tracheostomy care, (optimal tracheostomy tube size, role of tracheostomy tube cuffs, role of sutures and ties in preventing accidental decannulation, cleaning and suctioning techniques, frequency and timing of tracheostomy tube change) that correlate to early hospital discharge.
To define important factors in patients with a tracheostomy that may influence the frequency of site infections, accidental tube displacement, emergency room visits, and re-admission to hospital. Important factors may include optimal cleaning and suctioning techniques, patient and caregiver education, frequency of follow up care, training, and competency of home care nurses.
Determine whether trained Advanced Practice Providers (APPs) are able to perform initial tracheostomy changes with similar or fewer complication rates compared to experienced physicians.
This article is freely available to AAO-HNS members and the public at Otolaryngology—Head and Neck Surgery, visit http://oto.sagepub.com.
Hameed AA, Mohamed H, Al-Ansari M. Experience with 224 percutaneous dilatational tracheostomies at an adult intensive care unit in Bahrain: a descriptive study. Ann Thorac Med. Jan 2008;3(1):18-22.
Al-Ansari MA, Hijazi MH. Clinical review: percutaneous dilatational tracheostomy. Crit Care. Feb 2006;10(1):202.
Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest. Nov 2000;118(5):1412-1418.
Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care. 2006;10(2):R55.
Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. May 28 2005;330(7502):1243.
ANZICS. Percutaneous Dilational Tracheostomy Consensus Statement 2010.
MOH. Nursing Management of Adult Patients with Tracheostomy. Singapore: Ministry of Health; 2010.
Woodrow P. Managing patients with a tracheostomy in acute care. Nurs Stand. Jul 17-23 2002;16(44):39-46; quiz 47-38.
Durbin CG, Jr. Tracheostomy: why, when, and how? Respir Care. Aug 2010;55(8):1056-1068.
Pereira KD, MacGregor AR, Mitchell RB. Complications of neonatal tracheostomy: a 5-year review. Otolaryngol Head Neck Surg. Dec 2004;131(6):810-813.
Vonk Noordegraaf A, Huirne JA, Brolmann HA, van Mechelen W, Anema JR. Multidisciplinary convalescence recommendations after gynaecological surgery: a modified Delphi method among experts. BJOG. Dec 2011;118(13):1557-1567.
Dalkey NC. The Delphi Method: An Experimental Study of Group Opinion. Santa Monica: RAND Corporation;1969. RM-5888-PR.
Figure 1. Modified Delphi method for achieving consensus
Select Multidisciplinary Panel
Eight to 10 panel members
Conference Call 1
Identify evidence gaps in literature
Develop series of open-ended questions
Distribute to panel for completion
Conference Call 2
Discuss results from qualitative survey
Delphi Survey 1
Chair and staff liaison develop statements
Distribute to panel for completion
Conference Call 3
Discuss results achieving near or no consensus from Delphi survey 1
Delphi Survey 2
Revise statements and add new statements (if applicable)
Distribute to panel for completion
Conference Call 4
Discuss survey results and revise statements if necessary
Table 1. Likert scale used to measure level of agreement among respondents for both Delphi surveys.
Table 2. Key statements achieving consensus.
The purpose of this consensus statement is to improve care among pediatric and adult patients with a tracheostomy.
Patient and caregiver education should be provided prior to performing an elective tracheostomy.
A communication assessment should begin prior to the procedure when non-emergent tracheostomy is planned.
All supplies to replace a tracheostomy tube should be at bedside or within reach.
An initial tracheostomy tube change should normally be performed by an experienced physician with the assistance of nursing staff, a respiratory therapist, medical assistant, or assistance of another physician.
In the absence of aspiration, tracheostomy tube cuffs should be deflated when a patient no longer requires mechanical ventilation.
In children, prior to decannulation, a discussion with family regarding care needs and preparation for decannulation should take place.
Utilization of a defined tracheostomy care protocol for patient and caregiver education prior to discharge will improve patient outcomes and decrease complications related to their tracheostomy tube.
Patients and their caregivers should receive a checklist of emergency supplies prior to discharge that should remain with the patient at all times.
All patients and their caregivers should be evaluated prior to discharge to asses competency of tracheostomy care procedures.
Patients and their caregivers should be informed of what to do in an emergency situation prior to discharge.
In an emergency, a dislodged, mature tracheostomy should be replaced with the same size or a size smaller tube or an endotracheal tube through the trach wound.
In an emergency, patients with a dislodged tracheostomy that cannot be re-inserted should be intubated (when able to intubate orally) if the patient is either failing to oxygenate, ventilate, or there is fear the airway will be lost without intubation.
5-9 Rahul K. Shah, MD, George Washington University School of Medicine, Children’s National Medical Center, Washington, DC
There are myriad databases reporting on a physician’s outcomes, or a surgeon’s complications, your partner’s length of stay, and many other types of data being collected by societies, institutions, government, and commercial insurers, just to name a few. However, many of these databases and the data are not owned by the patients or the physicians that care for the patients. Hospitals, and in some cases, practices, submit data, often times mandatory, that is then collated and put together in aggregate. From there, the data is compiled at a national level to make meaningful analysis statistically significant.
We are excited to soon launch a patient safety event web portal on the AAO-HNS website. This is the end result of an attempt to develop a mechanism where we can have our physicians securely and confidentially report on near misses, adverse events, and medical errors.
The original idea was to consider forming an otolaryngology-specific Patient Safety Organization (PSO) that would serve such a role. There are significant administrative burdens to forming PSOs, and the investment did not appear to provide real value to members. Under the guidance the AAO-HNS quality improvement staff, the Patient Safety and Quality Improvement Committee has created a secure patient safety event web portal that enables physician members to enter events.
Academy staff have gone to great lengths to ensure the protection of the reporting physician’s information and the subsequent report. Furthermore, none of the fields in the reporting form allow for identification of a particular patient, location, venue, etc.
It is exciting to consider the potential of an event reporting database. The Federal Aviation Administration has the most robust reporting system where pilots and crew are mandated to complete such a report when specific events occur. No such system exists in healthcare or our specialty.
The power of some aggregate level data cannot be over-emphasized. The rare frequency of events that we are looking at may only happen in 1:30,000 instances, or less. An individual practitioner, for example, may have heard and known about a case of misadministration of concentrated epinephrine, but they may not have personally ever experienced such an occurrence. Does this make the problem less of a latent systems defect? Of course not. It just makes it much harder for physicians to see the magnitude and the scope of the issue.1
This is precisely where the reporting system becomes valuable. By surgeons reporting events that are of concern to them, we will have the ability to immediately identify zones of risk. Once these areas are identified, we can proactively study them to attempt to put measures in place to assist in mitigating future events.
The major caveat of this platform is that the data is only as good as the input. For example, if we have 1,000 reports (one per every four physician members) in our first year, we are confident that there would be actionable alerts and possibly interventions that would come from these reports. However, we do fear that if there are only five reports all year, then the database becomes meaningless. This is our opportunity to report on instances of near misses, adverse events, and medical errors that directly influence our practice and our patients. Rarely do we have such an ability to affect the safety and quality of the care provided to our patients. We look forward to periodically sharing the data with members.
Shah RK, Hoy E, Roberson DW, Nielsen D. Errors with Concentrated Epinephrine in Otolaryngology. Laryngoscope. 2008 Nov;118(11):1928-30.
We encourage members to write us with any topic of interest. 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. Email the Academy at firstname.lastname@example.org to engage us in a patient safety and quality discussion that is pertinent to your practice. It is critical that Academy members keep in mind that maintaining value for otolaryngology-head and neck surgery services is an enormous success in light of the rigorous review and cost-saving focus of both the AMA RUC and CMS. Therefore, the Academy is pleased that we were able to maintain, or increase, relative value units for nearly all codes reviewed in the 2012 RUC cycle. The table below includes values approved by CMS for CY 2013.
As was mentioned in the November 2012 edition of the Bulletin, members can expect several coding changes for ENT services in CY 2013. Many of these changes are discussed in our summary of the 2013 final Medicare Physician Fee Schedule, which is posted on the Academy website at http://www.entnet.org/Practice/Summaries-of-Regulations-and-Comment-Letters.cfm. The Academy also provided comments to CMS on all provisions of the final fee schedule that affect our members, including the valuation information for 2013.
Specific fluctuations in reimbursement for these services are demonstrated by the table below this article. The Academy participated either directly, or via comment and/or monitoring, in the development of recommendations to the AMA RUC for all of the following procedures. For several codes, such as the complex wound repair family of codes, the Academy was asked to collaborate with other specialty societies (e.g., American Society of Plastic Surgery and American Academy of Dermatology) to develop relative value and practice expense recommendations. Those recommendations are then reviewed by the AMA RUC and either approved or modified. CMS is then presented with the AMA RUC’s value recommendations and may either approve or modify the values for these services. They then post their final determinations in the final Medicare physician fee schedule final rule each year.
In the event members have any questions regarding the above information or modifications to specific codes, please email us at email@example.com. On November 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final Medicare physician fee schedule (MPFS) rule for calendar year (CY) 2013. The Academy submitted comments to CMS on the final rule, which can be viewed at http://www.entnet.org/Practice/Summaries-of-Regulations-and-Comment-Letters.cfm#CL.
Some key provisions finalized in the 2013 rule included:
Medicare Sustainable Growth Rate (SGR)
The Medicare law includes the standard statutory formula that will require (absent congressional intervention) a CMS projected reduction of 26.5 percent to the MPFS conversion factor (CF), which would result in a CF of $25.0008 in 2013. Contractors are required to issue fee schedule files to their participating physicians in their locality, which include the estimated SGR cut that you may receive. Since Congress has not taken action for 2013 to fix the SGR at press time, the contractors cannot show payment rates that assume the problem will be resolved until legislation has actually been passed to do so. Thus, the fee schedules from contractors may assume the SGR cuts to all services for 2013. As in previous years, however, it is expected that Congress will take action to avoid the impending cut due to the sustainable growth rate (SGR) before the January 1, 2013, deadline.
Impact for Otolaryngology-Head and Neck Surgery
Overall, our specialty fared well regarding the impact of policy changes within the Medicare physician fee schedule for CY 2013. Otolaryngology-head and neck surgery saw a 2 percent cumulative increase in allowed charges for 2013, but physicians may see fluctuations in the Practice Expense (PE) for some services due to several policy changes. Other related specialties that saw an increase were allergy, plastic surgery, and oral-maxillofacial. Unfortunately, audiology saw a slight decrease. Depending on the make up of services provided in your practice, the affects of these changes will vary in their effect on reimbursement rates. One modification in the final rule is the change in formula for determining a maximum interest rate for equipment-related PE RVUs. In addition, increases to some PE RVUs for otolaryngology-head and neck surgery services may also occur as a result of the last of a four year transition of the Physician Practice Expense Information Survey (PPIS) data used to calculate practice expense RVUs for services.
Improving Valuation of the Global Surgical Package
Since 1992, CMS has applied the concept of payment for a global surgical package under the PFS. This means that for each surgical procedure, they establish a single payment, which includes payment for all related services typically furnished by the surgeon providing the procedure during the global period. The global surgical package payment rate is based on the work necessary for the typical surgery and related pre and post-operative work. CMS noted that different methodologies have been used in valuing global surgical services and more recently reviewed codes tend to have fewer evaluation and management (E/M) visits in their global periods. They observed that codes reviewed less recently did not appear to have the full work RVUs of each E/M service in the global surgical package, resulting in inconsistent numbers of E/M visits during the post-operative period across families of procedures.
Under current policy, a surgeon is not required to document in the medical record what level of E/M visit is provided. CMS believes this practice makes it difficult to determine whether the number and type of visits provided in association with a surgical procedure is appropriate. As a result, CMS requested input in the proposed rule on how best to obtain accurate and current data on E/M services typically furnished as part of a global surgical package. Within the final rule they received a wealth of public feedback regarding methods to verify the number of E/M services provided within the global surgical period. In response, CMS stated it will carefully review and consider all input provided by commenters, and did not finalize any new requirements for tracking or reporting E/M visits associated with the global surgical period for CY 2013. The Agency was clear, however, that it intends to finalize new requirements during CY 2014 rulemaking.
Potentially Misvalued Services Under the Fee Schedule
Within the final rule, CMS identified 16 Harvard valued codes with annual allowed charges of greater than or equal to $10 million that warrant review as potentially misvalued services. Of these 16 codes, five were already scheduled for RUC review in 2012 and four had been referred to the CPT Editorial Panel. For the remaining codes, CMS stated that they are such low volume codes it may make gathering information on physician work and direct PE inputs difficult via the usual survey method. Given this, CMS encourages use of valid and reliable alternative data source to develop recommended values. Three of these codes had minor Otolaryngology use, including: 66180 Implant eye shunt; 67036 Removal of inner eye fluid; and 67917 Repair eyelid defect. The Academy staff and RUC team will monitor the review process for these procedures and determine if direct Academy involvement is warranted.
Validating RVUs of Services
Under the Affordable Care Act (ACA), CMS was directed to validate a sampling of RVUs for services. RAND and the Urban Institute will research processes for validating RVUs for potentially misvalued codes under the PFS. CMS notes they will provide additional detail on the validation contracts in future rulemaking. In the past, the Academy has expressed concern about the Agency’s engagement of an outside contractor and strongly urged CMS to be transparent with this process.
Therapy Caps and Changes to Reporting Requirements for Therapy Services in 2013
CMS announced the therapy cap amounts for CY 2013, $1,900 for occupational therapy services and $1,900 for combined physical therapy and speech-language pathology services. CMS also finalizes several key changes to reporting requirements associated with the provision of therapy services, including speech-language pathology services, with a test phase starting January 1, 2013, with non-payment enforcement starting on July 1, 2013. For more details on the new reporting requirements, see the Academy’s summary online.
Physician Quality Reporting System (PQRS)
CMS includes many overarching changes to the PQRS system, with highlights of those potentially affecting Academy members below:
Changes to Group Reporting: CMS changes the definition of a “group practice” from 25 or more eligible professionals to two or more eligible professionals.
Modification of Reporting Periods: CMS allows the continuation of a 6 month reporting period (July 1–Dec. 31) for reporting measures groups via registry in 2013 and 2014 only.
Satisfactorily reporting for 2013 and 2014 to avoid penalties in 2015 and 2016: CMS will allow individuals and group practices to report only one PQRS individual measure or one measures group to avoid the 2015 and 2016 penalty adjustment. The penalty adjustment will be a -1.5 percent in 2015 and -2 percent in 2016 and subsequent years.
Individual Quality Measures: CMS added 13 new measures for reporting individual quality measures in 2013 and 45 new individual measures for 2014. However, the newly approved “Adult Sinusitis” measures were not included in any of their proposals.
CMS finalized lowering the threshold of patients for reporting PQRS quality measures under the group practice reporting option to 20 beginning in 2013. This data is used to compile the published performance rates posted on the Physician Compare website. CMS finalized a policy allowing the reporting of measures that have been developed and collected by specialty societies to be reported on Physician Compare. CMS notes that they have begun to include physician information, such as successful participation in the Medicare E-prescribing (eRx) Incentive Program and PQRS. CMS also plans to publish additional information, a list of which is available in the Academy’s summary available online.
Electronic Prescribing (eRx) Incentive Program
CMS finalized reducing the minimum group practice size for participation in the eRx incentive program from 25 to two Eligible Professionals (EPs) for 2013. This is consistent with changes to the PQRS program for 2013. Groups of two to 24 EPs who wish to participate must have reassigned their Medicare billing rights to a single TIN to be eligible. CMS reduced the eRx reporting threshold for groups to 75, rather than the proposed 225, meaning groups of 2-24 will have to report the eRx numerator code during a denominator-eligible encounter at least 75 times from January 1 through December 31, 2013. CMS also lowered the 2014 reporting threshold for groups during the six month reporting period to 75.
Value-Based Payment Modifier
Beginning January 1, 2015, the ACA requires the Secretary to establish a value-based payment modifier (incentive or penalty) to specific physicians and groups of physicians. The incentive or penalty is based on measuring quality of care furnished as compared to cost of that care for Medicare beneficiaries with certain chronic conditions. The agency will begin a three year phase-in of the program that would apply the incentive or penalty (up to potential -1 percent) in 2015 based on 2013 performance for groups of 100 or more providers. CMS proposes that incentives or penalties in 2016 based on 2014 performance for groups of 100 or more providers. The program is voluntary the first two years, but not later than 2017, the value-based payment modifier will apply to all physicians, regardless of group size.
Physician Feedback Reporting Program
As part of the Value Based Payment Modifier program, the Secretary is required to provide Physician Feedback reports to providers that measure the resources used in providing care to beneficiaries and the quality of care. In 2013, CMS plans to circulate reports to all groups of physicians with 25 or more EPs (based on their TINs) and to individual physicians that satisfactorily reported measures through PQRS in 2012 regarding their performance on 15 administrative claims based measures. Finally, in the fall of 2014, CMS plans to issue reports based on 2013 data that show the amount of the VBP modifier, and the basis for its determination, to groups with 25 or more EPs. CMS will consider issuing reports to groups of less than 25 professionals, as well as individual professionals, in the future.
For a more detailed summary on the final requirements for the programs highlighted above, visit the Academy’s CMS Regulations and Comment letter page at http://www.entnet.org/Practice/Summaries-of-Regulations-and-Comment-Letters.cfm#CL or email Academy staff at HealthPolicy@entnet.org.