Reimbursement Update

Reimbursement challenges have tested sleep medicine’s profitability in the past, and 2013 will be no exception. This year, additional factors will impact clinical and financial operations: the expanding influences of accountable care organizations, the 2013 Office of Inspector General (OIG) Work Plan, the implementation of ICD-10-CM code changes, and rapid integration of out-of-center testing as the first line of testing for obstructive sleep apnea.

Code Changes
There are opportunities within the changes, as two new codes have been introduced to focus on an increasing integration of pediatric monitoring with the sleep center’s scope of practice:

  • 95782: PSG, younger than 6 years, attended by the tech using the standard sleep staging with four or more additional parameters of sleep;
  • 95783: PSG, younger than 6 years, attended by the tech with initiation of continuous positive airway pressure or bi-level ventilation.

In addition, the existing codes for billing diagnostic and therapeutic PSG have been revised:

  • 95810: PSG, age 6 years and older, attended by the tech using the standard sleep staging with four or more additional parameters of sleep;
  • 85811: PSG, age 6 years and older, attended by the tech with initiation of continuous positive airway pressure or bi-level ventilation;
  • 95808: PSG, any age, attended by a tech using the standard sleep staging and one to three additional parameters of sleep.

And, as a reminder, it is critical for correct coding and billing to include the use of modifier 52 when appropriate:

  • CPT codes 95800 – 95811: if the recording is less than six hours from lights out to lights on, a modifier 52 is added for clarification.
  • CPT codes 95782 – 95783: if the recording is less than seven hours from lights out to lights on, a modifier 52 is added.
  • CPT code 95805: if less than four naps are recorded, a modifier 52 is added.

Another very important change in wording for 2013, as documented in the CPT Coding Guidelines and subsequent CPT Codes, is the definition of a “qualified healthcare professional.” The description noted in the 2013 CPT Manual published by the AMA reads:

“When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same subspecialties as the physician. A ‘physician or other qualified healthcare professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service. These professionals are distinct from ‘clinical staff.’ A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional. who does not individually report that professional service.”

For practices who bill evaluation and management codes and professional services associated with interpretation of procedures, these changes may impact subsequent credentialing for contracting with third party payers.

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ACO Impact
Accountable care organizations are another factor to consider when addressing reimbursement changes. These entities seek to balance cost control with efforts to improve health outcomes and enhance patient satisfaction. They affect both private practice as well as large multi-specialty practices. Based on review of the ACO pilot projects, it is evident that healthcare providers will need to work more proactively to form new collaborative relationships with payers, since reimbursement will be closely linked to performance on quality measures.

Within the structure of the ACO, chronic disease management programs use case management of care to enhance savings and facilitate cost sharing among the providers. Successful ACO formation requires acknowledgment that the existing fragmented fee-for-service payment structure will require more collaboration with all payers and among payers. The sleep center medical staff will provide a significant role to break down any barriers, which currently may have become adversarial in many markets. To that end, data-sharing and analysis of historical claims will help providers and payers agree on performance targets.

Data Details
The need for an electronic medical record system to share data among all providers and payers also will impact sleep medicine. Providers will need to collect data and report performance on clinical quality measures. These clinical measures will have a heightened focus on outcomes with treatments and therapies. Therefore, it is critical to document evidence-based outcome indicators within our medical record charting and measure the effectiveness of therapy at regular intervals to identify performance and improved quality. The intent is to reduce redundant testing and increase patient adherence with appropriate therapies.

If your clinic and diagnostic facility become a part of an ACO, reporting and tracking improvement of health status indicators associated with diabetes and hypertension will be crucial, as these are beneficial improvements that may occur with effective treatment of obstructive sleep apnea.

Tips for Success
Increased scrutiny by the OIG on increasing claims for sleep-related diagnoses continues in 2013. To offset the impact, take time to complete internal audits of insurance claims codes. Better yet, integrate an ongoing monitoring system in collaboration with billing services to proactively scrub claims prior to submitting to the carrier, to reduce the incidence of filing a claim with errors.

To ensure revenue is received in a timely manner, regular reconciliation of remittance advices and EOBs will provide evidence for denials, which may be indicators of an improper code or a fraudulent claim. Using technology can improve efficiency and operating margins.

The integration of electronic medical records with comprehensive clinical templates to ensure more detailed documentation of the required clinical condition used to define the medical necessity for performing the sleep study can help reduce denials, delays in obtaining reimbursement for services and the time required to rework a claim. All of these delays cost money.

Insurance Landscape
A new analysis by the Employee Benefit Research Institute (EBRI) says self-insurance is a huge trend in employer-sponsored coverage that could become more pronounced in the wake of the healthcare law.

“In 2011, 58.5% of workers with health coverage were in self-insured plans, up from 40.9% in 1998,” an EBRI summary of the study says.

Within self-insured plans, starting in 2014, patients with pre-existing medical conditions will not be excluded. And the employer can define which services they wish to cover and do not have to comply with state benefit mandates. Since many small employers are concerned about the escalating cost of healthcare benefits, this may be a better opportunity to control healthcare costs for both small and large businesses. It is time to reach out to smaller businesses to negotiate a preferred arrangement for services under their self-insured arrangements.

Opportunities for success abound in the face of the changing landscape for sleep medicine providers. Collaboration with third party payers, the patient, your referral network, and the community will boost recognition of your services. Integrating monitoring of testing outcomes is needed to ensure effective therapies and patient adherence with therapy.

Kathryn Hansen is executive director, Kentucky Sleep Society; senior advisor, Sleep Center Management Institute; and owner, Integration Consultants LLC.


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