Under the best of circumstances, coding and documenting medical visits and procedures for Medicare and private payers can be a headache. Now, with the pandemic-related increased use of electronic communication between physicians and patients—including video, telephone, and portal-based email—things have gotten even more challenging. Thankfully, in a recent fast-tracked JBJS article, Hinckley et al. offer some valuable assistance with how to code and document telemedicine and other electronic interactions with patients.
The authors summarize the electronic-communication guidelines from the Centers for Medicare and Medicaid Services (CMS) for documenting these visits and for selecting the appropriate CPT codes and modifiers as of April 20, 2020. They emphasize that private payers may not follow CMS guidelines, so “continued attention to CMS, CPT, and private payer websites is necessary.”
Hinckley et al. also emphasize that CPT codes now distinguish between telemedicine (video) visits, email visits, and telephone services. One of the most useful tools the authors offer appears in an Appendix, where 4 sample grids for musculoskeletal documentation and coding are provided.
It might be wise to familiarize yourself and/or your office staff with these new policies, procedures, and codes, because, as the authors conclude, whatever “new normal” eventually emerges, electronic communication with patients “will likely become a more prominent aspect of our clinical presence and platforms.”
Many people predicted that the mandatory “bundling” of payments for knee and hip arthroplasty by the Centers for Medicare and Medicaid Services (CMS) that began on April 1, 2016 in several US metropolitan areas would lead to “cherry-picking” and ”lemon-dropping.” In other words, hospitals and surgeons wouldn’t take on more complex and sicker patients for joint replacement for fear that the bundled payment would be insufficient (lemon-dropping), and would instead select the healthier patients (cherry-picking). See related OrthoBuzz post.
In the February 19, 2020 issue of The Journal, Humbyrd et al. compare the characteristics of patients who underwent hip and knee replacement (HKR) from April to December 2015 with those of HKR patients during the same period in 2016, after CMS mandated the bundled-payment program in 67 metropolitan statistical areas (MSAs). The patients were matched so that those treated in bundled and non-bundled settings had similar socioeconomic backgrounds.
The matched groups included 12,388 HKR episodes in 40 bundled MSAs and 20,288 HKRs in 115 nonbundled MSAs. The authors also evaluated pre- and post-policy case-mix changes among 1,549 hip hemiarthroplasties, which are not subject to bundling, in the bundled MSAs.
Among patients who underwent HKR, Humbyrd et al. found no significant differences in patient characteristics—including race, dual Medicare-Medicaid eligibility, tobacco use, obesity, diabetes, and Charlson Comorbidity Index (CCI)—after the bundled-payment policy was implemented. Also, they found that patients in bundled MSAs undergoing hemiarthroplasty had significantly higher CCI values and were more likely to have diabetes than those who underwent HKR. This suggests that some surgeons opt for hemiarthroplasty over total hip replacement in less-healthy patients to avoid treating such patients under a bundled program.
From the MSA perspective, these results suggest that cherry picking and lemon dropping are not occurring in the short term. But we would do well as a profession to ensure that those controversial patient-selection practices are not happening at the individual surgeon level, and that the short-term results demonstrated here by Humbyrd et al. persist over the longer term. Even our sickest joint replacement patients deserve the best surgical care.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
The bundled-payment model has found some early success within the field of orthopaedic surgery, most notably in joint replacement (see related OrthoBuzz post), However, more robust risk-adjustment methods are needed, especially in terms of patient factors. That is the message delivered by Cairns et al. in their retrospective analysis of Medicare data from 2008 to 2012 published in the February 21, 2018 edition of JBJS. The authors make a compelling case for improved risk stratification of hip- and femur-fracture patients to ensure that all patient populations have and retain access to appropriate care.
The authors analyzed reimbursements for the surgical hospitalization and 90 days of post-discharge care among nearly 28,000 patients who met inclusion criteria for the Surgical Hip and Femur Fracture Treatment (SHFFT) model proposed by the Centers for Medicare and Medicaid Services (CMS). Their findings highlighted various inconsistencies that could have unintended consequences if not accounted for in the bundled-payment model. For example, reimbursements were $1000 to $2000 lower for patients in their 80s, who tend to have more comorbidities that require more care, than for younger patients. CMS proposed using Diagnosis Related Groups (DRGs) and geographic location to adjust for risk in its SHFFT bundled-payment model, but Cairns et al. identify several other factors (such as patient age and gender, ASA and Charlson Comorbidity Index scores, and procedure type) that could provide a more realistic stratification of risk.
The article clearly articulates how risk adjustments that don’t include more specific patient factors could lead to a multitude of unintended consequences for patients, providers, and the entire healthcare system. These findings could remain relevant now that CMS has announced an “advanced” voluntary bundled-payment model after the Trump administration cancelled SHFFT in late 2017.
Whatever bundled-payment model takes hold, the totality of the orthopaedic literature strongly suggests that the best outcomes are derived from making specific treatment plans for each patient based on the individual characteristics of his or her case. It seems reasonable that the best bundled-payment plans would do the same.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Are you confused and frustrated by Medicare’s Quality-Incentive Programs, such as the Merit Based Incentive Payment System (MIPS), Comprehensive Care for Joint Replacement (CJR) program, and the Surgical Hip and Femur Fracture Treatment (SHFFT) model? If so, this webinar is for you.
On Tuesday, August 15, 2017 at 8:00 PM EDT, The Journal of Bone & Joint Surgery (JBJS) and the American Orthopaedic Association (AOA) will host a complimentary LIVE webinar featuring the following speakers and topics:
- Brian McCardel, MD will discuss choosing MIPS-related quality measures, improving performance on those measures, and qualifying for bonuses.
- Thomas Barber, MD, FAOA will focus on managing clinical care including how to deliver low-cost high-quality care for high-risk orthopaedic patients.
- Alexandra Page, MD will discuss partnering with hospitals and post-acute organizations to improve patient care and reap financial rewards.
Moderated by Douglas Lundy, MD, FAOA, the webinar will include a live Q&A session between the audience and panelists.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Jason Weisstein, MD, MPH, FACS.
MIPS—the Merit-based Incentive Payment System—is still a mystery to many orthopaedic surgeons. But it can have a big positive or negative impact on your practice.
MIPS is a federal improvement-incentive program consisting of Quality, Resource Use, Clinical Practice Improvement, and Advancing Care components. To demonstrate excellent performance (and reap the associated rewards), physicians can choose the activities and measures that are most meaningful for their practice. Weights are assigned to each category based on a 1 to 100 point scale. In 2017, the transition year, weights are as follows: Quality-60 percent, Cost-0 percent, Improvement Activities-15 percent and Advancing Care Information-25 percent.
I often hear a lot of grumbling from colleagues about their electronic health record (EHR) systems as one of the major causes of physician burnout. However, implementing the right technology will help you excel under this new reimbursement model.
Here are 9 MIPS tips related to EHRs:
- Choose the Quality benchmarks that best fit your practice. You need at least 20 eligible cases per Quality measure. Go to the CMS website and select benchmarks that have established measures.
- Report Quality for an entire year or over 90 days.
- Make sure your EHR has built-in dashboards that enable you to keep an eye on your composite score in near real-time, from day to day.
- Be sure that the EHR you select captures data being entered at the point of care and can enable this data to be used for multiple purposes.
- Get a head start on the Advancing Care component. Selecting an EHR vendor with successful Meaningful Use (MU) attestations is critical.
- Earn bonus points via specialty registries and Clinical Improvement Activities.
- Make sure your EHR allows you to compare your performance with that of your peers using analytical tools.
- When engaging in Clinical Improvement Activities, follow guidelines based on your specific practice size.
- Submit only the required number of Clinical Improvement Activities for the given measurement year, because the following year, you may need to pick a different activity.
With the shift to MIPS and value-based care, orthopaedic surgeons and their teams can thrive by adapting and utilizing technology that fits within their workflows and that helps them understand how they are performing in real time, both within their own practices and compared with their peers nationwide.
Jason Weisstein, MD, MPH, FACS is the Medical Director of Orthopedics at Modernizing Medicine.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD.
In a recent issue of JAMA, Dummit et al. analyzed cost and quality results from the Centers for Medicare & Medicaid Services (CMS) Bundled Payment for Care Improvement (BPCI) initiative. The authors compared joint-replacement results between hospitals that voluntarily participate in the BPCI program versus matched comparison hospitals that do not participate. Nearly 60,000 lower extremity joint replacement procedures from each hospital type were included in the analysis.
Medicare payments declined over time in both groups of hospitals, but the authors noted a greater decline in costs among the BPCI hospitals, primarily due to reduced utilization of post-institutional acute care. There were no statistical differences in quality between the BPCI hospitals and comparison hospitals, as measured by unplanned admissions, emergency department visits, and mortality at both 30 and 90 days. These results echo those reported by other pilots in the United States and suggest that similar programs could reduce cost per episode of care without compromising quality.
However, even proponents of the new programs are cautious. For example, in his JAMA editorial, Elliot Fisher, MD warns readers that because BPCI is a voluntary program, the results may not reflect the true impact of a more widespread bundled-payment model. The incentives, he argues, could end up contributing to volume increases or shifts toward healthier—and “more profitable”—patients. As Fisher concludes, “Bundled payments leave the overarching incentive to increase volume solidly in place.”
In a separate JAMA Viewpoint article, Ibrahim et al. warn that another CMS program, the Comprehensive Care for Joint Replacement (CJR) model, could unintentionally amplify already existing racial disparities in elective joint replacement. CJR is a mandatory initiative in 67 randomly selected US metropolitan areas. The authors say that CJR might improve postoperative quality of care for minority patients after joint replacement, but that the program could also end up favoring healthier, well-insured patients.
Overall, at this early stage, these two CMS models offer promising, comprehensive approaches to joint replacement that may prove cost-saving without comprising quality of care. Results like the ones published by Dummit et al. are hopeful, but longer-term, outcomes-based, and cost-focused studies that include epidemiologic and racial impact must be performed as we move forward carefully.
Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.
“Alternative payment models are here to stay,” according to an AOA Critical Issues article by Greenwald et al. in the June 1, 2016 issue of The Journal of Bone & Joint Surgery. The article identifies successful implementation strategies related to the Bundled Payments for Care Improvement (BPCI) initiative launched by the Centers for Medicare and Medicaid Services (CMS) in 2013.
Alternative payment models represent an opportunity to reduce costs by eliminating waste and unwarranted variation in care by finding efficiencies within the system. One way to achieve this is through gainsharing incentives that align hospitals, physicians, and post-acute care providers in the redesign of care. But participants also assume financial risk.
Orthopaedics plays a big role in the BPCI risk-reward initiative. Sixteen of the 48 clinical “episodes of care” included in BPCI are orthopaedic-related. Moreover, three episodes (major lower-extremity joint replacement, femur/hip/pelvis fractures, and “medical non-infectious orthopaedic”) account for 40% of the 16 orthopaedic episodes being evaluated.
The nuts and bolts—and risks and rewards— of the initiative are well-described in the article, but here are several pearls extracted therefrom:
“Care improvement activities and care redesign…are the necessary prerequisites before entering into bundled payment arrangements.”
“The financial risk is real [because] outliers, those patients whose cost is substantially higher than the mean patient cost, cannot be controlled.”
“It is important that the physician or surgeon responsible for the patient is involved in all stages of the episode of care and interacts with all of the parties involved.”
“Specific to orthopaedics, there are substantial opportunities for cost savings by integrating preoperative and intraoperative processes, reviewing implant purchasing options, and negotiating post-acute care costs.”
“Changes in care delivery often require … managing patient expectations.”
The March 16, 2016 JBJS includes a careful incidence, treatment, and outcome analysis by Pearson et al. of CMS data regarding C2 cervical-spine fractures that occurred in the Medicare population from 2000 to 2011. The study’s methodological quality comes as no surprise, as the group hails from Dartmouth, the home of the renowned Dartmouth Atlas of Health Care, which has posed many vexing clinical and cost questions for the orthopaedic community.
Pearson et al. found that while the incidence of C2 fractures in the elderly increased 135% from 2000 to 2011, the rate of surgical treatment for this injury remained essentially unchanged. I find that static rate of surgical treatment troubling, because, after controlling for potential confounders, the authors found that surgical treatment was associated with a nearly 50% decrease in 30-day mortality and a 37% decrease in one-year mortality, relative to nonoperative approaches.
I believe that our apparent reluctance to perform surgery in these cases is due to the underlying belief that upper C-spine fixation/fusion in the elderly presents a prohibitively high risk. I question that general proposition because we think quite the opposite nowadays when managing hip fractures and many other metaphyseal fractures with high complication profiles in older people. Certainly, the major risks with upper C-spine surgery are potentially fatal neurologic and vascular injuries, but this well-done analysis demonstrates that the mortality outcomes are markedly better with surgery. In addition, JBJS recently published a paper by Joestl et al. on the outcomes of C2 fusions in geriatric patients with a dens fracture nonunion, which confirmed good outcomes and a favorable risk profile (see related OrthoBuzz post).
I think it is time for the orthopaedic, neurological-spine, and rehabilitation communities to seriously reconsider our approach to elders with C2 fractures. As Pearson et al. conclude, until an RCT is performed on this question (if ever), “surgeons and patients should use the available data in a shared decision-making model to choose the treatment consistent with an individual patient’s values.”
Marc Swiontkowski, MD
OrthoBuzz occasionally receives posts from guest bloggers. This “guest post” comes from Richard S. Yoon, MD and Alexander McLawhorn, MD, MBA.
Starting on April 1, 2016, Medicare will implement its Comprehensive Care for Joint Replacement (CJR) model in about 800 hospitals in 67 metropolitan areas around the United States. Finalized in November 2015, the CJR initiative is intended to enhance value for patients undergoing lower extremity joint replacement (LEJR) by motivating institutions to achieve quality improvement via cost control. (For a complete discussion of “value” in orthopaedics, see “Measuring Value in Orthopaedic Surgery” in JBJS Reviews.)
Medicare hopes CJR will promote standardized, coordinated care that takes each LEJR patient seamlessly through an “episode of care” that maximizes outcomes at a reduced cost. Episodes are triggered by hospital admission and are limited to admissions resulting in a discharge paid under MS-DRG 469 or 470. For CJR purposes, episodes last for 90 days following discharge.
Initially, episode target prices will be based on historical hospital-specific reimbursements, but over time, the target prices will increasingly reflect regional averages. If a hospital’s average LEJR episode cost is below the target price, it can receive a “bonus” from CMS. If its average cost is above the target price, it will owe CMS the difference. CMS has designed a gradual rollout plan to mitigate downside risk in the first year and provide current and future participants adequate time to implement evidence-based, cost-effective care and other quality programs in their institutions.
Richard Iorio, MD, chief of adult reconstruction at NYU-Langone Medical Center’s Department of Orthopaedic Surgery, says, “There will be definite winners and losers in CJR. Once geographic pricing becomes the dominant metric for target prices, there will be intense price competition in geographic areas and potential access problems for high risk patients.” At the moment, CJR stratifies risk based only on MS-DRG code and whether a patient has a hip fracture. Unless a more robust risk stratification method is implemented, “cherry-picking” patients may become a significant issue. (See related OrthoBuzz post “Tool for Pre-TJA Risk Stratification.”)
If you are an orthopaedic surgeon who performs LEJR, ask your department head or health system about CJR, because strategies that minimize cost and maximize quality may vary from hospital to hospital. Alignment of hospitals and surgeons is probably the most critical success factor with CJR. To that end, gainsharing— a key component of well-functioning hospital-surgeon partnerships within any bundled-payment environment —for individual orthopaedic surgeons is specifically allowed within the CJR final rule.
Click here for more information, including FAQs and a list of participating areas.
Richard S Yoon, MD is executive chief resident at the NYU Hospital for Joint Diseases.
Alexander McLawhorn, MD, MBA is an arthroplasty fellow at the Hospital for Special Surgery.
Meaningful use (MU) Stage 2 and 3 requirements have been a bane of existence for many physician practices, so a collective sigh of relief was heard when acting CMS administrator Andy Slavitt hinted recently that a more streamlined approach to regulating health care IT is coming.
Suggesting that MU as we know it may end altogether sometime in 2016, Slavitt offered few specifics in a speech at the recent JP Morgan Healthcare Conference, saying only that details of the new plan will come out “over the next few months.”
Beth Israel Deaconess Medical Center CIO John Halamka, MD, a frequent blogger on the subject of meaningful use, has said more than once that Stages 2 and 3 tried to do too much too fast, while lauding the functional foundation established by Stage 1. Halamka noted that when MU requirements are heaped on other rules and regulations such as HIPAA, the ACA, ICD-10, and Medicare value-based payment systems, the entire game becomes too complicated and confusing for everyone, including government auditors.
On January 14, 2016, 31 healthcare organizations (including notables such as Geisinger, Intermountain, and Partners) sent a letter to HHS secretary Sylvia Burwell, urging her to “restructure the MU program to fit future care needs and focus on improving interoperability and usability” of EHRs.
Stay tuned…OrthoBuzz will keep you posted.