Breaking the Code on the Codes

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Breaking the Code on the Codes
Grant P. Bagley, M.D., J.D.
March 27, 2007
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2007
CMS WILL ADOPT A FAIR AND USEFUL CODING SYSTEM
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THE WORLD OF CODES
CODES ARE NOT NEW CODES ARE SOMETIMES
MYSTERIOUS CODES ARE VITAL
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WHICH ONE IS THE BIGGER MYSTERY?
Or IS IT Really?
HCPCS
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OUR UNIVERSAL MESSAGE TO OTHERS IN SPACE
GOLD PLATE WITH A MESSAGE FOR OTHERS SENT
INTO SPACE BY NASA OUR UNIVERSAL CONCEPTS--WHAT
ARE THEY SAYING?
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THE REAL QUESTION IN OUR WORLD
I WONDER IF OTHER CIVILIZATIONS CAN GET A HCPCS
CODE FROM THEIR WORK GROUP
NO IM SURE ITS JUST A LAW OF NATURE FOR
HCPCS TO REFUSE
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THE WORLD OF CODES

• DRGs
• APCs
• ICD9
• CPT
• HCPCS

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THE MEDICARE VISION OF CODES
For Medicare and other health insurance programs
to ensure that these claims are processed in an
orderly and consistent manner, standardized
coding systems are essential.
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CPT CODES IN PARTICULAR
Decisions regarding the addition, deletion, or
revision of CPT codes are made by the AMA.
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WHAT IS THE ROLE FOR CMS IN CODE DEFINITION?
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DO CPT CODES WORK?

• INDUSTRY HAS NO VOICE IN THE PROCESS
• THE PUBLIC HAS NO VOICE IN THE PROCESS
• CONTROLLED BY THIRD PARTY PAYERS
• IN SPITE OF HIPPA--NO UNIFORMITY
• Medicare contractors and insurers change code
  definitions and applications at will
• CMS exercises little or no oversight

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HCPCS LEVEL II CODES

• FOR DEVICES
• FOR SUPPLIES
• FOR UNIQUE MEDICARE PURPOSES
• DRUGS/BIOLOGICS

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THE HCPCS DECISION TREE
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CRITERIA FOR A NEW CODE

• EVIDENCE OF IMPROVED OUTCOMES
• PEER REVIEWED LITERATURE
• COMPARATIVE STUDIES
• NOT CLEARLY DEFINED

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A DIFFERENT APPROACH FOR THE SAME SERVICE
REQUIRES LITTLE EVIDENCE BUT THE SAME CODE
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DO I NEED MORE EVIDENCE OR A LOWER COST TO GET A
CODE?
E V I D E N C E
COST TO THE PROGRAM
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ITEMS THAT PERFORM THE SAME FUNCTION MUST USE THE
SAME CODE UNLESS THEY HAVE PROOF OF IMPROVED
OUTCOMES
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The MEDICARE Policy Dilemma
WHO WILL PROTECT THE TRUST FUND?
CODING
PAYMENT
COVERAGE
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POLICIES IN CODE CLOTHING

• SHARING OF A CODE (REFERENCE PRICING)
• DENIAL OF A CODE
• CHANGING DESCRIPTION OF A CODE
• GENERIC/COMPOUNDING SUBSTITUTION
• PRICING
• EXPERIMENTAL/INVESTIGATIONAL DETERMINATION

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WHO WILL PROTECT THE TRUST FUND FROM THE WOLF?
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EVIDENCE BASED MEDICINE
WHAT DOES IT PROMISE US?
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FORMULATE THE QUESTION
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THE ANSWER FROM MEDICARE PERSPECTIVE---
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THE MEDICARE TRUST FUND UNDERATTACK
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THE FIRST CMS GROUP SAID WE WILL PROTECT THE
TRUST FUND WITH COVERAGE POLICIES.
AND THE WOLF DID STUDIES, HAD THEM PUBLISHED
AND APPLIED FOR AN NCD.
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THE SECOND CMS GROUP SAID, WE WILL PROTECT THE
TRUST FUND WITH A FEE SCHEDULE.
AND THE WOLF DEVELOPED COMMENTS TO THE
PROPOSED FEE SCHEDULE AND THE FINAL RULE WAS OK.
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BUT THE CLEVER THIRD GROUP SAID WE WILL PROTECT
THE TRUST FUND WITH A HOUSE MADE OF CODES
WE WILL MAKE THIS HOUSE FROM STRONG CODES-- HCPCS
CODES, CPT CODES, ICD9 CODES, J CODES K
CODES, C CODES, XYZ CODES AND SO THEY DID.
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AND THE WOLF CAME TO THE CODE HOUSE
AND THERE WAS NOTHING THE WOLF COULD DO
BECAUSE THERE WAS NO APPEAL PROCESS OR WAY THAT
HE COULD PARTICIPATE IN CODES.
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(No Transcript)
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THE CODE STRUCTURE CREATED BY CMS IS OUTMODED,
AND SHOULD BE CHANGED.
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THE FACT THAT IT CAN GET DOWN THE ROAD IS NOT A
GOOD REASON TO KEEP IT.
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THE EXISTING HCPCS CODE SET

• IS POORLY MANAGED AND MAINTAINED
• SERVES TO HIDE OTHER POLICY AGENDAS
• IS HOSTILE TO NEW TECHNOLOGY
• LACKS ADEQUATE COORDINATION
• FAILS TO SERVE THE NEEDS OF PUBLIC HEALTH
• FAILS TO MEET THE NEEDS OF OTHER AGENCIES
• FAILS TO SERVE THE NEEDS OF HOMELAND SECURITY
• FAILS TO MEET THE NEEDS OF MEDICA RESEARCH
• IS UNRESPONSIVE TO QUALITY IMPROVEMENT
• CONTROLLED BY PAYERS ONLY

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Dclawap
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WHAT NEEDS TO BE DONE

• USE MODERN TECHNOLOGY
• MAKE CODING AS SPECIFIC AS POSSIBLE
• PROVIDE A BASIS FOR INFORMATION ABOUT OUTCOMES
• INVOLVE ALL STAKEHOLDERS
• Public
• Industry
• Providers
• Payers
• Government