July 11, 2014 Home|Journals & Publications|  AGA AGA Quarterly: Practice
AGA Quarterly: Practice

Practice Management | Reimbursement | Coding | Regulations | Policy | Announcements

EDITORIAL

Passing the Gavel

At DDW® 2014 in Chicago, Lawrence Kosinski, MD, MBA, AGAF, held his last meeting as chair of the AGA Institute Practice Management and Economics Committee. Since he began his term in May 2011, the committee accomplished many things under his strong leadership that have proven valuable to AGA members. Among those are:

The committee and the AGA Governing Board applaud Dr. Kosinski for his tireless and valuable leadership of the committee and welcome him to the governing board as a practice councillor.

Rajeev Jain, MD, AGAF, assumed the reins of the committee after the May meeting. AGA and the committee are looking forward to his leadership. Dr. Jain is a dynamic leader with many new ideas and strategies to make AGA membership a valuable and necessary affiliation. Dr. Kosinski stated, “AGA is very fortunate to have the services of Rajeev Jain. He comes with tremendous ability and impeccable integrity. I look forward to seeing where he takes the committee.”

During DDW, the committee sponsored two timely and important sessions. The first session featured AGA consultant for ICD-10, vice president of AAPC, Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC. Ms. Buckholtz gave a revealing presentation on ICD-10 implementation and what steps to take now to prepare for the delayed regulatory date of Oct. 1, 2015. She acknowledged, “This gives everyone time to better prepare for the roll out of ICD-10 in October 2015.” She also emphasized that when it comes to ICD-10, or any medical record notes, “Documentation is only good if the next physician who treats the patient can pick up your record and know exactly what happened.”

Dr. Jain also moderated a special, five-part AGA session titled Survival Skills for Changing Times. Topics ranged from using patient portals to navigating the Physician Quality Reporting System, satisfying the requirements for Meaningful Use Stage 2 and moving to ICD-10.

“The federal government, payors and patients are all demanding change,” said Dr. Jain, a partner at Texas Digestive Disease Consultants, assistant clinical professor of medicine at the University of Texas Southwestern Medical School, and chief of gastroenterology at Presbyterian Hospital in Dallas. “Our goal is to help our members prepare to meet these new challenges with new survival strategies.”

The speakers for this session were: David Harano, MBA, MHA; Naresh Gunaratnam, MD, AGAF; Rajeev Jain, MD, AGAF; Joel Brill, MD, AGAF; Rhonda Buckholtz; and Lawrence Kosinski, MD, MBA, AGAF.

PRACTICE MANAGEMENT

Improving Communication Between Primary Care and Gastroenterology Physicians

By Shivan Mehta, MD, MBA, member, AGA Institute Practice Management & Economics Committee

How many times have you received a consult for a patient with one word or one sentence about the request? As subspecialists, we know that limited information about patients can lead to unnecessary testing, and it may even compromise care. With changes in reimbursement and quality measurement, it is even more important that we are able to obtain the essential data about patient history and diagnostic testing to inform our evaluation and treatment plans. That is why AGA has been working with the primary care and subspecialist community to develop a toolkit to facilitate care coordination.

AGA has participated in the American College of Physician’s High-Value Care Coordination (HVCC) project, which recently published an online toolkit to facilitate more patient-centered and efficient coordination of care. The toolkit includes:

  • A checklist for a referral to a subspecialist practice.
  • A checklist for a subspecialist’s response to a referral request.
  • Pertinent data sets to include in a referral.
  • Care coordination agreement templates between primary care and subspecialty practices.
  • Recommendations to physicians on preparing a patient for a referral.

AGA members developed pertinent data sets that describe the important pieces of information that may inform consultation for rectal bleeding, GERD, right upper quadrant abdominal pain and chronic diarrhea. Additionally, AGA worked with AASLD for data sets related to chronic hepatitis C and abnormal liver test results.

With the potential for patient-centered medical homes and neighborhoods, this type of dialogue will lay the foundation for future collaborations between specialties. These tools can also inform structured consultation forms embedded in the electronic medical record.

Working for the Firm

By Sarah E. Streett, MD, member, AGA Institute Practice Management & Economics Committee

AGA is launching a survey this fall to benchmark GI practices in order to characterize current practice patterns and provide peer data for AGA membership and strategic planning. One question we hope to answer is what is the current percentage of gastroenterologists working as employed physicians. Employed physicians are defined by not being self-employed or assuming direct financial risk, and are employed by a hospital, university, health plan or a large group practice. 

The number of physicians working in an employed setting in U.S. is steadily increasing. An AMA study of physician practice arrangements published in 2013 found that 40 percent of all physicians are working in non-physician-owned practices. The percentage of MDs employed by hospitals or in hospital-owned practices is rapidly growing — the number increased from 16 percent in 2008 to 29 percent in 2012. Merritt Hawkins, one of the largest physician placement firms, reported 64 percent of their job placements were for hospital employment, up from 11 percent in 2004. An estimated 39 percent of physicians under the age of 45 have never worked in a private practice.  

As physicians, regardless of our practice arrangement, we have taken an oath that loyalty to our patients is paramount. Employed gastroenterologists have an additional responsibility to their employer whether it is an HMO or a university. These dual loyalties can come into conflict when the goals of the health-care administration and those of the patient diverge. Managing these dilemmas while remaining true to the interests of the patient can be challenging. Physicians are trained to synthesize observations, knowledge and experience to make decisions. We pride ourselves on our acumen and are inherently independent. In an employed setting, autonomy can be at odds with the culture of a large organization.

This issue of the AGA Quarterly: Practice explores issues that arise when practicing medicine in an employed setting.

Participate in this Important Survey

Email Tricia Bardon at tbardon@gastro.org with contact information for the main contact at your U.S. practice who will be responsible for filling out the survey. 

New Research Highlights Need for Increased IBD Support Staff

In a recent article in Clinical Gastroenterology and Hepatology, Claudia Ramos–Rivers and colleagues analyzed telephone activity in the care of IBD patients. They found that telephone encounters outnumbered office visits two-fold — averaging eight to 10 calls per patient, per year.

The researchers found that patients with IBD with high telephone encounters suffered from heterogeneous clinical issues, which included increased inflammatory activity, chronic pain, and comorbidities of anxiety or depression. Based on these findings, IBD providers should be able to identify patients who are more likely to call the office frequently and thus require more resources. In addition, providers should flag patients who call the office frequently, especially those patients who cluster a large number of telephone calls within 30 days, as patients more likely to have poor clinical outcomes and increased use of health-care resources.

The findings of this study hopefully will result in increased support for physician extenders in busy IBD centers. It is anticipated that health-care reform will reward providers if care is provided outside of the ER and hospital for IBD. Physician extenders can help realize this goal, resulting in increased reimbursements for providers and cost savings for the health-care system overall. IBD providers should consider citing this study to both hospital and departmental administrators to garner support for additional resources to manage this complex group of patients.

Read the full article in Clinical Gastroenterology and Hepatology (login required).

GIs Are Positioned to Curb Obesity

By Naresh T. Gunaratnam, MD, AGAF, member, AGA Institute Practice Management & Economics Committee

The statistics are pretty depressing. Americans are getting fatter and the rest of the world is trying hard to catch up. In fact, obesity has evolved into a global epidemic such that it is shockingly more prevalent than malnutrition. WHO estimates that, by 2015, 700 million people worldwide will be overweight (BMI >30). Obesity is known to cause diabetes, heart disease, arthritis and even cancer; an estimated 400,000 deaths a year in the U.S. are attributed to obesity.

So who actually is in charge of trying to steer this freight train, which is heading off the cliff? Primary care physicians, bariatric surgeons and government officials have all been ineffective in changing the trajectory of the epidemic. Gastroenterologists are uniquely positioned to make an impact given our expertise in digestive health.

The simple solution of diet and exercise unfortunately is not an effective solution for most. Bariatric surgery is the most effective long-term solution resulting in sustainable weight loss and reversal of the associated morbidity and mortality. However, bariatric surgery is associated with mortality and morbidity rates of 0.5 percent and 15 percent, respectively, and can cost $18,000 to $35,000 with up to three days of hospitalization. The procedure volumes have also plateaued at more than 200,000 cases a year, which is a fraction of the demand.

An endoscopic therapy may bridge the supply-and-demand gap and be more cost effective in the long run if it could deliver sustainable weight loss. Fortunately, there are a handful of promising devices ranging from endoscopically placed balloons, duodenal-jejunal sleeves, gastric pacemakers and gastric stapling devices that are undergoing clinical trials.

These devices not only can be primary therapy for obesity, but may also serve as bridge procedures before surgery (bariatric, orthopedic, cardiovascular) to decrease operative risk or as adjunctive therapies for metabolic diseases. The duodenal-jejunal sleeve is currently undergoing phase 3 clinical trials with the primary endpoints focused on improved glycemic control.

Viable devices may allow procedure volumes to scale up in a manner similar to colonoscopy when it was approved as a screening tool. The associated increase in colonoscopy volume over the past decade has significantly reduced the morbidity and mortality related to colon cancer. An endoscopic obesity treatment may have a similar impact on obesity.

AGA is actively working to create programs that help members develop expertise in all aspects of obesity management including nutrition, exercise, pharmacological therapy, endoscopic interventions and appropriate surgical referrals. Armed with this expertise we can steer the train back onto the tracks. Stay tuned. Choo! Choo!

REIMBURSEMENT

Measure and Demonstrate Improved Patient Health Outcomes

AGA is proud to announce the AGA Digestive Health Recognition Program™ (DHRP) now includes a colorectal cancer (CRC) screening and prevention module. Now there are three disease states available to help you qualify for BTE Recognition, avoid CMS Physician Quality Reporting System (PQRS) penalties and earn valuable ABIM maintenance of certification (MOC) points. Enroll today in the DHRP, made possible by support from Santarus, Inc. and Bristol-Myers Squibb. Participants can:

  • Report to CMS PQRS to avoid Medicare reimbursement penalties and gain incentives: 2 percent penalty for not reporting; 0.5 percent incentive for reporting.
  • Demonstrate superior quality of care through BTE recognition to help negotiate with payors.
  • Receive quality measure results needed to complete an ABIM Self-Directed Practice Improvement Module and earn 20 ABIM MOC points.
  • Benchmark your practice and get instant feedback on ways to improve your quality.

MDs, DOs, nurse practitioners and physician assistants in the U.S. can apply. The following chart provides detailed reporting requirements for each disease state.

Disease State

Reporting Requirements

CRC

Report on 9 measures for 50% of eligible patients

HCV

Report on measures for 20 eligible patients

IBD

Report on 8 measures for 20 eligible patients

Get started today. For all of these benefits, AGA members pay only $300 per program option. Non-AGA members are welcome to participate for a fee of $550 per option. For more information and to enroll, please visit www.agarecognition.org or email recognition@gastro.org.

Medicare Value-Based Payment Modifier on the Horizon

Officials at CMS are working to implement changes to the Medicare physician fee schedule that will tie payment rates to quality and cost measures for physicians and physician groups. The value-based payment modifier (VBPM) will be phased-in starting next year and could result in a 2 percent reduction of Medicare payments for all eligible professionals (EPs).

When will the VBPM affect your practice?
CMS has spent the last two years collecting data from EPs and will begin adjusting payments in 2015 for physicians in groups of 100 or more. The affected population will expand in 2016 to include groups of 10 to 99. By 2017, all physicians will be impacted. Payment adjustments will be based on information submitted for the calendar year two years prior to the year in which the adjustment is effective, so that 2015 adjustments will be based on 2013 data and 2016 will be tied to 2014.

For 2015, physicians in groups of 100 or more will fall into one of three buckets for purposes of the VBPM:

  • Physicians who did not participate in PQRS will receive a 1 percent downward VBPM adjustment.
  • Physicians who participated in PQRS, but elected not to participate in quality tiering, will receive no adjustment.
  • Physicians who participated in PQRS and elected to participate in quality tiering will receive upward, downward or no adjustment based on performance.

For non-PQRS reporters, the VBPM is in addition to the PQRS payment adjustment. Physicians are able to obtain their VBPM metric performance by reviewing their Quality Resource and Use Reports provided by CMS.

Registration for the program is currently underway for groups of 10 or more and must be completed by Sept. 30, 2014, in order to avoid an automatic downward payment adjustment of 2 percent beginning in 2016.

Registration is available through the CMS Enterprise Portal. Additional information on the VBPM program is available on the AGA website.

UnitedHealthcare Multiple Procedures Policy Changes to Impact GIs

Beginning in the third quarter this year, UnitedHealthcare (UHC) will change its multiple procedure policies for its Medicare Advantage, Commercial and Community Plan lines of business to align with CMS’s multiple endoscopy payment rules.

Currently, UHC ranks the value of the primary, secondary and subsequent surgical procedures, including multiple endoscopy procedures, and applies a 50 percent reduction to secondary and subsequent procedures. Under the new policy, UHC will apply CMS special multiple endoscopic rules when related endoscopic procedures (within the same family) are performed on the same day. The lower ranking endoscopy codes in the same endoscopy family will receive an endoscopic adjustment to reduce the allowed amount based on the amount of the base endoscopy code. When multiple endoscopies in the same family are performed on the same date as other surgical procedures, the endoscopy codes may be subject to both the endoscopic and multiple surgery reductions.

These changes were announced in the May 2014 Network Bulletin.

CODING

ICD-10 Delay: What Now?

By Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, vice president of ICD-10 training and education, AAPC

With the recent CMS delay of ICD-10, multiple questions have been asked. There have been concerns from physicians and office staff about continuing current implementation plans. Some organizations have made the decision to hold any further efforts towards implementing ICD-10. If you’re on the fence about what to do, here are answers to frequently asked questions to help you decide.

Q: Why should we keep working at ICD-10 when we now have at least one more year until implementation?
A: Moving ahead allows time to fine tune your training and for coders to use the code set through dual coding or documentation assessments. Using the codes will enhance proficiency. Now is a good time to contact vendors and payors to see their progress towards implementation.

Q: How do I engage ICD-10-resistant physicians to provide education?
A: One of the biggest challenges of ICD-10 implementation is the lack of appropriate documentation. Improving clinical documentation should be addressed as quality improvement. Complete documentation supports medical necessity for services such as evaluation and management, diagnostic testing and surgical procedures, and is essential, whether coding in ICD-9 or ICD-10.

Q: In regards to our current documentation for ICD-10 readiness, what should we look for?
A: The first step is to review the physician’s most used ICD-9 codes. Pull documentation for those ICD-9 codes and determine if a code can be assigned using ICD-10, without the use of unspecified codes.

Q: Is it true that payors will not reimburse for unspecified codes?
A: The jury is still out; however, in some situations where a patient is still undergoing diagnostic testing, an unspecified code may be the only option available. If the code is specific to a time parameter, such as acute or chronic, or laterality with left or right, the information should be included in the documentation.

ICD-10 Resources

Be sure to download your ICD-10 translation guides for the top 50 most used GI-related diagnostic codes — one ranked alphabetically by disease state and the other ranked by ICD-9_CM code. The guides are free to AGA members but you must log in to view and download the PDF. Nonmembers can purchase either version for $25. The guides can only be downloaded and are not mailed.

Coding Q&A

Answers by AGA’s coding and billing specialist Kathy Mueller, RN, CPC, CCS-P, CMSCS, PCS, CCC

Question 1: I am considering adding a nutritional/weight loss clinic to my practice. Is a dietitian required for this service? Are there billing guidelines?
Answer: Nutritional and weight loss counseling can be performed by non-physician providers, such as nurse practitioners and physician assistants. The billing would utilize standard evaluation and management codes based on time spent counseling and coordination of care. Registered dietitians can provide the service and billing, which should be submitted under their corresponding National Provider Identifier numbers; the use of group or individual counseling can be based on time documentation. Medicare does not recognize this for all medical conditions. Pre-determination should be done on patients with commercial insurance. Non-covered conditions can utilize a cash-pay scenario.

Question 2: My physician stated that a patient had a Dieulafoy's lesion of the stomach. What is that and how would I code the condition?
Answer: A Dieulafoy's lesion is a tortuous, submucosal arterial malformation that has a propensity to bleed. Most are located in the stomach, but can be found in the duodenum, jejunum, ileum colon and esophagus. The occurrence is rare, causing approximately 5 percent of the gastrointestinal bleeds in adults. The clinical presentation is painless, massive bleeding. The condition, which is not familial, is more prevalent in males and can occur at an age. The ICD-9 code is 537.84. The ICD-10 code will be K31.82.

Question 3: My physician dictated Brunner Gland hyperplasia. What is it and how would I code it?
Answer: The Brunner gland is located in the submucosa of the duodenum. The function of the gland is to secrete a mucous that protects the lining of the duodenum from the acids secreted in the stomach. It makes up about 10 percent of the benign tumors of the duodenum; it rarely presents any symptoms, such as melena or obstruction. Code 537.89 (ICD-10 will be K31.89).

REGULATIONS

CMS Open Payment Phase II

Although CMS has not yet announced precisely when physicians will be able to access the Open Payments (Sunshine Act) system to check their payments, the agency has said that the 45-day dispute resolution period will take place in “August/September (TBD).” CMS noted that their auditing process of manufacturer reports would begin after publication of the data, and would include an appeals process. An Open Payments user guide, new FAQs and the latest timeline is available on the CMS Open Payments website.

On June 1, registration began in CMS’ Enterprise Portal for physicians and teaching hospital representatives. Registration is required to view and dispute any information about payments or other transfers of value given to them by the industry prior to public posting of the data. Any data that is disputed, if not corrected by industry, will still be made public, but will be marked by CMS as disputed. This phased approach to Open Payments registration and data submission is for the 2013 program year only (data collected between Aug. 1, 2013, and Dec. 31, 2013).

Additional information about the Open Payments system is available on the AGA website.

POLICY

2015 Medicare Payment Proposals Are Out

Despite aggressive advocacy by AGA, ACG and ASGE, CMS did not include anticipated changes to payments for lower endoscopy, including colonoscopy, in the proposed rule for payments that begin on Jan. 1, 2015. We anticipate that CMS will release proposed changes to the lower endoscopy codes in the November final rule, as they did last year with the upper endoscopy codes. We continue to engage CMS in discussions about their process and will continue to fight for fair colonoscopy reimbursement and transparency in the rulemaking process.

Read our press statement.

Read more details about the proposed rules.

AGA, ACG and ASGE are committed to working together to advocate for fair reimbursement for GI procedures. Watch your email for details on how to get involved.

ANNOUNCEMENTS

UpToDate®: Dedicated to Improving Quality and Effectiveness of Health Care Worldwide

UpToDate® is an indispensable clinical information resource relied on by more than 850,000 physicians and health-care practitioners globally. UpToDate serves as a trusted medical “colleague” that provides unbiased, evidence-based medical information. It is also the only clinical knowledge system associated with improved outcomes.1

UpToDate's mission is to improve the quality and effectiveness of health care worldwide by improving clinical decisions at the point of care.

UpToDate covers more than 10,000 medical topics spanning 21 medical specialties, including gastroenterology and hepatology. And with access from your computer, mobile device or tablet, and our highly rated mobile apps optimized for leading platforms, you are sure to find the clinical answers you need, when and where you need them.*

Join your colleagues and subscribe to UpToDate risk-free at learn.uptodate.com/AGA2014.†

As an AGA member, you may also access a 14-day free trial to UpToDate at with your AGA member login. 

*An individual subscription is required for access to UpToDate content through mobile apps.
If you aren’t completely satisfied, simply cancel your annual subscription within 60 days and request a full refund in U.S. dollars. 30-day recurring billing subscriptions do not qualify for money-back guarantee.
1Isaac, T., Zheng, J. and Jha, A. (2012), Use of UpToDate and outcomes in US hospitals. J. Hosp. Med., 7: 85–90. doi: 10.1002/jhm.944

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