*NEW* Academy Urges CMS to Revisit Onerous 90-Day Grace Period Policy (3/13/2014)
Under the ACA, consumers who purchase certain health insurance plans are allowed a three-month grace period if they miss a monthly premium payment. During the last two months of this grace provision, insurers are allowed to pend and/or deny claims submitted during this time frame. In other words, insurers are able to unfairly shift the burden and risk of potential loss for patient non-payment to physicians by having physicians bear the cost of the services provided. In an effort to protect members from this onerous policy, the Academy joined an AMA letter urging CMS to require insurers to notify providers of a patient’s grace period status as part of the insurance eligibility verification process. The Academy will continue to call on CMS to revisit this policy and will keep members apprised of all pertinent information via eNews, HP Update and other outreach media. View the sign-on letter here.
*NEW* Coding Update: New CMS G-Code/Modifier Requirements for Therapy Services (3/13/2014)
Last year, CMS finalized several key changes to reporting requirements regarding therapy services. Specifically, CMS implemented a claims-based data collection strategy to collect data on patient function, which impacts key services provided by Otolaryngologists. CMS defines “therapists” as all practitioners who furnish outpatient therapy services. Under this policy, claims for therapy services must now include non-payable G-codes and modifiers, which will allow the agency to capture data on the beneficiary’s functional limitations at various points during the provision of therapy. For therapy services being furnished that are not intended to treat a functional limitation, the therapist should use the G-code for “other” and the modifier representing zero. For a full summary of the issue, click here.
*NEW* Health Policy Attends March MedPAC Meeting (3/8/2014)
As members know, MedPAC is the independent commission charged with annually reviewing Medicare payment policies and making recommendations to Congress based on its review and findings. The Commission just recently released its annual report to Congress for 2014, a summary of which will be available to members shortly. In addition to its annual report, Medpac held meetings on March 6 & 7 where Health Policy staff were in attendance. Discussion at the March meetings focused on topics such as: Next Steps in Measuring Quality Across Medicare’s Delivery Systems and Developing Payment Policy to Promote Use of Services Based on Clinical Evidence. To view a summary of the March meeting, click here.
Academy Signs onto AMA Letter Regarding Backlogged Medicare Appeals (2/12/2014)
On February 12, the Academy signed onto an AMA letter sent to the Office of Medicare Hearings and Appeals (OMHA) regarding its delayed adjudication of provider appeals to Medicare audits. Click here to view the letter.
Academy Works to Resolve Concerns Related to CMS 2014 Payment Policy for Removal of Cerumen (69210) (2/5/2014)
On February 3, the Academy held a conference call with CMS regarding its reimbursement policy for cerumen removal, CPT 69210, after hearing from Academy members who've experienced issues with billing 69210 using the -50 modifier. Per CMS instruction on the call, this reimbursement policy will remain in place through CY 2014 as an interim value for the service which was finalized in the Final Medicare Physician Fee Schedule (MPFS) for 2014. As a reminder, CMS implemented this payment policy based on their disagreement with the assumption by the RUC that this procedure will be furnished in both ears only 10 percent of the time, as they feel the physiologic processes that create cerumen impaction likely will affect both ears. Based on CMS' guidance, the Academy recommends that members NOT report 69210 using modifier -50, as MACs are denying these claims entirely and not paying for even one unit reported. This requires providers to reprocess the denied claim which takes additional time and administrative effort. CMS has stated they will not issue a transmittal to providers at this time, and have asked the Academy to share this coding directive with members. We are working with the Agency to provide them with concrete data related to the percentage of time 69210 is provided bilaterally, in hopes that this will allow them the necessary evidence to revisit this payment policy in CY 2015. As the dialogue continues with CMS, we will keep members apprised of our progress on these advocacy efforts via the weekly e-news, monthly HP-Update, and printed Bulletin. Please email us with any questions at: firstname.lastname@example.org.
Academy Update on Concerns Related to CMS 2014 Payment Policy for Removal of Cerumen (69210) (1/17/2014)
The Health Policy team is actively working to resolve billing issues regarding Removal of Cerumen (69210) with CMS. Please note that while the CPT code book and coding guidance direct that you may bill using a -50 modifier when performed bilaterally, CMS has stated in their 2014 final Medicare physician fee schedule rule that they will not pay for more than one unit of 69210, as they believe it will be performed bilaterally virtually all the time. The Academy is planning to comment to CMS and outline our disagreement with this assessment in our comments on the final rule (due end of January) and we are also working to schedule a phone call with CMS officials to discuss our concerns. As part of these conversations we are seeking clarification from CMS regarding how to code and bill for this service given that the CPT code descriptor and code book are not consistent with the policy CMS has stated they will implement. To date, we have not heard that private payers are following the CMS policy, but please let us know (email@example.com) if you receive denials from private payers when coding 69210 -50 as well. Members should keep an eye out for future Academy correspondence via the e-news and Bulletin related to this issue as we will be getting further guidance out to members as soon as we have more information from CMS. To view the Academy summary of the MPFS rule, click here.
Academy Attends January MedPac Commission Meeting (1/23/2014)
On January 16 & 17, Health Policy staff attended Medpac meetings in Washington, D.C. As members may know, MedPac is an independent Congressional agency that advises Congress on issues affecting the Medicare program, including payment adequacy, quality of care, and access to care. During the meetings the commission discussed and voted on recommendations regarding: payment adequacy for hospital inpatient and outpatient services; policy options for Medicare Accountable Care Organizations (ACOs); Medicare Advantage program; and payment adequacy for Ambulatory Surgical Centers (ASCs). To view a summary of the meeting, click here
CMS Issues New Hospital Inpatient Admission Requirements for 2014 (1/10/2014)
Recently, CMS released the 2014 Inpatient Prospective Payment System final rule which clarifies that a beneficiary is an inpatient of a hospital if formally admitted via an order by a physician or other qualified practitioner. The rule, commonly referred to as the "2 Midnight Rule" establishes new principles of which members should be aware, including:
Inpatient status only applies prospectively from the time of formal admission. The new rules are aimed at reducing long beneficiary stays as outpatients, and clarify that if the ordering practitioner expects a beneficiary to stay at least two midnights, they should be admitted as an inpatient. Click here to view the rules. For more instruction for orders and certifications, click here.
- Admission must be "certified" by a physician with an order a required component of that certification. The order must be written, cited in the medical chart, signed by a physician or other qualified practitioner and must be completed either prior to admission or at the time of admission.
- Certification must include the reason for the inpatient admission, estimated duration and a tentative post-discharge plan. A specific format is not required.
- A physician should generally order an inpatient admission when he or she determines care is expected to transcend two midnights or involves a procedure designated by OPPS as an inpatient-only procedure. However, physicians should be aware CMS has emphasized that there must be "no reasonable possibility that the care could have been adequately provided in an outpatient setting."
FDA's ENT Panel Reviews Safety and Effectiveness of Hybrid Cochlear Device
On November 8, 2013, the Food and Drug Administration (FDA’s) Ear Nose and Throat Devices Panel (ENT panel) met in Silver Spring, Maryland to discuss the safety and effectiveness of a new hybrid cochlear implant device, the Nucleus® Hybrid™ L24 Implant System (Hybrid L24), to make a recommendation about pre-market approval status. The Hybrid L24 is designed for the treatment of adults who are 18 years or older, have residual low-frequency hearing sensitivity and bilateral severe to profound high-frequency sensorineural hearing loss, and obtain limited benefit from hearing aids amongst other indications.
Several Academy leaders hold prominent roles at the FDA and many voting members of the FDA panel are also Academy members. Notably, Gayle Woodson, MD, AAO-HNS President-Elect, serves as chairperson of the FDA ENT panel and several Academy members participate during meetings. Anjum Khan, MD, MPH, also an Academy member and a Medical Officer with the FDA, presented on the safety and effectiveness of the Hybrid L24. In addition, Academy members J. Thomas Roland, MD, and Bruce J. Gantz, MD both attended and presented at the meeting as principal investigators of the device.
The following Academy members sat in on ENT panel discussions as voting members or temporary voting members including: Steven W. Cheung, MD, MBA, Roberto A. Cueva, MD , Barry E. Hirsch, MD, Michael E. Hoffer, MD, CAPT MC, USN, Akira Ishiyama, MD, Herman A. Jenkins, MD, Margaret A. Kenna, MD, MPH, Arnaldo L. Rivera, MD, CDR, MC, Jeffrey T. Vrabec, MD, Bevan Yueh, MD, MPH, and Ronald von Jako, MD, PhD.
After listening to several patient experiences and clinical research presentations, the FDA panel members deliberated, unanimously recommending that the Hybrid L24 device is safe, effective, and provides benefits that outweigh the risks for patients meeting the criteria specified in the proposed indications. The FDA is not bound by the recommendations of its advisory committees, but will consider the recommendations and guidance during the final review of the device.
For further details on research presented at the meeting and other relevant materials, please visit the FDA website and view the Committee meeting materials here.
Academy Reaffirms Proposed Revisions to ICD-10 Unilateral Hearing Loss Codes (11/21/2013)
In a November 13th comment letter to the National Center for Health Statistics (NCHS), the Academy reaffirmed its previously proposed revisions to several unilateral hearing loss codes in the new ICD-10 code set. Along with 4 other organizations, the Academy proposed editorial changes to improve accuracy and classification of the codes. To view the letter, click here
Academy Meets with CMS to Advocate for You (11/12/2013)
On November 7, 2013 the Academy met with top officials at CMS to discuss payment reform efforts, the need for development of additional clinical quality measures to ensure successful participation in the Physician Quality Reporting System (PQRS) and Value Based Modifier programs, and inquired as to why 5 of the 9 sinusitis measures were not accepted within the 2014 proposed fee schedule. Health Policy staff and physician leaders also outlined our continued concerns regarding CMS’ proposed OPPS cap policy which would reduce practice expense relative value units for 13 Otolaryngology services when performed in the office setting, if finalized in the final 2014 rule. The meeting was yet another effort by the Academy to ensure CMS understands the critical role otolaryngologists play in the health care system and the impact these programs and policies have on our specialty.
2012 PQRS Feedback and QRUR Reports Available(11/7/2013)
Access your 2012 PQRS Feedback Reports Today
If you participated in the PQRS program from January 1 and December 31, 2012, you may now access feedback on your 2012 performance. Additionally, provider Quality Resource Use Reports (QRURs) are available on the CMS website for providers to assess their resource use and cost performance for CY 2012. Visit the Academy's quality website for instructions on obtaining both reports.
Doc Caucus Sends Letter to CMS Urging Repeal of OPPS Cap Proposal in 2014 MPFS (10/17/2013)
On October 17, 16 members of the House of Representatives’ Doc Caucus sent a letter to CMS outlining their concerns with CMS’ proposal to use hospital outpatient and ambulatory surgical center payment rates to cap practice expense payments in the physician office setting for CY 2014. If finalized, 13 ENT services would see reductions from 6-60 percent in 2014. The Academy is pleased to see the Hill take action in support of our position on this issue, and we continue to push CMS to retract this flawed policy proposal in the final rule. View the Academy's summary of the 2014 MPFS here.
CMS Releases New Rules on Hospital Inpatient Admissions (10/10/2013)
Recently, CMS released the 2014 Inpatient Prospective Payment System final rule which clarifies that a beneficiary is an inpatient of a hospital if formally admitted via an order by a physician or other qualified practitioner. The new rules are aimed at reducing long beneficiary stays as outpatients, and clarify if the ordering practitioner expects a beneficiary to stay at least two midnights, they should be admitted as an inpatient. Click here to view the rules.
Senators Urge CMS to Delay Meaningful Use Stage 2 Requirements (9/24/2013)
Recently, 17 Members of the U.S. Senate joined together to send a letter to Secretary Sebelius and the Centers for Medicare & Medicaid Services, urging them to implement a one year delay (from 2014 to 2015) for Stage 2 Electronic Health Record (EHR) Meaningful Use requirements. Click here to access the letter.
Aetna Clarifies Allergy Immunotherapy Policy
Through the joint advocacy efforts of the Academy, AAOA and AOA, we have received clarification from Aetna Medical Directors regarding their new Allergy Immunotherapy Policy for CPT 95165. To view the joint letter sent to Aetna in July, click here. We are particularly pleased that Aetna has chosen to accept our request to allow 120 units during the first year of escalation, and 90 units for years thereafter, for maintenance. For more information, access the response from Aetna on August 8th.
FDA's Nonprescription Drug Advisory Committee Recommends OTC access to Nasacort AQ
(7/31/2013)The FDA's Nonprescription Drug Advisory Committee (NDAC) has recommended over the counter (OTC) access to Nasacort AQ. AAO-HNS CEO David R. Nielsen spoke in opposition to the application, as did AAAAI, ACAAI, and AAOA, at an NDAC meeting July 31. Dr. Nielsen shared information from a joint AAOA/Academy letter outlining our opposition due to safety concerns and lack of evidence to support the change. Although the original application was for adults only, the Advisory Committee extended it to include ages 2-18, so the label would reflect the dosing difference for children. The Consumer Health Product Association gave data and testimony on the benefits of OTC medications, relatively low incidence of adverse outcomes, and the overall reduced costs of health care associated with OTC medications. The panel voted 10 to 6 (with 2 abstentions) in favor of OTC use. While the FDA is not required to follow the NDAC recommendations, they typically do so. The Academy will report out to members the FDA’s final ruling. For additional background information from the FDA Advisory Committee meeting, click here.
If you have any inquiries regarding this issue, please email firstname.lastname@example.org.
Academy Issues Summary for 2014 Proposed Rules for the Medicare Physician Fee Schedule. Hospital Outpatient/Ambulatory Surgical Centers Proposed Rule Released
The Center for Medicare / Medicaid Services (CMS) released the proposed 2014 Medicare Physician Fee Schedule (MPFS) and 2014 Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Centers (ASCs) proposed rules. The Academy has summarized the MPFS, which can be found below. The OPPS Rule has been divided into two summaries, one for the OPPS section and one for the ASC section as listed below:
*NEW* Academy Summary of 2014 HOPPS Section of Proposed Rule*NEW* Academy Summary of 2014 ASC Section of Proposed Rule *NEW* Academy Summary 2014 Proposed Medicare Physician Fee Schedule
Links to each proposed rule are provided below:
CMS 2014 Proposed Medicare Physician Fee ScheduleCMS 2014 Proposed OPPS / ASC Proposed Rule
Academy Submits Comments to CMS on 2014 IPPS Proposed Rule
On June 20th, the Academy submitted comments to the Centers for Medicare & Medicaid Services (CMS) on the 2014 Hospital Inpatient Prospective Payment System (IPPS) Proposed Rule. Comments focused on clarifying the definitions for inpatients and outpatients in a hospital setting. See the letter here.
Academy Submits Comments to CDC Requesting New Pulsatile Tinnitus ICD-10 Code
Academy Reapplies for DME Oral Appliance LCD Revision
On June 18th, the Academy sent comments to the Centers for Disease Control and Prevention (CDC) regarding a change.org petition received by the CDC from over 1000 patients, supporting the creation of a new ICD-10 code to distinguish between Pulsatile Tinnitus (whooshing sound) and non Pulsatile Tinnitus (ringing of the ears). Without a diagnosis code, patients with pulsatile tinnitus are being improperly classified as part of the larger tinnitus community, with whom they share few medical similarities, resulting in inadequate medical attention, diagnoses, and treatments. See the letter here.
On May 16th, the Academy resubmitted an application for CMS to revise their DME Oral Appliance LCD, which prohibits ENTs from fitting and billing for oral appliances. In the letter, the Academy addressed concerns regarding Stark law prohibitions. Read the letter here.
Academy Expresses Concerns to AARP Regarding United Healthcare Direct to Consumer Hearing Aid Sales
On May 16th, the Academy sent a letter to American Association of Retired Persons (AARP) regarding our concerns about patient safety and quality of care related to United Healthcare's Hi Health Innovations direct-to-consumer hearing aid program. We also too the opportunity to highlight our ongoing quality initiatives in the letter. See the letter here.
Academy Sends Request for Disclosure of Milliman Care Guidelines
On May 14, the Academy sent a letter to leaders at Milliman Care Guidelines (MCG), operated by the Hearst Corporation, regarding their care guideline for Stapedectomy procedures which requires a CT scan prior to the procedure. This requirement is contrary to the Academy's current clinical indicator, which does not require a CT scan. Milliman has not responded to our request to date, but Academy staff will continue to monitor the issue as many private payers utilize the Milliman criteria as part of their claims review process. Read the letter here
Academy Comments on Application of Exclusivity Rules to ACOs
The Academy recently submitted comments to CMS outlining concerns with the manner in which the Agency was interpreting exclusivity requirements for providers participating in Accountable Care Organizations (ACOs). These comments were crafted in response to feedback from various practices and specialties that had experienced issues surrounding exclusivity when trying to participate in more than one ACO. See the letter here
Academy Advocates for Modification to CMS DME MAC policy on Tracheostomy Tube Policy
Recently, the Academy led an effort to request that CMS modify the new tracheostomy tube replacement policy implemented by their DME MACs in late 2012. Under the new policy, tracheostomy tubes can only be replaced every 90 days. Upon learning of this new policy, the Academy collaborated with 10 other medical specialty societies to craft a letter requesting modification of the policy to allow replacement of trach tubes every 30 days to maintain consistency with available clinical evidence, including the Academy's Tracheostomy Care Clinical Consensus Statement, and standard care practices. See the letter here.