Medicare Audits Update

AAOS in Action: Medicare Audits and

Coverage DeterminationsAAOS Fall Meeting

October 20, 2012Craig A. Butler, MD, MBA

Chair, Health Care Systems Committee

AAOS Response

• Alert via AAHKS (Parsley, Halsey)• Issue presented to AAOS Board of

Directors• BOD Coverage Determination

Project Team (CDPT) created• Chair - David Templeman, MD• 6 Members

Project Team Charges1. Advocate for the suspension of audit programs in all jurisdictions until coverage determination criteria can be reviewed by all

concerned professionals.

2. Track, monitor and comment on Medicare Local Coverage Determinations (LCDs), as well as those of private payers and state Medicaid coverage boards

3. Communicate information about LCDs to our members

4. Educate members about Medicare Recovery Audit Contractors (RACs) and Medicare Administrative Contractors (MACs) and, closely monitor their activities.

5. Consider the pros and cons of advocating for Medicare national coverage determinations (NCDs) and make recommendations to the Board.

6. Develop model coverage determination documents to be used in advocacy efforts

7. Develop educational tools, such as documentation checklists, that convey existing documentation requirements to orthopaedic surgeons, recognizing that these documentation requirements may not be optimal

8. Engage, promote, facilitate and monitor the participation of orthopaedic surgeons serving on Contractor Advisory Committees (CACs).

9. Provide timely status reports to the Board.

CDPT/AAOS Actions

• Model LCD for TJA Procedures• Congressional Letter • Meetings with CMS • MLN Matters Article • Meetings with MACs• Orthopaedic CAC Network• Audit Reporting Tool • Member Education• Member Publications• Regulatory Comment Letters

Model LCD

• Modeled after First Coast Service Options LCD in Florida (which was edited by AAOS/AAHKS/FOS)

• Reviewed by AAHKS• Improved by CDPT and PL• Sent via postal mail and e-mail to ALL

Contractor Medical Directors• Available at www.aaos.org/Medicare101

Congressional Letter

• Letter from Rep. Ruppersberger (D-MD) and Rep. Burgess (R-TX) - 43 co-signatories

• Asked CMS to pressure MACs to halt audits until the MACs provide clear documentation guidance

• OGR staff visited 70+ of the 87 Targeted Congressional offices

• Through grassroots action alerts, AAOS Fellows sent 80 emails to Members of Congress asking for their sign-on

• Find the letter at www.aaos.org/Medicare101• Response – September 25, 2012

Meetings with CMS

• OGR Staff first met with CMS 12/27/11• This led to CMS participation in the Annual

Meeting panel on Medicare Audits

• OGR Staff again met with CMS 8/21/12 to discuss the Congressional letter • CMS then published an MLN Matters article

September 17, 2012

MLN Matters Article

• AAOS first submitted a draft 3/2012• CMS did not seem eager to publish it until the

Congressional letter and AAOS meeting with CMS

• AAOS resubmitted an updated draft in early September

• CMS published MLN Matters article 9/17/2012• AAOS has published this guidance widely

Meetings with MAC CMDs

• AAOS and AAHKS Members met with Contractor Medical Directors 6/14/2012

• Resulted from relationship developed between Brian Parsley, MD and CMD Debra Patterson, MD after AAOS Annual Meeting

• Led to communication of model LCD to all CMDs nationwide

Orthopaedic CAC Network

• Led by Fred Redfern, MD, AAOS has information on the Contractor Advisory Committee (CAC) representatives in 41 states

• 15 of those 41 CACs have vacancies for orthopaedic surgeons

• Still missing information on CAC representatives in 10 states

• 5 of 10 missing states are in J14 (New England)

Next Steps for CAC Network

• Who will lead the Orthopaedic CAC Network?• What information should be shared with the

Orthopaedic CAC Network?• How should information be shared?• Will it have any review or decision-making

authority? Or is it just a list-serv?• How will we maintain the most updated contact

list?

Audit Reporting Tool

• AAOS Fellows can report audit activity to the AAOS

• Distributed via Advocacy Now, state orthopaedic societies, the BOC list-serv, and AAOE

• Find it at www.aaos.org/Medicare101

Member Education

• 2012 Annual Meeting symposium on Medicare Audits

• 2012 Fall Meeting symposium on Medicare Audits (today!)

• Webinar Series• To follow the content of Fall Meeting

symposium

Member Publications

Regulatory Comment Letters

• AAOS/AAHKS/FOS collaborated on comments on proposed LCD for TJA (J9) in summer 2011• Most requested amendments were made

• AAOS/AAHKS/AAPM&R collaborated on opposition to proposed LCD denying IRF admission for a class of patients after single joint replacement procedures (J10)• Letter submitted 9/10/12• Proposed LCD rescinded 9/13/12

Stormy Seas Ahead

• Clawbacks based upon FL LCD• LCD for Ultrasound guided joint

aspirations• High intensity E & M coding

For the Latest Information

Visit the Medicare Audits 101 webpage:

www.aaos.org/Medicare101