News to Note – October 2024

  • Along with our newsletter – ACPA Update – this publication, and others, online discussion groups can also contribute to the work of physician advisors.  Posts about complicated cases, regulatory questions, and professional celebrations abound.  But, always remember that what you read on the internet is not always correct.  A recent discussion on a Facebook case manager forum illustrated this:
    • A case manager asked, “are total hip and knee revisions coded as inpatient or can they be coded as outpatient procedures?”  One respondent wrote, “usually outpatient in a bed.”  Another wrote, “same day surgery.”  Yet another wrote, “used to be IPO [Inpatient Only] but changed about 2 years ago.”  Another wrote, “TKA [total knee arthroplasty] are always outpatient unless there is a complication.”  That person went on to say, “none of my hips get out in less than 2 midnights.”
    • What’s wrong here?  First, until we have Medicare for All or some variation thereof, there are a myriad of payors with their own rules.  Was the initial question referring to Medicare or commercial patients?  Based on the responses, it appears most assumed Medicare and sadly, most answers were wrong.  
      • Revision surgery is still on the Medicare inpatient only list, so it is inpatient for Medicare and Medicare Advantage (MA) plans.
      • Even if referring to first-time surgery, not a revision, the statement about outpatient unless there is a complication, is wrong.
      • What about the hospital where all hip replacements stay two days when patients at other hospitals frequently go home the same day?  How is that kind of variation appropriate in 2024?  
    • Continue to use these online forums for what they can provide but be careful and aware of the potential pitfalls, as well.
  • The Office of the Inspector General (OIG) works with the Department of Health and Human Services (HHS) to protect the Medicare Trust Fund from cheaters and thieves.  Recently, they released an audit of an MA plan, MMM Healthcare.  
    • Like every other OIG audit of an MA plan, the OIG requested the plan send a sample of charts to the OIG contractor.  The contractor then determined if the diagnoses submitted by the MA plan for risk adjustment – leading to an increased capitation payment to the plan – were valid.  As has been the case with many other of these types of audits, it was concluded that the MA plan submitted many invalid diagnoses and as a result, was drastically overpaid by Medicare.
    • Of course, it’s a positive thing that the OIG is catching these cheaters.  But, it’s 2024.  This audit examined diagnoses submitted by the MA plan in 2017.  Seven years ago!
    • In the report, the OIG also noted the audit consisted of a review of 200 charts.  For those of you who participate in chart audits of any kind, how long do you think 200 charts would take you to review followed by production of a summary report?  The OIG gave their contractor three years, between November 2000 and August 2024.
    • The audit found that in the 200 records there were 108 improperly reported HCCs and as a result, the plan was overpaid $165,000.  Using extrapolation, the OIG calculated the plan was overpaid about $59 million.  But, there is a problem: the OIG wasn’t allowed to start extrapolating error rates for the calculation of overpayments until 2018.  As a result, all the OIG could demand from the MA plan was to pay back the $165,000.  This plan was paid $1.4 billion by the Centers for Medicare and Medicaid Services (CMS) for 2017.  $165,000 is pocket change to the MA plan.  Additionally, the contractor which did the audits for the OIG likely was paid a pretty penny, eating up most of the $165,000 recoupment.  
    • Why in 2020 did the OIG decide to go back three years and audit payments made in 2017 when extrapolation was not allowed?  Why not audit 2018 payments where they could protect the Trust Fund by using extrapolation and get back the full overpayment?  This is not clear.
  • Last year, CMS added code G2211 that physicians can use in addition to their visit codes 99202 to 99215.  It’s labelled as a code to compensate for the inherent complexity of the longitudinal care of patients.  In reality, it was designed to allow doctors to earn a little more money in the face of continuing payment cuts.  That movement continues in the 2025 Physician Fee Schedule Proposed Rule where CMS proposes adding a code for use by infectious disease (ID) doctors to describe intensity and complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease.  CMS notes that the COVID-19 pandemic has, as they state, “ignited a hypervigilance for infectious diseases.”
    • ID doctors absolutely deserve this boost in payment, but so does every other doctor that cares for hospitalized patients.  Pulmonary physicians are exposed to airborne infectious diseases all day long.  Do they not also deserve to have an add-on code?  The Emergency Department doctor is encountering the patient with an infectious disease even before the diagnosis is made by the ID doctor, do they not deserve an add-on code? 
    • Keep in mind that codes 99202 to 99215 are not only used in office settings, but they are also used in the hospital for outpatients with observation services seen by consultants.  ACPA Update Editor Dr. Ronald Hirsch had the opportunity to ask CMS about the code during an open forum, specifically if its use is limited to the office place of service.  
      • The answer was no, the code can be used anywhere that the use of those visit codes is appropriate.  This means a consultant seeing a hospitalized outpatient with observation services or a hospitalist seeing a surgical patient can also bill for G2211, if applicable.  
      • To really get into the weeds on this physician billing topic, please keep the following in mind:
        • A hospitalist, caring for a patient as the attending physician, would use codes 99221 – 99233 for a hospitalized patient in Outpatient with Observation services and would not be able to use the G2211 code.  
        • If a hospitalist was acting as a consultant for a surgical patient, say, managing the patient’s insulin-dependent diabetes mellitus, they would use office visit codes and in that instance, be able to add on the additional code of G2211.  
        • The same goes for a hospitalist acting as attending physician for a patient hospitalized as Outpatient for a custodial admission.  They ALSO would use office codes and be able to use the additional G2211 code.
      • Hospitalists generally don’t provide longitudinal care over weeks or months or years, but CMS never really defines “longitudinal care”.  As such, are two hospital visits considered longitudinal and G2211 can be used?  This is not yet clear.  
      • The same is not necessarily true when it comes to consultants seeing hospital patients.  Their care could be considered longitudinal as many would have seen the patient in their office before the hospitalization, or WILL see them in their office after the hospital stay.  This clearly means a cardiologist who is asked to see their heart failure clinic patient who is hospitalized for observation services, can add G2211 to their visit billing.
      • The above point brings up another question: do doctors in the same practice count as one doctor when considering provision of longitudinal care?  If the patient sees cardiologist Dr. Braun in the office but when the patient is hospitalized, Dr. Braun’s partner, Dr. Wald is on call and sees the patient, can Dr. Wald use G2211 since he is providing continuation of longitudinal care which was started by Dr. Braun?  Once again, this is not clear.
    • Picture the patient hospitalized as outpatient with observation services for a recurrent urinary tract infection.  The hospitalist starts antibiotics and consults ID.  The ID consultant sees the patient, discusses therapy options, and decides to see the patient in the office for ongoing care.  That ID physician would bill for their evaluation and management visit with a code from 99202 to 99215 making the place of service, outpatient hospital.  Because they are starting a longitudinal care relationship, they can bill G2211.  But starting in 2025, if CMS finalizes the new code for ID doctors mentioned above, that doctor could also add that new code.  Would this be allowed?  It remains to be seen but hopefully they will address and clarify in the 2025 Physician Fee Schedule (PFS) Final Rule. 
  • The 2025 Inpatient Prospective Services (IPPS) Final Rule has been released and it is 2,985 pages long.  CMS is finalizing their Transforming Episode Accountability Model (TEAM), a bundled payment program for coronary artery bypass graft surgery, lower extremity joint replacement, major bowel procedure, surgical hip/femur fracture treatment, and spinal fusion covering all services from hospitalization to 30 days after discharge.  Don’t panic yet – this program won’t start until 2026 so we all have time to understand it.  There are 188 metropolitan areas that will be included in this program.  If you want to know if you are included, click here.