October 24, 2011
Millennium Invitation to FREE one-day CME conference
Millennium Research Institute invites you to attend one of three, FREE one-day CME conferences in Florida on chronic pain management, risk management, and the new Florida regulations,
Expanding the Conversations Encompassing Pain Management.
This conference, offers an opportunity to dialogue around the clinical and regulatory issues facing practicing physicians. Joining the dialogue is Dave Aronberg, the “Florida Drug Czar”, Howard Heit, MD and Doug Gourlay, MD, who will lead clinical case studies and other great speakers who will focus on the regulatory changes related to pain care and walk participants through a practice self-audit.
Seating is limited for each of these events so register now if you wish to attend. Attached is a PDF of the conference information and you can register at www.millenniumresearchinstitute.org/florida .
October 20, 2011
TV - 60 Minutes - Feature on Prescription Epidemic in Florida
FSIPP Membership:
This past Sunday, CBS ran an 8 minute feature on the prescription drug epidemic in Florida and across the country. The youtube link to this report is below. The report features law enforcement in Palm Beach and Pinellas Counties.
Nation's Overdose by Tracy Smith 10-16-11 CBS Sunday Morning
http://www.youtube.com/watch?v=3QUPmD5Sa8U
October 19, 2011
CPT Coding Changes for 2012 for Interventional Pain
FSIPP Membership:
The new AMA 2012 CPT® code books are now available. The CPT® code changes that will impact interventional pain physicians (IPM) are provided in this link. Please look over these carefully and consult your billing department to inform them of these changes. Please read each description carefully as descriptions have been revised and the text in red represents new text.
- New codes for radiofrequency have been assigned with fluoroscopy bundled.
- For disc decompression, discography, epidural and fluoroscopy is bundled.
- Fluoroscopy is bundled for SI joints
Only the pertinent changes for interventional pain management are described in the following information. Click here for the 2012 IPM coding changes.
October 17, 2011
Reminder: The Deadline to request a Medicare eRx incentive program hardship exemption for the 2012 eRx payment adjustment is November 1, 2011.
FSIPP Membership;
The Centers for Medicare & Medicaid Services (CMS) would like to remind eligible professionals and group practices participating in the Medicare electronic prescribing (eRx) incentive program that the deadline to request a hardship exemption for the 2012 eRx payment adjustment is November 1, 2011.
Eligible professionals and group practices should determine if they are subject to the 2012 eRx payment adjustment by reviewing the MLN Article SE1107 , “2011 Electronic Prescribing Incentive Program Update – Future Payment Adjustments.” If you believe that you may be subject to the 2012 eRx payment adjustment, you should determine if you meet any of the hardship exemption categories specified by CMS in the 2011 Medicare electronic prescribing (eRx) incentive program final rule.
Avoiding the 2012 eRx Payment Adjustment:
An eligible professional can avoid the 2012 eRx Payment Adjustment if he or she:
- Is not a physician (MD, DO, or podiatrist), Nurse Practitioner, or Physician Assistant as of June 30, 2011, based on primary taxonomy code in the National Plan and Provider Enumeration System (NPPES);
- Does not have prescribing privileges and reports G-code G8644 (defined as not having prescribing privileges) at least one time on an eligible claim prior to June 30, 2011;
- Does not have at least 100 cases containing an encounter code in the measure’s denominator;
- Becomes a successful electronic prescriber (submits required number of electronic prescriptions (10 for individual) via claims and reports this to CMS before June 30, 2011
October 12, 2011
OIG 2012 Work-Plan
FSIPP Membership;
Attached is the OIG 2012 Work-Plan. We have extracted below a few key areas of focus. We recommend you scan this document.
Physicians and Suppliers: Compliance With Assignment Rules
We will review the extent to which providers comply with assignment rules and determine to what
extent beneficiaries are inappropriately billed in excess of amounts allowed by Medicare. We will
also assess beneficiaries’ awareness of their rights and responsibilities regarding potential billing
violations and Medicare coverage guidelines. Physicians participating in Medicare agree to accept
payment on an “assignment” for all items and services furnished to individuals enrolled in Medicare.
(Social Security Act, § 1842(h)(1).) CMS defines “assignment” as a written agreement between
beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to allow the
physician or other supplier to request direct payment from Medicare for covered Part B services,
equipment, and supplies by assigning the claim to the physician or supplier. The physician or other
supplier in return agrees to accept the Medicare-allowed amount indicated by the carrier as the full
charge for the items or services provided. (OEI; 00-00-00000; expected issue date: FY 2013;
new start)
Physicians and Other Suppliers: High Cumulative Part B Payments (New)
We will review payment systems controls that identify high cumulative Medicare Part B payments
to physicians and suppliers. We will determine whether payment system controls are in place to
identify such payments and assess the effectiveness of those controls. Medicare Part B services
must be reasonable and necessary (Social Security Act, § 1862(a)(1)(A)), adequately documented
(§ 1833(e)), and provided consistent with Federal regulations (42 CFR, § 410). A high cumulative
payment is an unusually high payment made to an individual physician or supplier, or on behalf of an
individual beneficiary, over a specified period. Prior OIG work has shown that unusually high
Medicare payments may indicate incorrect billing or fraud and abuse. (OAS; W-00-12-35605; various
reviews; expected issue date: FY 2012; new start)
Physician-Owned Distributors of Spinal Implants (New)
We will determine the extent to which physician-owned distributors (POD) provide spinal implants
purchased by hospitals. We will also analyze Medicare claims data to determine whether PODs we
identify in our review are associated with high use of spinal implants. PODs are business
arrangements involving physician ownership of medical device companies and distributorships.
PODs are focused primarily in the surgical arena and are currently primarily involve orthopedic
implants such as spine and total joints. However, PODs appear to be quickly growing into other
areas such as cardiac implants. (HHS OIG Work Plan | FY 2012 Part I: Medicare Part A and Part B
Page I-18) Congress has expressed concern that PODs could create conflicts of
interest and safety concerns for patients. (OEI; 01-11-00660; expected issue date: FY 2012; work in
progress)
Physicians: Place-of-Service Errors
We will review physicians’ coding on Medicare Part B claims for services performed in ambulatory
surgical centers and hospital outpatient departments to determine whether they properly coded the
places of service. Federal regulations provide for different levels of payments to physicians
depending on where services are performed. (42 CFR § 414.32.) Medicare pays a physician a higher
amount when a service is performed in a nonfacility setting, such as a physician’s office, than it does
when the service is performed in a hospital outpatient department or, with certain exceptions, in an
ambulatory surgical center. (OAS; W-00-10-35113; W-00-11-35113; various reviews; expected issue
date: FY 2012; work in progress)
Physicians: Incident-To Services (New)
We will review physician billing for “incident-to” services to determine whether payment for such
services had a higher error rate than that for non-incident-to services. We will also assess CMS’s
ability to monitor services billed as “incident-to.” Medicare Part B pays for certain services billed by
physicians that are performed by nonphysicians incident to a physician office visit. A 2009 OIG
review found that when Medicare allowed physicians’ billings for more than 24 hours of services in a
day, half of the services were not performed by a physician. We also found that unqualified
nonphysicians performed 21 percent of the services that physicians did not perform personally.
Incident-to services represent a program vulnerability in that they do not appear in claims data and
can be identified only by reviewing the medical record. They may also be vulnerable to
overutilization and expose Medicare beneficiaries to care that does not meet professional standards
of quality. Medicare’s Part B coverage of services and supplies that are performed incident to the
professional services of a physician is in the Social Security Act, § 1861(s)(2)(A). Medicare requires
providers to furnish such information as may be necessary to determine the amounts due to receive
payment. (Social Security Act, § 1833(e).) (OEI; 00-00-00000; expected issue date: FY 2013; new start)
Physicians: Impact of Opting Out of Medicare (New)
We will review the extent to which physicians are opting out of Medicare and determine whether
physicians who have opted out of Medicare are submitting claims to Medicare. We will also examine
whether specific areas of the country have seen higher numbers of physicians opting out and its
potential impact on beneficiaries. Physicians are permitted to enter into private contracts with
Medicare beneficiaries. (Social Security Act, § 1802(b).) As a result of entering into private contracts,
physicians must commit that they will not submit a claim to Medicare for any Medicare beneficiary.
(OEI; 07-11-00340; expected issue date: FY 2012; work in progress)
October 5, 2011
Practitioner Profile Registration for Prescribing Controlled Substances for Chronic Pain
FSIPP Membership;
Effective January 1, 2012 in accordance with s. 456.44(2), Florida Statutes, an allopathic physician licensed under chapter 458, an osteopathic physician licensed under chapter 459, a podiatric physician licensed under chapter 461 or a dentist licensed under chapter 466 who prescribes any controlled substance as defined in s. 893.03, for the treatment of chronic nonmalignant pain, must designate himself or herself as a controlled substance prescribing practitioner on the practitioner profile.
You must register as a prescriber even if you are exempt:
To Register Go To: http://www.doh.state.fl.us/mqa/ControlledSubstance_RxReg.html
October 5, 2011
Attorney Allen Grossman Update on Department of Health Activities Regarding Pain Clinic Laws
FSIPP Membership:
Please see below the recent update from Attorney Grossman regarding the BOM, BOOM and DOH activities in interpreting and enforcing the new prescribing and pain clinic laws.
I attended the Board of Medicine meetings this past weekend, including the Rules and Legislative Committee. I am providing this report addressing the various aspects of the pain management law and rule as they were relevant during the meeting.
As has previously been discussed, §458.3265(1)(a)1.b., Florida Statutes*, defines the term “pain management clinic” as any publicly or privately owned facility that advertises in any medium for any type of pain-management services; or where in any month a majority of patients are prescribed opioids, benzodiazipines, barbiturates, or carisoprodol for the treatment of chronic nonmalignant pain. Section 458.3265(1)(a)2., Florida Statutes, requires such clinics to register with the Department of Health unless such clinic meets one of the eight identified exceptions to the registration requirement. (Some of you have determined that you meet one or more of those specific exceptions and therefore have not registered with the Department of Health even though your activities meet the definition of a pain management clinic.
Section 458.3265(2)(a), Florida Statutes, prohibits a physician from practicing in a pain management clinic that is required to be registered unless it is actually registered. Furthermore, any physician who qualifies to practice medicine in a pain-management clinic pursuant to rules adopted by the Board of Medicine as of July 1, 2012, may continue to practice medicine in a pain-management clinic as long as the physician continues to meet the qualifications set forth in the board rules.
The Board of Medicine adopted its rule on the qualifications of physicians to practice in pain management clinics with an effective date of May 17, 2011. (The Board of Osteopathic Medicine adopted a very similar rule [64B15-14.0051, Florida Administrative Code] with an effective date of March 16, 2011.) The Board of Medicine’s rule, 64B8-9.0131, Florida Administrative Code, requires that any physician prescribing or dispensing controlled substance medications in registered pain management clinics must meet one or more of the following qualifications:
(1) Board certification by a specialty board recognized by the American Board of Medical Specialties (ABMS) and holds a sub-specialty certification in pain medicine;
(2) Board certification in pain medicine by the American Board of Pain Management (ABPM);
(3) Successful completion of a pain medicine fellowship or residency accredited by the ACGME;
(4) Successful completion of a residency program in physical medicine and rehabilitation, anesthesiology, neurology, neurosurgery, family practice, internal medicine, orthopedics or psychiatry approved by the ACGME or hold a sub-specialty certification in hospice and palliative medicine or geriatric medicine recognized by the ABMS;
(5) Hold current staff privileges at a Florida-licensed hospital to practice pain medicine or perform pain medicine procedures; or
(6) Have 3 years of documented full-time practice, which is defined as an average of 20 hours per week each year, in pain-management and within six months of the effective date of this rule, attendance and successful completion of 40 hours of in-person, live-participatory AMA Category I CME courses in pain management that address all the following subject areas:
(a) The goals of treating both short term and ongoing pain treatment;
(b) Controlled substance prescribing rules, including controlled substances agreements;
(c) Drug screening or testing, including usefulness and limitations;
(d) The use of controlled substances in treating short-term and ongoing pain syndromes, including usefulness and limitations;
(e) Evidenced-based non-controlled pharmacological pain treatments;
(f) Evidenced-based non-pharmacological pain treatments;
(g) A complete pain medicine history and a physical examination;
(h) Appropriate progress note keeping;
(i) Comorbidities with pain disorders, including psychiatric and addictive disorders;
(j) Drug abuse and diversion, and prevention of same;
(k) Risk management; and
(l) Medical ethics.
In addition, if a physician utilizes option (6) he or she must also document hospital privileges at a Florida-licensed hospital; practice under the direct supervision of a physician who is qualified under options (1)-(4); or have the practice reviewed by a Florida-licensed risk manager and document compliance with all recommendations of the risk management review.
In spite of its acknowledgement that there do not appear to be any specific courses that provided the requirements, at its meeting last weekend, the Florida Board of Medicine decided once again not to amend its rule regarding the date by which a physician qualifying pursuant to option (6) must complete the 40 hour CME requirement. As of right now, in spite of the fact that he statute provides for compliance by July 1, 2012, the Board of Medicine’s rule requires that the 40 hours of CME be completed by November 17, 2011. The biggest problem in meeting that deadline is that no such single course has been identified. The only course provider who has requested approval of a course, Dannemiller, was told that they had not provided enough information for the Board to grant approval. For now, licensees are required to piece together 40 hours of individual courses that might reasonably be considered to include all of the required elements set forth in the rule. It should be noted that nothing in the rule sets up a time-frame in which the CME hours could have been completed prior to the date set forth in the rule. It might be possible to select various courses from a physician’s completed CME hours in prior years. Most importantly, if any of your members are or employ physicians who will want to qualify to work in a registered pain management clinic on or after July 1, 2012, they need to make sure that the 40 hour CME requirement is fulfilled by the time set forth in the Boards’ rules. It is likely that the Board will have to do some rulemaking because the current rule references dispensing of controlled substances, which is no longer permitted as a matter of law. If such rulemaking is initiated, there may be another opportunity to ask the Board to address the issue of when the coursework must be completed for option 6.
*Each of the herein referenced statutory provisions has an identical provision in the Osteopathic Medicine Practice Act (Ch. 459, Florida Statutes.)
It appears that he Department of Health has activated the section in the on-line practitioner profiles for physicians to add their self-designation as a prescriber of controlled substances. Section 456.44(2), Florida Statutes requires that before January 1, 2012, physicians who prescribe controlled substances for the treatment of chronic nonmalignant pain register as a controlled substance prescribing physician on their practitioner profile maintained by the Department of Health. During the Board of Medicine meeting this past weekend, the Board finalized its Declaratory Statement to the Hospice physicians that asked the Board to confirm that they are not prescribing controlled substances for the “treatment of chronic nonmalignant pain” when they prescribe controlled substance pain medications for hospice patients who will need pain medication until they die. (Draft copy attached) However, a similar question asked by a group of physicians who primarily perform interventional pain and other surgical procedures did not receive a response from the Board of Medicine. The physicians provided a specific list of diseases and conditions that routinely require extended use of controlled substances for pain relief and asked whether because the pain was the result of an injury or disease that was within its reasonably expected duration (sometimes lifelong) their prescribing would be considered as being for the treatment of chronic nonmalignant pain, which is defined as being pain that persists beyond the usual course of disease or injury causing the pain. Although the Board of Medicine ultimately declined to answer the question, during the course of their discussion, it was repeatedly acknowledged that the law clearly defines chronic nonmalignant pain as being outside the usual course of a disease or injury. Logically then, a physician prescribing a controlled substance for pain that is existing during the reasonably defined “usual course” of the disease or injury causing the pain would not be prescribing controlled substances for the treatment of chronic nonmalignant pain. We can expect to see more issues in this regard as the Department of Health and State Attorneys’ offices attempt to prosecute physicians.
The Department of Health has taken the position in regard to the quarterly reporting of patient data by registered pain management clinics that follow-up patient visits should only be reported once each quarter. Therefore, a continuing patient who returns to a clinic for prescriptions throughout the quarter should only be included once in the returning patient data, even if that patient had multiple follow-up visits during the quarter. The Department only wants the number of patients not the actual number of visits at which prescriptions for controlled substances were provided. This may be a bit confusing to anyone who read the reporting requirement and recommended reporting form to require identification of each returning patient encounter.
There was a rally against the Board of Medicine that was held during the Friday morning portion of the Board of Medicine’s meeting in Tampa. The rally group was reportedly comprised of family members who had lost young adults to drug overdoses. They remained outside the hotel for the most part and did not disrupt the meeting in any way. Their position appeared to be that the Board is not being hard enough on physicians who prescribe pain medications and that all production of Oxycontin should be halted.
For those of you who may be interested, I have attached a copy of the Department of Health’s recent Declaratory Statement on the issue of registering a pain management clinic. In the reported case, the physician was operating a clinic with the word pain in the name of the clinic and wishes to advertise the clinic on the internet. However, the physician held board certification by the American Board of Anesthesiology and the American Board of Pain Medicine (and others) and the physicians at the clinic did not prescribe controlled substances for the treatment of chronic nonmalignant pain for the majority of its patients. Based on the owner physician’s specialty certification and the fact that less than 50% of the clinic’s patients received controlled substance prescriptions for the treatment of chronic nonmalignant pain, the Department of Health opined that the clinic is not required to be registered.
Allen R. Grossman
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