JULY 2007


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BREAKING NEWS FOR ALL UROLOGISTS

The CUA has just received important information pertaining to new CMS Proposed Regulations impacting a wide range of urology revenue centers, including major changes for ESWL and laser partnership contracts. CMS just published a draft of  proposed rule changes controlling Medicare payments for 2008 and we have prepared and posted a summary of the aspects relevant to urologists on our web site for your review and comment to CMS/AUA accordingly.

Alternatives and t
he implications of this will be fully discussed by our expert speaker -healthcare attorney, Greg Smith - at this year's Socioeconomic Forum in Scottsdale in October. Any investor in ESWL or laser partnerships, any doctor with in-office pathology or imaging services or any urologist planning to treat Medicare patients in 2008 will not want to miss this year's Forum. 


CMS PROPOSED FEE CHANGES NOW OPEN FOR COMMENT
Major changes for ESWL and laser partnership contracts
by Greg L. Smith, a healthcare attorney practicing with Womble Carlyle Sandridge & Rice, PLLC

On July 2nd CMS made available for viewing on its website proposed regulations and commentary that would materially affect the manner in which urologists have historically exploited ancillary revenue opportunities.
READ MORE...


2007 PHYSICIAN QUALITY REPORTING INITIATIVE (PQRI)
by Jeffrey Kaufman, M.D., FACS
PQRI is upon us. Although reporting efforts will ultimately be reimbursed, many have felt that the potential payment available was not worth the effort involved (at least 80% compliance with at least 3 different applicable criteria is eligible for a bonus payment up to a maximum of 1.5% of all Medicare allowable charges for the interval involved capped by a complicated formula related to the volume fo reported events). READ MORE...


WESTERN SECTION AUA SOCIOECONOMICS FORUM
by Jeffrey Kaufman, M.D., FACS
We hope that you and your partners are planning to join us at the Western Section meeting in Scottsdale this October. The socioeconomics forum already has an excellent program scheduled for Sunday, October 28. 
Emphasizing economic issues, we will have an update on the P4P program and new coding tips.
READ MORE...



California Urological Association
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TEL: 714-550-9155
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Western Section AUA / CUA - Socioeconomics Forum
Tuesday, October 30, 2007 (12:00pm - 1:30pm)
During the Western Section AUA 83rd Annual Meeting
MORE INFO... 

Western Section AUA - 83rd Annual Meeting
October 28-November 1, 2007
Hyatt Regency at Gainey Ranch
MORE INFO... 

Share your best practice management tips, ideas, useful links, resources or questions with the CUA.
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CMS PROPOSED FEE CHANGES NOW OPEN FOR COMMENT         


On July 2nd CMS made available for viewing on its website proposed regulations and commentary that would materially affect the manner in which urologists have historically exploited ancillary revenue opportunities.  The new proposed regulations and commentary are expected to be published in the Federal Register on July 12.  The proposed regulations and commentary cover 924 pages, and comments are being solicited by CMS until 5 p.m. August 31, 2007.  The regulations and commentary most material to urology practices are summarized below:

  1. Cuts in Physician Fee Schedule.  CMS has issued a proposed rule to revise payment rates and policies under its Medicare Physician Fee Schedule for 2008.  Pursuant to the proposed changes, the fee schedule would receive a 9.9% cut in benefits.
  2. Prohibition on Per Procedure Fees.  Historically, Stark law exceptions have allowed urologist-owned vendors of lithotripsy, bph laser and other medical equipment services to contract with hospitals in exchange for a per procedure fee.  The proposed regulations intend to amend the Stark exceptions to eliminate per procedure (unit of service) payments to referral physician sources in the context of equipment and space rentals.
  3. Prohibition on Percentage Fees.  Certain Stark law exceptions required that payments to referral-based physician ventures be "set in advance," which phrase was defined by CMS to allow percentage compensation arrangements (e.g., a percentage of revenues or collections).  CMS proposes to amend the "set in advance" requirement to exclude percentage payments, except for personally performed physician services.
  4. Changes in Under Arrangement Contracting.  Medicare allows a hospital to contract with outside providers to obtain services for its patients "under arrangements."  The hospital then bills and obtains Medicare reimbursement for the services, and pays the provider an agreed upon contract rate.  Because the only venue for lithotripsy technical fee reimbursement is at hospitals, almost all urologist-owned lithotripsy ventures contract under arrangements with hospitals for the treatment of Medicare patients.  CMS is concerned that certain "under arrangement" relationships encourage physician-owners to over-utilize services that result in higher costs to the Medicare program.  In an effort to combat this perceived abuse, CMS proposes a new rule that could eliminate under arrangement contracting between hospitals and referring physician owners of ventures that provide certain services. Further clarification is required to determine if the proposed regulations would apply to services that are Stark designated health services solely because they are hospital inpatient or outpatient services (such as lithotripsy and bph laser services).
  5. In-office Imaging and Path Lab Services.  Over the past few years there has been a proliferation of financial arrangements whereby urologists have provided and billed office-based path lab and imaging services under the Stark in-office ancillary services exception.  In some arrangements the urology practice also globally bills the professional interpretation performed by an outside radiologist or pathologist.  CMS proposes under its new regulations to prohibit physicians from marking up the charges submitted to Medicare for technical component services above what the physician paid to purchase the test from an outside supplier.  Further, when the physician globally bills the technical and professional component of a diagnostic test, the new proposed rules would prohibit the billing physician from profiting from the assigned or purchased professional component.  Under the proposed rules, the only technical or professional diagnostic services a professional practice can mark-up are those actually performed by the practice's full-time employees.

We will provide you with additional guidance in the near future to assist you in timely preparing and submitting comments to CMS regarding the proposed regulations.  The proposed regulations certainly threaten many urology ancillary income opportunities but, more importantly, raise serious concerns with patient care and access.

This update on the new proposed regulations was prepared and submitted by Greg L. Smith, a healthcare attorney practicing with Womble Carlyle Sandridge & Rice, PLLC, and specializing in urology-based ancillary revenue opportunities.  Greg can be reached at gsmith@wcsr.com and 336-721-3665.


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2007 PHYSICIAN QUALITY REPORTING INITIATIVE (PQRI)

PQRI is upon us.  Although reporting efforts will ultimately be reimbursed, many have felt that the potential payment available was not worth the effort involved (at least 80% compliance with at least 3 different applicable criteria is eligible for a bonus payment up to a maximum of 1.5% of all Medicare allowable charges for the interval involved capped by a complicated formula related to the volume of reported events).  Certainly this is true if reporting takes significant work, thought, energy or overhead.  However, if the process can be made streamlined and effortless by automating your reporting, then the financial reward is an attractive addition to your bottom line. 


Out of the potential 74 different measures available currently, there are only 5 that really pertain to most urology practices and 3 of those need only be reported once this year to qualify.  The fact is that almost every urologist already performs the quality events PQRI is surveying.  Therefore, the process does not involve changing practice patterns; it merely requires that you report what you already do. (I will leave aside for the moment any editorial arguments that the PQRI effort will not have any impact on overall quality since it is most likely only going to reward those who already provide quality care; those who do not are not likely to participate and the rewards are insufficient to have any real impact on practice patterns.  Thus the program is better characterized as Pay for Reporting than Pay for Performance). 

If reporting requires you to search through your records, expend any mental energy considering which code to use and when, or spend any time deciding how to enter the CPT II information, then the financial rewards are insufficient to warrant your participation.  However, a little planning up front should allow the process to become routine and automatic and thus cost effective.  This shouldn't be a problem for those with EMR.  However, even for paper based offices like ours, we have developed a simplified system that will involve a minimum of effort and allow us to participate with virtually no increase in time, energy or overhead costs.  The goal is to simplify reporting and minimize our workload.


Like most urologists, we already perform and document the events in question so participating is nothing more than reporting our compliance.  Since the 3 incontinence codes (assessing the presence or absence of urinary incontinence in women over 65 years old, characterizing the type of urinary incontinence and documenting a plan of care for urinary incontinence) need be documented and reported but once per year, we place an easy to identify checklist on the outside of the chart telling us at a glance whether the criteria have been reported this year or not.  If not, at check out for all new and return visits for women over 65 years old, our superbill is checked next to the CPT code for the visit to tell our billers to add the CPT II code indicating that we asked about and documented the presence or absence of incontinence (this is done regardless of the actual presenting complaint).  The superbill is also starred next to the CPT code for incontinence (urge, stress or other) to indicate that any identified incontinence was characterized and a plan of action documented when incontinence is the reason for which the patient was seen (placing that patient among the denominators in calculating participation in that criteria category).  If our billers see a check or star (and many charts have both), they automatically add the appropriate CPT II code to the superbill that day (CPT II codes used for PQRI must accompany the appropriate CPT code for the E&M visit on the same bill to count toward participation.  They may not be added on a subsequent bill nor may the bill be re-submitted to add a CPT II code if you forgot to include it originally).  Many bills will include all 3 CPT II codes if the visit actually was for a complaint of incontinence.  If the patient's chart indicates that the pertinent CPT II codes have already been submitted once, no further checks or stars are added to the superbill and no further CPT II codes are submitted to CMS on that patient this year.


With regard to the two surgical codes, since we utilize appropriate DVT prevention efforts and prophylactic antibiotics on every surgical patient, our billers are automatically submitting the appropriate CPT II codes along with the charges for all operations (placing the CPT II codes more than once per claim if more than one surgery is billed on that date).  This will inevitably involve some over-reporting since the PQRI criteria do not indicate that DVT or antibiotic prophylaxis is necessary on every surgical procedure.  However, it takes too much effort for our billers to cross check our surgical codes with the list of those requiring DVT or antibiotic prophylaxis every time they submit a claim.  If it is necessary to spend that amount of time and mental energy to limit reporting to only those procedures on the list, the process immediately becomes cumbersome and our overhead costs out weigh the rewards.  We feel it is better to over-report than spend too much time thinking about which codes to report on or fail to meet the 80% participation threshold to qualify for reimbursement. 


Our system is set up to be as automatic as possible and require the least possible time and thought process.  It assumes that the work was done properly and adequately documented.  The reality is that, although all reports are subject to retroactive review, CMS simply lacks adequate staff and resources to reasonably review anything more than a mere token of the multiple millions of reported submitted claims this program will generate.  They are far more interested in developing participation among physicians than they are with technical compliance at this time.  The potential for any chart to be reviewed for PQRI compliance in the near future is between slim and none.  Again, the program is designed as nothing more than Pay for Reporting which you either do or don't.  There is little you can do to fail at this unless you refuse to report at least 80% of the events included in the criteria's denominator. 

To further simplify our participation, we have elected to ignore all exclusionary modifiers for the present (1P, 2P, 3P or 8P) since we virtually always have done the work that the PQRI reporting addresses.  In the future, these explanations for why the event was not performed even though reported may become more appropriate.


In this simplified fashion, we have entered into the brave new (but ultimately futile) world of Pay for Performance reporting.  Many of you have already been participating in similar programs with private payers, often in managed care groups.  However, for the rest, the mantra of Performance Based Purchasing has become an article of faith inWashington and various state capitols.  We might as well become experienced in the process since it promises to be with us for a very long time to come and future participation is unlikely to remain voluntary.  And the bottom line is, if you do it, they will pay.

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WESTERN SECTION AUA SOCIOECONOMICS FORUM 

We hope you and your partners are planning to join us at the Western Section meeting in Scottsdale this October.  The socioeconomic forum already has an excellent program scheduled for Sunday, October 28.  Emphasizing ancillary revenue strategies, we will have an update on the new CMS regulations, new strategies to grow income, P4P program and new coding tips.  We will feature an extended presentation on enhancing revenue through ancillary services including legal advice on how to structure your programs properly and to your advantage.  News on the imaging wars (credentialing, certification and payment) from the AUA imaging task force chair and further updates on state, regional and national political and legislative challenges will round out the program.  You absolutely cannot afford to miss this program (and lunch is included!).  We look forward to seeing you there. For full meeting details please visit http://www.wsaua.org/Scottsdale07/2007.htm .

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Disclaimer: The "CUA 4.5 Frontline Briefing" e-bulletin is published by the California Urological Association as a service to CUA members. Your comments are welcomed. The California Urological Association, Inc. (CUA) believes the information in this newsletter is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any kind are disclaimed. This newsletter is not intended as legal advice nor is the CUA engaged in rendering legal or other professional services.

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