NYS SOciety of ORTHOPAEDIC Surgeons

OrthoInfo, the AAOS patient education website, is a free member resource that provides orthopaedic surgeons and patients with authoritative, in-depth information about musculoskeletal health.

The website features more than 400 articles, videos, and animations on common orthopaedic problems, surgical procedures, nonsurgical treatments, injury prevention, and healthy living. All content is developed and peer reviewed by AAOS members.

Written in simple language, OrthoInfo articles can help your patients be better informed and participate more fully in their care and recovery.

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The Centers for Medicare & Medicaid Services (CMS) proposed a three-year extension and changes pertaining to episode definition and pricing to its Comprehensive Care for Joint Replacement (CJR) model.

The proposed changes would incorporate outpatient hip and knee replacements into the episode of care definition, as well as change the reconciliation process, the beneficiary notice requirements, gainsharing caps, and the appeals process.

The CJR model three-year extension would provide time to assess the changes in practice. > Learn More

Editor’s note: AAOS partners with KarenZupko & Associates, Inc. (KZA) on the organization’s coding education, and KZA often provides content for AAOS Now. For more information, visit www.aaos.org/membership/coding-and-reimbursement.

Whether due to the complexities of hiring billing staff or a result of hospital employment and practice acquisition, many orthopaedic practices are moving their billing operations to a third-party entity or centralized billing office.

This process is part of what institutions call revenue cycle management.

If you find yourself in this situation, these best practices will help improve coding accuracy:

1. Keep Current Procedural Terminology (CPT) and International Classification of Diseases, 10th Edition coding as physician-primary tasks.
2. Insist that the third party follows AAOS coding guidelines.
3. Verify that the third-party billing staff includes coding experts, not just billing staff.
4. Ask for reports that illustrate the third party’s coding knowledge and performance.
5. Require ongoing orthopaedic coding education.

> Learn more

The AAOS Office of Government Relations (OGR) is proud to introduce its 2020 Resident Advocacy Fellows: Carl L. Herndon, MD, and Kacy Peek, MD.

Launched in early 2018, the one-year fellowship is designed to encourage orthopaedic residents to participate in the national health policy arena and ultimately become lifelong advocates of the profession. Eligible post-graduate year (PGY)-3 and -4 residents who are selected for the fellowship have the opportunity to gain a greater understanding of health policy legislative and regulatory processes; contribute to the development of new policies and programs, as well as strategic planning; work on various projects with senior AAOS staff; and develop a strong foundation for leadership in the healthcare environment.

During their tenure as Resident Advocacy Fellows, participants will attend the National Orthopaedic Leadership Conference, partake in Capitol Hill visits and advocacy training, spend a week at the AAOS OGR office, develop a presentation on health policy issues covered during the program, and actively engage in resident advocacy.

Carl L. Herndon, MD

Dr. Herndon is a PGY-4 orthopaedic surgery resident at the Columbia University Medical Center in New York. Originally from the Chicago area, he graduated from Northwestern University and completed medical school at the University of Florida College of Medicine prior to residency. From an early age, he has had multiple opportunities to travel on medical missions abroad with his mother, an obstetrician-gynecologist, and cultivate a heart of service. After graduating from Northwestern University and before enrolling in medical school, Dr. Herndon worked on the medical operations team of a large, federally qualified, inner-city health center, where he was first exposed to advocacy and how health policy can affect the daily lives of both patients and healthcare professionals. In medical school, he served as president of his class and was a member of both the local chapter of the American Medical Association and the Florida Medical Association. He was elected to the Alpha Omega Alpha Honor Medical Society and won several other awards for service. During residency, he has been an active member of the New York State Society of Orthopaedic Surgeons and also serves on both the AAOS Council on Education and the Resident Assembly Health Policy Committee. After residency, he plans to pursue a fellowship in total joint arthroplasty and continue to advocate for both surgeons and patients.

A study published in the Feb. 15 issue of the Journal of the AAOS evaluated how Affordable Care Act (ACA)-associated Medicaid expansion impacted the utilization of elective orthopaedic surgery in New York state. The abstract is below.  Full article can be found here.

Background: 

As part of the Patient Protection and Affordable Care Act, states were given the option of expanding Medicaid coverage to include adults younger than age 65 years with income at or below 138% of the federal poverty level. Although this expansion was intended to provide health care coverage to an estimated 20 million Americans, several studies have shown increased coverage does not equate to increased access to care by specialty providers.

Methods: 

We queried the New York Statewide Planning and Research Cooperative System database and identified all patients who underwent the 10 most common elective orthopaedic surgeries from January 1, 2012, through March 31, 2016. Medicaid monthly enrollment for the 4-year study period was obtained from NY Department of Health Medicaid Managed Care Enrollment Reports.

Results: 

Our query identified 700,159 patients who underwent the investigated orthopaedic surgeries. Of these, 60,786 were Medicaid recipients. During the 4-year study period, Medicaid enrollment and the number of procedures reimbursed by Medicaid increased significantly (P < 0.001 for both).

Conclusions: 

Affordable Care Act–supported Medicaid expansion was associated with an increase in Medicaid enrollment and a concomitant increase in the utilization of orthopaedic surgery by Medicaid beneficiaries in New York State.

Late last week, the House Ways & Means Committee issued bipartisan legislation tackling surprise medical billing. The proposal, which is scheduled for markup on Feb. 12, would eliminate balance billing for emergent procedures. Conflicts would be resolved with an independent mediation process.

AAOS is reviewing the proposal and continues to advocate for a fair, accessible Independent Dispute Resolution process for resolving payment disputes.

Contact your congressional representative to voice your concerns.

Each year, KarenZupko & Associates, Inc., (KZA) sends a precourse survey to those who have registered for the KZA/AAOS coding and reimbursement workshops. The results provide insights on a variety of coding, documentation, and revenue-cycle processes and trends. In 2019, KZA received 178 completed surveys.

This article summarizes three revenue cycle data points from the 2019 survey results and provides commentary and guidance from two revenue-cycle experts.

1. Collect at the time of service for office visits and surgery. Most practices could boost their revenue by $25,000 to $75,000 per surgeon by doing this.
2. Adequately document failed conservative treatment in the office note to support that advanced imaging or surgery is indicated. The amount of administrative time spent piecing together information that may or may not exist in the patient’s records is astronomical. A concise summary of the failed conservative treatments, with dates and specifics, significantly reduces the amount of time it takes for preauthorization to be approved.
3. Be proactive with denials. Most denials we see in practices are preventable. Review denial patterns and develop a plan to address them proactively.

—Cheyenne Brinson, CPA (inactive), MBA, of KarenZupko & Associates, Inc. (KZA)

1. Fully preregister patients at the time of scheduling, which includes capturing their full insurance information and verifying eligibility. This essential step lays the groundwork for tips 2 and 3.
2. Collect from patients at the time of service.
3. Collect presurgical deposits.

Tips 2 and 3 are the two most impactful things a practice can do to increase patient collections and decrease patient accounts receivable.

—Amy Anderson, MBA, of KZA

The Academy’s numerous free practice management resources provide knowledge, education, clinical tools, and professional support that help you meet the challenges of your chosen specialty and build mastery throughout your career.

Access white papers, the Practice Management Advice Center, webinar recordings, and learn about topics such as Medicare Access and CHIP Reauthorization Act delivery reform and the Quality Payment Program.

> Practice Management Center

To support the successful implementation of the New York Workers’ Compensation Formulary (NY WC Formulary), the Board continues to educate medical providers and payers about the Formulary and prior authorization process. This includes providing timely responses to frequently asked questions and requests for clarification. This week, the Board published a new round of frequently asked questions (FAQs). Please visit the Board’s Drug Formulary Overview webpage for the latest FAQs as well as:

• An overview of the NY WC Formulary and the prior authorization process
• The latest version of the NY WC Formulary
• A Quick Guide to the NY WC Formulary
• NY WC Formulary Dashboard Guides for Providers and Payers/TPAs

More Information

• For more information, visit the Drug Formulary Overview Page
• General NY WC Formulary questions: WCBFormularyQuestions@wcb.ny.gov
• Technical support questions: WCBCustomerSupport@wcb.ny.gov
• Subscribe for email notifications

The Joint Commission released its updated total hip and knee replacements requirements for hospitals and ambulatory surgical centers that are part of the Advanced Total Hip and Total Knee Replacement Certification program.

Among the new requirements, which take effect on July 1, participating groups are required to follow AAOS clinical practice guidelines.

>Learn more