How to Build a Successful BMD Practice

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How to Build a Successful BMD Practice
January 2009
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GE Healthcare, Lunar

• Disclaimer
• Information presented is hypothetical and for
  illustrative purposes only, and you should not
  rely upon it as an indicator of actual revenues
  and expenses. Actual revenues and expenses will
  vary depending on your specific operating costs,
  numbers and types of procedures performed, and
  reimbursement amounts. Third party reimbursement
  amounts and coverage policies for specific
  procedures will vary by payer and by locality, as
  well as by type of provider entity.
• Please note that the federal statute known as the
  Stark Law (42 U.S.C. 1395nn) imposes certain
  requirements which must be met in order for
  physicians to bill Medicare/Medicaid or other
  federal healthcare program patients for in-office
  radiology services. In some states, similar laws
  cover billing for all patients. Additional
  licensure, certificate of need, and other
  restrictions may be applicable.
• You should consult with your reimbursement
  manager or healthcare consultant, as well as
  experienced legal counsel, prior to any expansion
  of service.

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Pieces to a Successful BMD Practice
Identify Patients
Patient Awareness
Staff Involvement
Billing Reimbursement
Implementation Plan
EMR
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Part OneIdentify Patients
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Know the Risk Factors

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Diseases and Conditions That Cause Bone Loss

• Anorexia Nervosa and other eating disorders
• Celiac Disease
• Depression
• Hyperparathyroidism
• Hyperthyroidism
• Inflammatory Bowel Disease
• Loss of Height
• Multiple Myeloma
• Rheumatoid Arthritis
• Weight Loss

Run billing reports by diagnosis codes for
secondary conditions to identify new BMD patients.
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Medical Conditions That Can Lead To
Osteoporosis

• AIDS / HIV
• Ankylosing spondylitis
• Blood and bone marrow disorders
• Breast cancer
• Cushings syndrome
• Emphysema
• Female athlete triad
• Gastrectomy
• Gastrointestinal bypass procedure
• Idiopathic scoliosis
• Diabetes Mellitus
• Kidney Disease
  

• Lupus
• Lymphoma and leukemia disease
• Multiple sclerosis
• Organ transplant
• Parkinsons disease
• Post-polio syndrome
• Premature menopause
• Prostate cancer
• Severe liver disease (including biliary
  cirrhosis)
• Stroke
• Thalassemia
• Thyrotoxicosis

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Part TwoStaff Involvement
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Adjust Office Protocol to Identify Patients

• Front desk distributes patient risk assessment
  form during check-in
• Patient completes risk assessment while waiting
  to be called back
• Technician flag patients with 2-3 risk factors
  checked
• Physician has consultation on bone health and
  makes determination if DXA is needed

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Sample Patient Risk Assessment Form Ask your GE
representative for a copy.
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Keep Staff Involved Informed

• Evaluate staff with DXA to build understanding
• Provide training via a pharmaceutical rep
• Participate in ISCD courses
• Bone Densitometry Course
• Vertebral Fracture Assessment Course
• Pediatric Bone Densitometry Course
• See the ISCD website for complete course
  information and schedule http//www.iscd.org/Visi
  tors/education/upcoming_courses.cfm

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Part ThreePatient Awareness
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Create Demand

• With Promotional Materials in the Waiting Room
• Medicare offers FREE Preventive Service Brochure
• http//www.cms.hhs.gov/MLNProducts/35_PreventiveS
  ervices.asp
• NOF offers pamphlets, posters and brochures
• http//www.nofstore.org/Merchant2/merchant.mvc?
• GE Lunar Provides Counter Displays, Posters,
  Patient Information brochures
• Ask your GE representative for a copy

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Create Demand

• With Direct Mail Campaigns
• To existing patients
• to announce your BMD service
• to inform patients of risk factors
• to remind patients of follow-up exams
• to explain the significance of exam results
• To referring physicians and local hospitals
• to announce your BMD service is accepting
  referrals
• to invite to an open house or for demonstrations
• to explain the significance of test results of
  referred patients

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Samples of Promotions Mailings
Ask your GE representative for copies.
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Respond to Patient Demand
Emphasize Prevention

• Counsel on the risk of osteoporosis and related
  fractures.
• Check for secondary causes.
• Advise on adequate amounts of calcium and vitamin
  D.
• Recommend regular weight-bearing and
  muscle-strengthening exercise to reduce the risk
  of falls and fractures.
• Advise avoidance of tobacco smoking and excessive
  alcohol intake.
• In women age 65 and men age 70 and older,
  recommend BMD testing.
• In postmenopausal women and men age 50-70,
  recommend BMD testing when you have concern based
  on their risk factors profile.
• Recommend BMD testing to those who have suffered
  a fracture, to determine degree of disease
  severity.
• Based on clinical assessment of risk factors and
  medical conditions, recommend BMD testing for
  baseline.

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Part FourReimbursement

• DISCLAIMER
• The information contain herein is hypothetical
  only and for informational purposes only. This
  document is intended to assist you in
  understanding the billing and coding requirements
  for billing bone mineral density studies and
  vertebral fracture assessments. Coverage
  guidelines vary by payer, therefore this
  information should not be relied on as a
  guarantee of coverage and/or payment.
  Reimbursement from insurance payers is determined
  by several factors, including, but not limited
  to, the patients benefit plan, physician
  contract, medical coverage policy, and radiology
  guidelines may apply.

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General BMD Reimbursement FAQs

• Who will order BMD scans?
• The treating Physician, NP/PA for the indication
  meeting medical necessity.
• How often can a BMD scan be ordered?
• Frequency varies by payer, however Medicare
  allows
• 1. Patients on long-term steroid use
• 2. Confirmatory baselines when the initial test
  was another
• modality other than DEXA.
• 3. Monitoring a patient on an FDA approved
  osteoporosis medication.
• It is strongly recommended that you review your
  payers for complete on billing and coding
  guidelines.
• How do you document an order for a scan?
• Progress note must include the reason for
  ordering the test, the results and how the
  results aided in the treatment of the patient

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Bone Mass Measurement Act

• Key Points Of The Bone Mass Measurement Act
• Health Care Financing Administration (HCFA)
  regulation that became effective July 1, 1998 and
  implement provision 186 1 (s)(15) 5) to Section
  4106(a)(1) of the BBA to Provide for Uniform
  Coverage of Bone Mass Measurements.
• Definition of a Qualified Individual (Medicare
  Only)
• An estrogen deficient women at clinical risk of
  osteoporosis as determined by a physician or
  qualified nonphysician practitioner based on her
  medical history and other findings
• A person with vertebral abnormalities as
  demonstrated by x-ray to be indicative of
  osteoporosis, osteopenia, or vertebral fracture
• A person receiving or expecting to receive
  long-term glucocorticoid (steroid) therapy
  (equivalent to 5.0mg or greater of prednisone per
  day for gt 3 months)
• A person with primary hyperparathyroidism
• A person being monitored to assess the response
  to or efficacy of an FDA-approved osteoporosis
  therapy. Follow-up will be limited to one test
  every 2 years. Peripheral and central site
  measurement are acceptable and reimbursable

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How To LocateLocal Coverage Determinations

• Log onto Payer Website (for payer websites, see
  slides 26 and 27)
• Look for Provider and/or Healthcare Professional
  link
• Look under Medical Coverage Policy / Bulletins /
  LCD (local coverage determination) or medical
  review
• Type in search feature one of the following Bone
  Mineral Density, Bone Mass Measurement, and/or
  CPT 77080
• Please Note
• CMSs website contains all Medicare contractors
  articles, coding/billing guidelines, and local
  coverage determinations.
• Payers may or may not have a written coverage
  determination
• A patient benefit plan will supersede any
  written coverage policy

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Reimbursement OverviewGetting it right the first
time!

• Step One Identify who is at risk and
  qualifies for a scan
• Tools Patient Risk Assessment Form
• Chart Flag (sticky pad)
• Step Two Understand payer coding and
  billing guidelines
• Tool Review local coverage
  determination (LCD) issued by payer
• LCD includes indications, frequency,
  limitations and may include
• DX codes
• Step Three Code it right use appropriate CPT
  and corresponding DX code (s)
• Tool AMA CPT 2008 Professional
  Edition (77080, 77081, 77082)
• Physician ICD-9- CM Volume 1 and 2
• Local Coverage Determination

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Sample Cigna Website
1 Search Website 2 Select Results 3 Find Policy!
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Billing - Comply With The Payers!

• Understand the coverage policies
• Know the indications for use
• Use the proper ICD-9 Code(s) for the indication
• Know the frequency
• Know the limitations
• Know the documentation requirements

Typical Codes for demonstration only
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Understand their Diagnosis Codes
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Understand their Indications
Coverage Policies are different! Know the
indications!
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Medicare Carriers
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Commercial Carriers
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Step FiveImplementation Plan
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Create a TeamOrganize staff by assigning roles
with specific responsibilities

• BMD ChampionOversees BMD program
• Billing ReimbursementLearns local payers
  payment, coding billing for BMD
• Patient RecruitingExecutes patient
  identification and awareness efforts
• Operator/Technician, PhysicianUndertakes
  training

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Create a PlanSet up a schedule to ensure the
timely and organized execution of BMD
responsibilities
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Continue to Improve

• Use your Practice Management Tools
• Check activity of referring physicians
• Identify and generate letters for patients who
  need follow-up exams
• Graph data to identify trends

Pie Chart on Practice Management Tools
Follow-up Report and Mail Merge Letter on
Practice Management Tools
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Part SixElectronic Medical Records (EMR)
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Unlocking Your Practice Potential with EMR

• Electronic Health Records-based programs
  triples osteoporosis screening rates.
• Use EHR, or Electronic Claims Reporting

Source Geisinger Health System
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Typical Reporting
Typical EMR Filter
SpringChartsEMR
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Typical Output

• Typical EMR Report

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AppendixHub Spoke

• Only if you have or are considering adding an
  Achilles ultrasonometer

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Benefits of the Hub Spoke Model(Achilles QUS /
DXA)

• Identify more patients for the DXA test using
  Achilles.
• Initially test for low bone density using
  Achilles, and use DXA to confirm results and to
  monitor over time.
• Take Achilles on the road to other sites,
  health fairs, and community centers.
• Improve access to osteoporosis testing while
  providing reliable results.

Check your local payer for complete payment
billing guidance
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St Ritas Medical Center, A Hub Spoke Case Study
Evolving Model
Early Innovation

• 2006 5th unit was added and updated locations
• 1 stationary within the Womens Center
• 3 stationary within affiliated facilities
• 1 is used for outreach
• Made strong connection into mammo centers through
  cross education
• Redesigned results form to ensure proper follow
  up procedures were being followed

• 1998 placed 4 Achilles in service
• 2 stationary in Womens Center
• 1 at a local mall cite
• 1 mobile unit for Health Fairs
• Scans conducted free of charge by existing staff
  under the supervision of a Medical Director
• Results sent to subjects physician with
  information on how to interpret.

You need to be where the patients are Mary Kay
Verhoff Director Womens Wellness Center