Volume 3, #3

August 2006

In this issue:

• CMS Published Plan for New Medicaid Compliance Program
• Medicare’s Physician Voluntary Reporting Program (PVRP): Should Emergency Physicians Participate?

CMS Publishes Plan for New Medicaid Compliance Program

Candace E. Shaeffer, RN, MBA, RHIA
Vice President of Coding Policy

On Tuesday, July 18, 2006, the Centers for Medicare & Medicaid Services (CMS) released the initial Comprehensive Medicaid Integrity Plan (MIP). Under the rules of the Deficit Reduction Act of 2005, Congress allocated resources to CMS to establish the MIP. This plan represents the first national initiative to detect and prevent Medicaid fraud and abuse in the program’s history. Under the leadership of the Center for Medicaid & State Operations (CMSO), the agency will fulfill the mandates of this new program. The Comprehensive Medicaid Integrity Plan will guide CMSO’s efforts to fulfill this new obligation.

Traditionally, Medicaid claims have had a much lower level of scrutiny than Medicare’s. Not surprisingly, this new plan sounds similar to what CMS and the OIG are doing for the Medicare program. This federally funded MIP program will initially have 100 FTEs and provide oversight of the state Medicaid programs beginning later this year. CMS states they expect a “high rate of return on investment from its prevention efforts.”

CMS will develop a detailed work plan over the next several months. They plan to place five field operation offices, responsible for specific states and territories in the US, in “fraud hot spots” including Southern CA, Southern FL, the Gulf Coast, New England-NY-NJ, and in the Chicago Detroit area. A few high points from the plan and appendices:

• The main activities of the field operations will be to audit claims.

• The Medicaid policies to support the program have yet to be determined.

• CMS plans to develop performance metrics and standards to measure states’ performance.

• Effective 1/1/2007, any entity that receives or makes payments of $5M or more from or to a Medicaid program will have to develop policies and procedures and provide education to all its employees, agents, and/or contractors on compliance. These policies and standards must address plans to prevent and detect fraud, abuse and waste.

• CMS plans to focus efforts on areas with high expenditures and those not requiring prior authorization. (Prior authorization is not required for ED visits by Medicaid recipients.)

• Specific areas identified for program monitoring include:

  • Long Term Care nursing service and Home health
  • Prescription drugs
  • DME and other suppliers
  • Improper claims for payment from hospitals and individual providers

This new Medicaid initiative will affect ED physicians primarily because of the increase in claims auditing. LYNX compliance plan policies and procedures follow OIG compliance plan recommendations and since both the Medicare and Medicaid programs fall under CMS we don’t expect significant changes will be required. We will keep you informed regarding any requirements for new education, processes or documentation. The Comprehensive Medicaid Integrity Plan can be found via the following link: http://www.cms.hhs.gov/DeficitReductionAct/.

Medicare’s Physician Voluntary Reporting Program (PVRP): Should Emergency Physicians Participate?

Jeffery L. Wajda, DO, MS, FACEP
Vice President, Clinical Support Services

The Physician Voluntary Reporting Program (PVRP) is a 2006 physician directed CMS program which is designed to capture data regarding the quality of care provided to Medicare Beneficiaries. PVRP is by definition voluntary. Hospital Pay for Performance (P4P) programs initially were voluntary and are now required. It is reasonable to expect a similar reporting requirement with physician specific quality indicators. As Congress contemplates revising the sustainable growth rate (the formula determining physician fee schedule updates) there is interest in incorporating pay for reporting and pay for performance programs. Those physicians participating now will receive performance summaries prior to future payment attachment to these measures. Physicians can simply register to participate at http://www.qualitynet.org/pvrpintent. Should you register? We recommend that you do register. The march of quality reporting will not go away and voluntary reporting can serve as an effective way to introduce yourself and group to the likely incorporation of Medicare physician directed P4P. The program specifics and the history of the initiatives behind this program are important to every practicing ED physician.

The Details of PVRP.

The basis of the PVRP program is 16 quality measures co-developed by the AMA Physician Consortium, Ambulatory Quality Alliance and National Quality Forum. ED doctors need to understand that these are not hospital measures but specifically apply to individual physician practice. Of these 16 initial measures, two are directed at emergency doctors, seven are primary care measures, five directed at surgeons and two are for nephrologists. Sixteen measures exist today, however, the AMA has announced its intention of providing Medicare with 140 physician directed quality measures by the end of 2006. It has now been over five years since the initial Institute of Medicine (IOM) report identifying serious quality deficiencies in the US healthcare system. The PVRP program, like hospital Pay for Performance (P4P) initiatives, is designed to improve healthcare outcomes.

Emergency Physician PVRP.

The two EP specific PVRP measures involve Aspirin administration in the setting of AMI and Beta Blocker administration in AMI. CMS has created HCPCS billing codes for these measures. These Emergency Medicine (EM) specific HCPCS codes are as follows:

• G8006 – AMI patient documented to have received aspirin at arrival measure
• G8007 – AMI patient not documented to have received aspirin at arrival
• G8008 – Physician documented that AMI patient was not an eligible candidate to receive aspirin at arrival
• G8009 – AMI patient documented to have received a beta blocker at arrival
• G8010 – AMI patient not documented to receive a beta blocker at arrival
• G8011 – Physician documented that AMI patient was not a candidate to receive a beta blocker at arrival

Interestingly, the arrival measure referred to above is defined as the 24-hour period up until arrival of the patient in the ED and the 24-hours after arrival. CMS identifies a 48-hour window in which administration of aspirin, once documented, would satisfy the criteria for assignment of code G8006. The EM specific CMS physician worksheet addressing these codes is available at: http://www.cms.hhs.gov/pvrp/downloads/pvrpemergencymedicineworksheet.pdf.

LYNX Coding Services will assign these codes based on your Professional ED documentation. Clients using E/Map will find the indicators associated with these codes included in the ED course section of the appropriate E/Map charts. For clients dictating records or using other templates, we suggest a separate procedure note which specifically states that treatment(s) were given (by EMS, patient administered or in ED) or a statement that the patient was not a candidate. Although the LYNX assignment of these codes will automatically serve as voluntary reporting, a physician must register with CMS if they desire to receive CMS report cards comparing their compliance to other physicians. We advise registration at the above Web site. Please inform your LYNX client manager of your group’s intention to participate in the PVRP.