Meaningful Use may have been the top continuing news story of the year

With millions of dollars available for physician practices, the year 2010 started with the unveiling of the proposed rules for Meaningful Use last January.  February offered time for provides to understand the proposed rules and provide feedback to the Centers for Medicare and Medicaid Services (CMS).

In March, the healthcare reform bill, which includes benchmarks that emphasize quality care, was signed into law. Electronic health record that can be accessed by all providers within a system can coordinate patient care more effectively.

During April and May, the many regional extension centers around the country were providing physicians with critical customized advice to assist with the purchase and implementation of health information systems.

Seventeen Beacon awards were announced in June – they will serve as models for the broad use of healthcare information technology and help lead the way to lower cost healthcare through the use of electronic health records.

In July, offices around the country reviewed the final rule on meaningful use of health IT and Dr. Donald Berwick was sworn in as head of CMS. And in August, the nation’s health IT chief, Dr David Blumenthal, endorsed quality of care data collection as established under the HITECH act and was quoted as saying collecting data on care brings out the best in physicians.

In September, we learned the names of three entities authorized to certify electronic health record systems, and EHR vendors began the process of proving their systems met the meaningful use criteria.

By October, some larger healthcare practices were expressing concern that there would not be enough experienced IT personnel to help with all the necessary information technology changes. Speaking at a conference in Washington D.C., Dr Berwick shared his belief that all physicians involved in a patients’ episode of care need access to a single set of electronic health records.

In November, Kaiser Permanente put collaboration ahead of competition and announced it would share technology developed to achieve key meaningful use standards with other healthcare professionals.

CMS continued to plan for better care, better population health and reduction of per capita healthcare costs & placed many updates on their EHR incentive program website during the month of December.

Meaningful use will continue to be a top news story in 2011!  Registration for the Medicare and Medicaid incentive programs begins January 3, 2011; however, not all states will begin Medicaid incentives immediately.   CMS will continue to update their website as additional information about the program is developed. 

For more information, go to: http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp#TopOfPage

New Tools to Fight Health Care Fraud

CMS has taken their fight against health care fraud to a new level, announcing the start of a partnership with companies that provide predictive modeling to anticipate and prevent potentially wasteful, abusive or fraudulent payments before they occur.

Soon, every Medicare claim will be subject to a computerized analysis that reveals all claims paid to that provider.  By tracking billing patterns and other statistical information, real-time aberrant trends can be spotted that will alert CMS to locating fraudulent providers before they begin receiving Medicare funds. 

Predictive modeling tools are already used by banks and credit card companies to identify potential fraud before it occurs. CMS has used the tool in pilot projects, and has used those results to begin administrative actions against "false fronts" in several states.  

Historically, CMS relied on the "pay and chase" method to track down potential violators and then tried to recover the funds.  In 2010, the Department of Justice obtained settlements and judgements of more than $2.5 billion in False Claims Act matters alleging health care fraud.  Thanks to funding from a portion of the Affordable Care Act, CMS will be purchasing new tools and resources to track provider specific trends and quickly catch anyone attempting to steal taxpayer dollars.

AANEM calls on CMS to distribute overdue reimbursements

Two hundred million dollars has been included in the recently passed Medicare & Medicaid Extenders Act to address overdue Medicare reimbursements that should have been received by physicians under the Affordable Care Act (ACA ) of 2010.

ACA called on CMS to reimburse physicians retroactively to January 1, 2010 for calculation errors in the geographic practice cost index (GPCI) for work and practice expenses.   Additionally, miscalculations in professional liability insurance and practice expenses associated with some high risk procedures forced many physicians to accept payments 40% lower than they should have been.  

The short-term stop-gap measures enacted throughout 2010 caused payment uncertainties, delays and disruptions for many of our members.  Recognizing the need for relief, AANEM has joined with the American Medical Association to request CMS immediately announce how it intends to act to ensure all retroactive payment increases are distributed to physicians in a timely manner. 

Sales of neurostimulation devices under scrutiny

A Midwest maker of neurostimulation devices disclosed that it has received a subpoena from the US Attorney's office for the Western District of New York related to the sales of it's devices and reimbursement to physicians who use the products.  The subpoena is seeking information regarding sales, marketing and reimbursement and is related to the Health Insurance Portability and Accounting Act of 1996. 

The company, Medtronic, says it received the subpoena in October and is fully cooperating with the investigation. 

FDA Extends Review of Multiple Sclerosis Pill

The Food and Drug Administration has extended Merck's priority review of the drug cladribine, a sphingosine 1-phosphate receptor modulator, by three months to examine additional information on the product.  The FDA's decision puts Merck further behind in the race to provide MS patients in the United States with a first-line oral treatment for relapsing forms of multiple sclerosis.

In MS, the immune system damages the covering that protects nerve fibers in the central nervous system (CNS), which includes the brain and spinal cord. Sphingosine 1-phosphate receptor (S1PR) modulators  reduce the immune system's attack on the CNS by retaining certain white blood cells (lymphocytes) in the lymph nodes. This prevents the white blood cells from reaching the CNS, where they could potentially attack the protective covering around the nerve fibers, resulting in less inflammatory damage to the nerve cells. The white blood cell retention is reversible if treatment is stopped.


European regulators rejected cladribine in September, saying the drug's benefits didn't outweigh the risks.  U.S. regulators didn't request more clinical trials, and  Merck representatives declined to elaborate on what additional information the FDA is reviewing.   The FDA had originally granted cladribine a priority review in July, shortening the standard 10 month review period to six months.  Based on this request for additional information, the FDA review is expected to now end on February 28, 2011.

Health insurers will soon be required to spend a specific amount of premium dollars on health care

Insurance has traditionally been regulated at the state level. When health insurers sell policies, they charge premiums. The share of premiums NOT paid out on health care claims goes towards administrative expenses, marketing costs and profits. The share of premiums paid out is termed "medical loss ratio." 

State imposed medical loss ratios vary widely. North Dakota currently requires a 55% medical loss ratio, New Jersey requires an 80% ratio. Medicare maintains a loss ratio of 97-98%.

Beginning in 2011, the Affordable Care Act will require health insurance companies to spend a minimum percentage of the premiums they collect on services and quality improvement activities for the people they insure and the Act creates a federal minimum medical loss ratio for all insurers.

Health insurers predict this new mandate will drive insurers out of business.  The argue overly stringent ratios will stifle innovation and eliminate quality measures.  Proponents believe the legislation will improve quality of care & keep premiums low by limiting administrative spending and improving transparency.

Beginning in 2011, insurers will have to report their 2010 ratio & adjust internal practices accordingly. By 2012, if a medical loss ratio exceeds the federal standard, insurers will be required to rebate policyholders.  If an insurer fails to meet the ratio for three consecutive years, they could be banned from signing up new customers. If the problem continues for 5 years, HHS could terminate the contract for the health plan in question.

HHS Secretary Sebelius recognizes the potential for "unintended consequences" arising from the new rules but assures both sides that her office will work to ensure a smooth transition to 2014, when state exchanges will guarantee insurance coverage.  

Study Finds Health IT Adoption Growing

A new study released by the Computing Technology Industry Association (CompTIA) shows that up to 50% of healthcare provides have either adopted electronic health records are are partially using them.

The study, which included 300 US healthcare providers, found that 34% are now using a "comprehensive" electronic health record system and 16% say they are using a "partial" system.

About 29% said they are evaluating their options, while another 20% indicated they have not yet looked at the issue.

Of those who have adopted EHRs, 59% said they were completely or mostly satisfied with their EHR and 36% indicated they were partly satisfied or partly dissatisfied.  The survey would seem to indicate dentists are the most satisfied  user of EHRs (70%) compared to medical doctors (57% satisfied).

OIG Work Plan for Fiscal Year 2011

A quick review of the Office of Inspector General's work plan indicates 2011 reviews will continue to focus on ensuring providers can justify the appropriateness of what they are doing, either from a clincial perspective or a documentation perspective.

 

Evaluation & Management (E&M) claims will be evaluated to ensure:

•  Documentation supports the level of service reported - specifically that there is not identical documenation used to record the patient encounter for each & every patient. 
• Coding patterns, by provider, accurately reflect the service provided.  Specifically, that billing for E&M services reflect the individual type, setting and complexity of services provided to each patient.    

For services performed in hospital outpatient departments or ambulatory surgical centers (ASC), the OIG will audit to determine whether physicains properly coded the place of service on claims.  To review the current list of location codes used for billing go to: https://www.cms.gov/MedHCPCSGenInfo/Downloads/Place_of_Service.pdf

 

 

 

Meaningful Use - What's Next?

The Health IT Policy Committee, a federal advisory group, has begun work on developing the meaningful use requirements for stages 2 and 3 of the federal Medicare and Medicaid healthcare IT adoption incentive program. 

Stage 1 incentives begin in January, 2011 and CMS and the Office of the National Coordinator for Health Information Technology will begin monitoring data submitted to help fomulate some aspects of the stage 2 and 3 requirements.  Currently, interoperability appears to be a big focus of the stage 2 requirements, however a meaningful use workgroup is expected to present recommendations to the HIT policy committee today (October 20th), with opportunities for additional public input beginning in November. 

If all goes well, providers and vendors should have a good idea of what will be expcted in the Stage 2 and 3 incentives by mid-year 2011. 

Collaborative efforts could speed medical advances

Is there a gap in the medical research system?  A recent segment on PBS highlights the need to change the model for connecting academic research to the pharmaceutical and biotech industry.   Their premise:  Basic scientific research may address intriguing scientific questions, but doesn’t always focus on research that might help the patient the most.  Instead, a more collaborative approach will be necessary to ensure the creation of new drugs and treatments for diseases like Multiple Sclerosis.

For more information go to:  http://www.pbs.org/newshour/video/module.html?s=news01s43bcqf7f

New pain-medication law in the state of Washington

Earlier this year, legislators in the state of Washington passed a first of a kind bill that changes the way providers can prescribe opiates to chronic pain patients.  This bill directs five boards and commissions to adopt rules concerning management of chronic, noncancer pain. Thus far, it appears the rules will govern how physicians and other prescribers maintain and update detailed screening, history and treatment plans for most pain patients.  Additionally, a prescriber whose patient reaches a certain dosage level must consult a pain specialist. 

To learn more about the law, or to receive email notifications about pain management prescribing rules, go to:  http://www.doh.wa.gov/hsqa/Professions/PainManagement/

No EMG for PAs in New Jersey

The Appellate Division of the New Jersey Supreme Court ruled in July that “physician assistants are precluded by statute from performing EMG needle tests.” This ruling was the result of a case involving a physician billing for EMG studies performed by a physician assistant. The court relied heavily on the legislative intent of the statutory language added in 2005 that limits performance of needle EMG to a “person licensed to practice medicine and surgery” in New Jersey.

As a result of this case the AANEM Board of Directors considered the organization’s policies regarding non-physician providers and voted to add specific language to the organization’s Recommended Policy for EDX Medicine and its Model Policy for EMG and NCS.

Those policies are available at http://www.aanem.org/.

AANEM files a motion to intervene in the Red Flag lawsuit

Normally, a lawsuit involves the plaintiffs (who bring the suit), and the defendants (whom the suit is brought against). A motion to intervene is used when a someone not party to a lawsuit in progress wants to become a party in that suit.


On Monday, August 16th, AANEM joined forces with 25 other medical societies to file a motion to intervene in the AMA lawsuit seeking relief from the Red Flag Rules for physicians.   Without other groups intervening in the lawsuit, there were concerns raised that any ruling would apply only to AMA members.

Once the motion is granted, all 26 medical societies will file a proposed complaint and ask the FTC to expand the current stipulation to refrain from enforcing the Red Flags Rule against physicians, including those who are not members of the AMA, and their medical practice groups. The AANEM action will ensure that any decision will apply to all AANEM members

For more information on the Red Flags Rule, visit: http://www.ftc.gov/opa/2010/05/redflags.shtm

CMS awards funding to six states & District of Columbia for EHR incentive programs

Connecticut, Delaware, Indiana, New Hampshire, Rhode Island, West Virginia, and the District of Columbia are the latest to receive federal matching funds for state planning activities necessary to implement the electronic health record incentive program established by the American Recovery and Reinvestment Act of 2009.

The recipients will use the funds for planning activities that include an analysis of health IT activities in the region.  They will gather information on issues such as existing barriers to use of EHRs, provider eligibility for EHR inventive payments and the creation of a state Medicaid health IT plan, all of which will help define the vision for long-term health IT use.

CMS has thus far allocated funding to 39 other states and Puerto Rico and the US Virgin Islands.

Regional Extension Center News

As part of the HITECH act, Regional Extension Centers were established to offer technical assistance, guidance and information to support and accelerate health care provider's efforts to become meaningful users of an Electronic Health Record. 

The federally designated Regional Extension Center for New York City (NYC REACH) will be offering an electronic medical record and practice management system developed by eClinicalWorks to its providers in the five boroughs of New York City.  NYC REACH will be using a $21.7 million grant awarded by HHS to assist providers with the purchase and implementation of an EHR. Check out their website (www.nycreach.org) for upcoming events that are designed to help providers learn more about switching from a paper based record to an electronic record.

West Virginia has also established a Regional Health Information Technology Extension Center (WVRHITEC) to help providers across the state implement electronic health records systems.  WVRHITEC will begin working with regional and community based organizations during the summer of 2010 to provide information, guidance and technical assistance to eligible participants in primary care settings.  This includes providers in rural and medically under served areas, community health centers and certain public, not for profit or critical access hospitals.

To find information about these and other State's Regional Extension Centers, click on this link:  http://healthit.hhs.gov/portal/server.pt?open=512&objID=1495&mode=2&cached=true

CMS began processing claims

The "Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010" establishes a 2.2 percent update to the Medicare Physician Fee Schedule payment rates retroactive from June 1 through November 30, 2010. CMS has directed Medicare claims administrative contractors to discontinue processing claims at the negative update rates and to temporarily hold all claims for services rendered June 1, 2010 and later, until the new 2.2 percent update rates are tested and loaded into the processing systems. CMS expects that claims will be processed at the new rates no later than July 1, 2010.

Claims containing June 2010 dates of service which have been paid at the negative update rates will be reprocessed as soon as possible.

2.2 Percent SGR Fix..until November 2010

On June 24, the U.S. House of Representatives passed H.R. 3962, the "Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010." This legislation includes provisions to replace the 21 percent Medicare physician payment cut that took effect at the beginning of June with a 2.2 percent payment update that will extend through November 2010.

House passes 19-month SGR relief

The House passed an amended version of the “American Jobs and Closing Tax Loopholes Act of 2010,” which includes a provision to suspend Medicare physician payment cuts produced by the SGR formula for 19 months. The Act will prevent the 21% cut originally scheduled for 2010, with the House proposing a 2.2% payment update for the remainder of this year, and a 1% update for 2011. Under the House’s proposal the SGR challenges will resume in 2012, with an estimated 33% payment cut for that year. The Senate will not resume until June 7 to consider the legislation.

Congress needs to hear from you! Contact your representative and senators today using the AMA’s toll-free grassroots hotline at (800) 833-6354 or send them an email. A long-term solution to the SGR is needed today!

The Centers for Medicare and Medicaid Services (CMS) has notified physicians it will delay processing claims for two weeks. CMS told its contractors to hold claims for Medicare reimbursement for 10 business days “to avoid disruption in the delivery of health care services to beneficiaries and payment of claims for physicians.”

FTC delays enforcement of Red Flags Rule again

On May 28, the Federal Trade Commission (FTC) announced that, for the fifth time, it will again delay enforcement date of the Red Flags Rule—this time through December 31, 2010. The AANEM along with many other physician organization oppose the FTC’s view that any physician who does not require payment at the time patients receive medical services is bound to comply with the Red Flags Rule, which requires creditors to develop and implement written identify theft programs. Interim guidance is available at: http://www.ftc.gov/redflagsrule

AMA Morning Rounds: FDA approves Genzyme's Lumizyme to treat patients with Pompe disease

The AP (5/26) reports that the Food and Drug Administration "approved Genzyme's drug to treat a muscle development disease." The drug, called Lumizyme (alglucosidase alfa), has just been approved to treat patients with Pompe disease in the United States and is currently manufactured in Belgium, where it is known as Myozyme.

The Boston Globe (5/26, Weisman) reports, "The decision represents the most important US drug approval for the Cambridge biotechnology company since 2003, when regulators signed off on Fabrazyme [agalsidase beta], a treatment for Fabry disease. Genzyme hopes Lumizyme will become a blockbuster, with worldwide sales of at least $1 billion annually."

The Boston Herald (5/26, McConville) reports, "The Cambridge biotechnology company said the drug will be sold in a box that warns users of potentially life-threatening anaphylactic reactions, severe allergic reactions and immune-mediated reactions." According to the company, it "will only give the drug to patients who are eight or older and enrolled in a risk mitigation program."

Potential ALS Drug Fails in Study

The AP (5/18) reports, "Teva Pharmaceutical Industries Ltd. said Monday its potential Lou Gehrig's disease treatment," talampanel, "failed to meet a key goal in a midstage study." The drug failed to meet its effectiveness goal in a study of 559 patients, although it did meet its safety goals.

Your voice needed in SGR survey

Please take a short survey designed by the AMA to determine how threatened cuts to Medicare physician payments and instability in the Medicare program are affecting physician practices. The survey will be open through close of business May 21, and results will be used in advocacy efforts to reform Medicare's current physician payment formula.

AMA Morning Rounds: Physicians using novel procedures for pain management.

Laura Landro writes in the Wall Street Journal (5/11) The Informed Patient column that peripheral-nerve stimulation, a procedure which allows a physician to implant a tiny, battery-operated generator, is one of a growing number of treatments for people who endure chronic pain, and who have been unable to find relief from drugs, physical therapy, or even acupuncture. The procedures typically cost between $15,000 and $50,000. Data show that about 76 million Americans suffer from chronic pain. Notably, the CDC has said that over eight million Americans use pain management drugs.

AMA Morning Rounds: Several medical groups say new financial regulations aimed at Wall Street are too broad

The Hill (5/3, Brush) "On the Money" blog reported that several "of the nation's largest healthcare associations," including the American Medical Association, "are warning Congress that they would fall under sweeping new financial regulations aimed at Wall Street." The association, in a letter, "said the scope and reach of a new consumer financial protection office are too broad and that they would face new regulations designed for banks and other financial companies."

AMA Offers Physicians Help Claiming Damages From UnitedHealth Settlement

The American Medical Association (AMA) today launched a new online resource that will help thousands of physicians file claims in the record-breaking settlement reached in the AMA legal victory against UnitedHealth Group—the nation’s largest health insurer. More than $350 million is available to compensate physicians and their patients for 15 years of artificially low payments for out-of-network services.

The UnitedHealth settlement is governed by a series of court-imposed deadlines that physicians must follow. The current settlement deadlines include the following key dates:

July 27 – Deadline for filing objections to the settlement or for opting out of the settlement.

September 13 – Date for the final settlement hearing to consider any filed objections.

October 5 – Deadline for filing a claim to share in the settlement fund.

AMA Morning Rounds: Some patients feel betrayed by Genzyme over drug shortage.

On the front page of its Business Day section, the New York Times (4/16, B1, Pollack) reports that thousands of people "have been hard hit by a shortage of drugs made by the biotechnology company Genzyme to treat two rare inherited" conditions, Fabry disease and Pompe disease. As a result, "the close relationship -- unusual in the pharmaceutical industry -- that Genzyme had carefully built with the several thousand users of its high-price medicines" has "frayed." In fact, "some of those patients now say they feel betrayed by the company they once viewed as their savior." The company, "which initially predicted that the drug shortages would last six to eight weeks, has repeatedly backtracked on when supplies would be fully restored, as it has run into further manufacturing problems."

Medicare Cuts Delayed Until June 1

Last night, the President signed H.R. 4851, the Continuing Extension Act of 2010, into law, reinstating Medicare physician payments to where they were on March 31 and again postponing the 21.3 percent cut that was supposed to take effect in 2010. This most recent extension of 2009 payment rates will continue through the end of May, and will be applied retroactively to all physician services provided to Medicare patients in April.

Yesterday, the hold on processing April claims that the CMS had placed to avoid implementing the payment cut technically expired. However, with Congressional action so imminent, do not believe many claims were actually processed at the lower payment rates. However, CMS indicated that any claims paid that reflected the 21.3 percent cut will be reprocessed automatically without any action required from physicians.

Senate Advances Delay of Medicare Cuts

Yesterday the Senate voted 60-34 to limit debate on a bill that extends a number of expiring programs, including a dealy of the 21% Medicare physician payment cut. No deal has been struck to expedite passage of the bill. Without such an agreement, Senate procedures do not allow for a final vote until later in the week.

CMS instructed its carriers to refrain from processing any claims for services provided on or after April 1 for 10 working days, to minimize administrative complications and other disruptions that would result from calculating payments that reflect a rate reduction that Congress is expected to overturn. That 10 day grace period expires on Wednesday, April 14. If Congress fails to pass legislation by close of business on Wednesday, Medicare law will require carriers to begin processing claims for services provided in April with the 21 percent cut. However, it is expected Congress will to pass legislation that retroactively restores payments to levels in place prior to April 1.

AMA Morning Rounds: Lithium may not help patients with ALS

The AP (4/6, Cheng) reports, "Lithium doesn't help patients with ALS, or Lou Gehrig's disease, contrary to previous study results, new research says." For the "first trial to scientifically assess whether lithium works for Lou Gehrig's disease, doctors found it had no effect -- and stopped the study early because it seemed futile." Eighty-four "patients with Lou Gehrig's disease" were enrolled in the study, and after "nearly six months, researchers didn't see any difference: 22 of the 40 patients in the lithium group had gotten worse versus 20 of 44 patients in the placebo group." The Los Angeles Times (4/5, Maugh) "Booster Shots" blog and MedPage Today (4/5, Gever) also covered the story.

CPT Code Resequencing

I don't believe CPT's resequencing initative altered any codes that are used for EDX studies. Here is a short summary in case members encounter it in other aspects of their practice.

Instead of deleting and renumbering codes in order to display related codes together, resequencing allows adjacent placement of related concepts in the codebook regardless of the availability of code numbers for numerical placement. This change allows for greater code continuity over time and creates more options for future growth and flexibility of content.

Resequenced codes are noted with a # symbol in their new, out-of-sequence location. References have been placed numerically throughout the codebook at codes' previous locations that direct users to the out-of-sequence code. Appendix N also contains a list of resequenced codes.

CMS to Hold April Claims for 10 Business Days

CMS is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of services and payment of claims paid under the Medicare Physician Fee Schedule (MPFS). The Temporary Extension Act of 2010, enacted on March 2, 2010, extended the 0% update to the 2010 MPFS through March 31, 2010.

CMS believes Congress will take measures to avert the negative update slated to take effect April 1. Consequently, CMS has instructed its contractors to hold claims containing services paid under the MPFS for the first 10 business days of April. This hold will only affect claims with dates of service starting on April 1, 2010, and forward. In addition, The hold should have minimal impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt.

AANEM will continue to update its members on new information related to the 2010 MPFS extension.

News Coverage of Healthcare Bill Signing

AMA Morning Rounds compiled this summary of news coverage.

Obama signs healthcare bill into law.

The signing of the healthcare reform legislation received very extensive, and overwhelmingly positive, media coverage, much of it casting the event as a historic occasion and as a major triumph for the President and his party. While Republicans continued to appear confident that the new law will be an electoral boon for them this fall, some analysts are now predicting that the win on healthcare gives Democrats new momentum and could change the political dynamic of recent months.

The bill itself is being described in generally positive terms. ABC World News (3/23, lead story, 2:45, Sawyer) said in its lead story last night, devoted to the bill signing at the White House, "As of today, it is the law of the land that every man, woman and child in America will have healthcare coverage." ABC (Tapper) added that Obama "was as happy as we've seen him, perhaps since the inauguration." The CBS Evening News (3/23, lead story, 3:00, Smith) led its broadcast announcing that this is "the closest the nation has ever come to universal coverage," and added that "ecstatic Congressional Democrats treated the President and Vice President like conquering heroes."

NBC Nightly News (3/23, lead story, 3:05, Williams) reported, "It was the end of the fight" Obama "staked his presidency on, and for him a crowning achievement." In his remarks, "the President took pains to highlight reforms that will happen immediately, and nightmare scenarios that won't." USA Today (3/23, Hall), the Washington Post (3/24, A1, Wilson), the New York Times (3/24, A19, Stolberg, Pear), the AP (3/24, Loven), and the Los Angeles Times (3/24, Nicholas, Parsons) also cover the story.

Electrodiagnostic Laboratory Accreditation Program Launches Today!

The much anticipated Electrodiagnostic (EDX) Laboratory Accreditation Program is ready for its first applications. Be among the first EDX laboratories to become accredited. The program recognizes laboratories that demonstrate clinical excellence and commitment to providing the highest quality patient care. The AANEM EDX Laboratory Accreditation designation provides patients, referral sources, and payers with a credible measure of excellence. recognition will be given to the first accredited laboratory in each state. Learn more about the accreditation program, then request an application today!

Healthcare reform passes House 219-212

Last night the House passed the Senate-approved healthcare reform bill 219-212. After passing the bill, the House proceeded to approve "key changes" to it, "part of a prearranged agreement to guarantee passage of the historic legislation. The changes passed by a 220-211 vote. That bill now goes to the Senate for final approval, where it only requires a simple majority to pass. Passage in the Senate and signing by President Obama is expected to occur quickly in the next few days.

Further CMS Guidance on Consultation Services

MLN Matters® SE1010 provides further clarity from CMS for those who who perform initial E/M services previously reported by CPT consultation codes for Medicare beneficiaries and submit claims to Medicare MACs for those services. The document follows a Q&A format. It includes the first information I have seen from CMS regarding low-level inpatient consultation codes 99251 and 99252. A question on page 3 asks how services previously reported with these codes should be billed since they do not meet key requirements for 99221-99223.

AMA Morning Rounds: FDA grants orphan drug status to potential ALS treatment.

The AP (3/10) reported, "Cytokinetics Inc. said Wednesday regulators have granted 'orphan drug' status to its potential" amyotrophic lateral sclerosis, or "Lou Gehrig's disease treatment." The company also "said it plans to start a mid-stage clinical trial in the first half of this year to test the drug's effectiveness." Reuters (3/10, Sengupta) noted that the drug is called CK-2017357.

Senate votes to again delay Medicare cut

The U.S. Senate voted yesterday to delay this year's 21 percent cut in Medicare physician payments until Oct. 1. The AMA continues to call for permanent reform of Medicare's sustainable growth rate formula. "If the House adopts this Senate bill, America's seniors and their physicians will be left in limbo, and access to health care for Medicare patients will continue to be in grave danger," AMA President J. James Rohack, MD, said in a statement.

AMA Morning Rounds: FDA approves Botox to treat elbow, wrist, and finger spasms.

The AP (3/10, Perrone) reports that "the Food and Drug Administration said Tuesday it approved Allergan's...Botox [Botulinum toxin Type A] to treat spasms of the elbow, wrist and fingers." The agency "stressed in a statement that Botox is not approved to treat spasms in larger muscles of the arms or legs." In 2009, "the agency added warnings to Botox about its potential to migrate from limbs to other parts of the body, causing breathing problems."

Bloomberg News (3/10, Peterson) reports that "clinical trials showed the drug helped patients with muscle spasms in the upper limbs, Russell Katz, director of the Food and Drug Administration's Division of Neurology Products, said...in an e-mailed statement." Dow Jones Newswire (3/10, Dooren), Reuters (3/10), and HealthDay (3/9, Roberts) also covered the story.

AMA Morning Rounds: Bristol-Myers Squibb, Allergan to jointly develop drug to treat neuropathic pain

The AP (3/3) reported that "Bristol-Myers Squibb and Allergan will jointly attempt to develop a drug to treat chronic pain from tissue damage, the drugmakers said." According to the AP, "the drug is said to be ready for mid-stage human trials as a treatment for neuropathic pain, or chronic pain usually accompanied by tissue injury. It is common in people with arthritis, cancer, and nerve damage."

The Orange County Business Journal (3/3) reported that "Bristol-Myers gains the rights to develop, make and market the compound," currently known as AGN-209323, "for just about all uses except for those related to the eye, which Allergan retains." Allergan will receive "an initial payment of $40 million and potential payments of up to $373 million if the compound is successful." Reuters (3/3) and the Wall Street Journal (3/3, Becker) also covered the story.

SGR Cut Averted for 1 Month

Last night the Senate voted 78-19 to pass H.R. 4691, the "Temporary Extension Act of 2010," which included provisions to extend 2009 Medicare physician payment rates through the end of the month. As a result, the 21% payment cut that took effect on March 1 has been postponed until April 1.

The bill passed the House on February 25, only to encounter opposition on the Senate floor by Senator Jim Bunning (R-KY), who objected to the legislation being considered as an emergency measure that would not require budgetary offsets. In addition to postponing Medicare physician payment cuts, the bill extended a variety of other expiring programs including unemployment insurance and premium subsidies for COBRA continuation coverage for those whose employment was involuntarily terminated.

Discussions are still underway in the House and Senate on the next steps that will be taken to address the Medicare payment crisis. Proposals are being circulated that would implement still another short-term patch to the sustainable growth rate (SGR) formula, including proposals that would postpone cuts for 90 days, 7 months, or through the end of 2010. The AMA and those currently attending its 2010 National Advocacy Conference in Washington, DC, continue to press for permanent repeal of the SGR, rather than repeating the pattern of short-term remedies that serve to make future payment cuts more severe and increase the cost of permanent Medicare payment reform.

Members are urged to keep up the pressure, especially in the Senate, for enacting legislation to permanently resolve the Medicare physician payment crisis. Use the AMA’s Grassroots Hotline at 800-833-6354 or write an email.

Senate Fails to Prevent SGR Cuts

Yesterday, the House passed HR 4691, legislation that extends a number of expiring programs for 30 days, including current Medicare physician payment rates, which would once again postpone the 21% cut that was scheduled to take effect this year. The Senate attempted unsuccessfully on several occasions last night and this morning to pass the same bill by unanimous consent, but objections were raised by Senator Jim Bunning (R-KY), on the basis that $10 billion cost of the program extensions was not offset. The Senate has now adjourned for the weekend, so the 21% Medicare physician payment cut will be effective on Monday, March 1.


The Centers for Medicare and Medicaid Services (CMS) informed the AMA that they are notifying their contractors to hold Medicare physician claims for 10 business days, effective Monday. The agency will also be sending out a similar message on its various list serves this afternoon to physicians, and contractors will be instructed to disseminate this information as well.

Express your outrage to Congress about its terrible mismanagement of the Medicare and TRICARE programs, which are so important to the health and well-being of Americans who have served our nation so long and so well. Tell them:

• Congress had more than a year to repeal the Medicare payment formula and ensure the security and stability of the program. Instead, it has abandoned patients who rely on Medicare and TRICARE for their health care.
• Parliamentary procedures offer no excuse for the harm they are causing these programs.
• Stop playing games with patients and the physicians; repeal the sustainable growth rate (SGR) formula once and for all.

Use the AMA's toll-free grassroots hotline at (800) 833-6354 or write them an e-mail.

Needle Electromyography Through a Tattoo

This morning I found an interesting question in my email: "Is needle EMG through a tattoo contraindicated?" The physician who inquired was concerned about both an increased risk of infection and possible damage to the tattoo.

The AANEM does not address this issue in any of its documents, although Risks in Electrodiagnostic Medicine says, "Insertion of needle electrodes through infected skin or sores is contraindicated." A search in Muscle & Nerve produced no articles that mention tattoos in any context. I located a statement from the American Association of Nurse Anesthetists that discusses the risk of piercing a tattoo for an epidural. Similar information was available at mayoclinic.com. An increased risk of infection has not been documented, although needle insertion of a fresh tattoo is not advised. When possible, it is desireable to avoid piercing any tattoo should a small scar disfigure the image.

If you have experience with EMG through a tattoo or a similar "preexisting condition," please share it using the comments feature.

AMA Morning Rounds: H1N1 Hits Children with Neuromuscular Disorders

USA Today (2/18, Sternberg) reports that "thousands of children and adolescents with neuromuscular disorders, asthma and other conditions...are suffering consequences of H1N1 that will linger long after the 2009/2010 swine flu pandemic ends." Although "no one knows exactly why flu has such a devastating effect on" these children, "the evidence has been mounting since late 2005. Researchers at Children's Hospital of Philadelphia "reported that, even in typical flu years, children with these ailments were six times more likely than other children to develop severe complications from flu."

Access 2007 Re-Run and 2008 PQRI Feedback Reports

Physicians may now access their 2007 re-run and 2008 Physician Quality Reporting Initiative (PQRI) data through a new tool. CMS has created the “Verify Report Portal” which is available on the PQRI Qualitynet Portal. In addition to PQRI information, these reports will provide individual physicians with information on their Medicare Part B Physician Fee Schedule allowed charges for the 2007 or 2008 PQRI reporting period, upon which an incentive payment is based.

The tool is available at https://www.qualitynet.org/portal/server.pt.

Paraspinal Mapping Superior to Imaging for Diagnosing Stenosis

A recent JAMA commentary by AANEM member Dr. Andy Haig, notes that while most surgeons use imaging to diagnose stenosis and make surgical recommendations, recent studies have shed doubt on the ability of imaging to confirm a diagnosis of stenosis. In contrast, new data has shown that paraspinal mapping can reliably identify patients with clinical stenosis. Haig says there are three key steps that need to be taken:“Find and treat what is not stenosis, define and treat the effects of stenosis, and treat presumed stenosis without a definitive diagnosis. Failing all of these steps, a positive diagnosis is an important consideration before surgery,” said Haig.

“I hope this commentary can begin a shift in the way some of these topics are considered and researched. Patients don’t present with stenosis; they present with back pain. As physicians, our guidelines should reflect that we diagnose and treat patients who have symptoms that help us make a diagnosis and treatment plan,” Haig concluded.

The commentary written was published in the January 6, 2010, issue of JAMA. The article was co-author by Christy Tomkins, PhD.

SGR Delay Expires March 1

The clock is ticking—tell your senators to repeal the SGR. With a 21 percent cut in Medicare physician payments scheduled to take effect in just 20 days, the time to persuade lawmakers to pass a permanent repeal of Medicare's sustainable growth rate (SGR) formula is ticking away. Contact your U.S. senators and insist that they pass legislation to repeal the SGR formula to avert the cuts, which are slated to take effect March 1. Use the AMA's toll-free grassroots hotline at (800) 833-6354 or write them an e-mail.

New Jersey Legislature Fixes Nerve Conduction Statute

On January 16, one of his last days in office, Governor Jon Corzine signed into law a bill correcting an error that restricted both performance and interpretation of NCSs to physicians and certain other health care professionals. The law took effect immediately. It is now again be statutorily legal for physicians to supervise the performance of NCSs by technologists.

It was never the legislature's intent to prohibit this practice. The inadvertent addition of a single word to a 2005 law during committee revision changed the meaning to require both interpretation and performance of NCSs by physicians and certain other health care professionals. That problem is now fixed.

CPT Publishes Guidance for Consultation Coding

CPT just released an informational memo addressing consultation services and transfer of care. Much of the memo will not apply for Medicare patients since CMS is no longer accepting consultation codes. The memo suggests that Medicare contractor websites are the best place to locate further coding inforamtion for Medicare patients.

Unfortunately, a lack of direction from CMS to contractors has resulted different solutions for reporting low-level inpatient consultations. Until more specific guidance from CMS is given, adhere to the key elements of the service provided when selecting the appropriate code. For example, level 3 inpatient consultation (99253) requires detailed history, detailed exam, and low complexity decision making. This matches exactly with level 1 inpatient hospital care (99221), which requires detailed history, detailed exam, and low complexity decision making.

AMA Morning Rounds: Genzyme expects Pompe drug determination

The AP (1/21) reported, "Genzyme Corp. said Thursday the Food and Drug Administration is scheduled to make a decision on its Pompe disease drug Lumizyme [alglucosidase alfa] by June 17." The agency "had refused to approve Lumizyme until Genzyme fixed manufacturing problems at a facility in Allston Landing, MA," where "some of the bioreactors...contained a virus that slowed down the production of the company's drugs." The drugmaker "is seeking FDA clearance to market the Lumizyme it produces in 4,000-liter bioreactor tanks at its facility in Belgium."

The Boston Business Journal (1/22, Donnelly) reports, "The company said in November it would address the FDA's concerns about the manufacturing processes at the Allston plant by adding internal controls, updating the filling and finishing capabilities and using contract manufacturers and Genzyme's own Ireland manufacturing plant." Since then, "Genzyme has...hired a new senior vice president of global product quality and entered into an agreement with" Hospira Worldwide Inc. "to provide fill and finish manufacturing services." Dow Jones Newswire (1/22, Gryta) also covers the story.

CMS expands Medicare Advantage payment dispute resolution process

Last year, CMS established a payment dispute resolution process for physicians who encountered problems in getting accurate compensation from Medicare Advantage (MA) private fee-for-service (PFFS) plans. Now, CMS has expanded the process to include non-contracted physicians and to include all MA organizations, including HMOs and PPOs, not just PFFS plans. The dispute resolution process can be used by non-contracted physicians to address problems of MA organizations paying less than regular Medicare rates as well as downcoding of claims, but not for denied claims. The contractor handling the disputed payments is First Coast Service Options, Inc. Information on how to initiate the dispute resolution process is available on the FSCO website.

Limited Study EMG: 95870

Parenthetical directions below code 95870 refer users to 95860-95864 when reporting a complete study of an extremity(s). It's not always clear what this means. I have heard from some members who want more information regarding what constitutes a complete study versus a limited study, and when to use the limited code in general.

First, the language of the code 95870 is helpful. "Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters." Study of thoracic paraspinal muscles T2-T11 is reported using 95869. Study of cranial nerve supplied muscle(s) is reported with 95867 (unilateral) or 95868 (bilateral). Study of sphincters is reported with 51785-51792. Additiaonlly, oculoelectromyography is reported with 92262. Finally, laryngeal and diaphragm muscles are also not reported using the limited code becasue they have separate codes, 95865 and 95866 respectively.

Second, five muscles have to be examined to report needle EMG study of a limb. CMS provided specific guidance for codes 95860-95864 in its Final Rule for 1998 on page 59090. “To bill these codes, extremity muscles innervated by three nerves (for example, radial ulnar, median, tibial, peroneal, femoral, not sub branches) or four spinal levels must be evaluated, with a minimum of five muscles studied.” Use this standard for all EMG coding as it is now universally accepted.

If EMG testing fails to meet the five muscle standard described above and cannot be reported using a code for other anatomic sites, report limited needle electromyography code 95870. When appropriate, multiple units of 95870 can be reported for limited study of two, three, or four extremities. It may be necessary to add modifier 59 to additional units of 95870 with some payers.

Needle Electrode Expense

Occasionally I am contacted by a member who wants to know if it is possible bill for the needle electrodes that are used to perform EMG. It is incorrect to report this supply separately becasue it is already included int he value of the procedure code.

Some of these people have tried reporting HCPCS supply code A4215: Needle, sterile, any size, each. I suspect that most of the communication I get on this topic comes after a denial when someone tries A4215 for the first time, because people usually ask if they can bill for the needle, then they ask, "What about A4215?" There may be providers who bill separately for needle electrodes without any problems, but it is technically incorrect and could raise issues in the future during an audit or chart review.

Medicare Consultation Coding: MLN Matters MM6740

Medicare released a Medicare Learning Network bulletin last month that provides additional guidance on billling patient visits instead of consultations. This change regulatory change was discussed in an earlier post when first finalized in November.