Getting a DME License

Durable medical equipment (DME) is provided by home healthcare agencies, physicians or DME companies. DME is generally defined as medical equipment that is not disposable, is medically necessary and appropriate for home use.
The process for getting a DME license is as outlined below,

1. Apply for an Employer Identification Number (EIN). This number serves as your business identity for tax purposes.
2. Contact your state's department of health and obtain information regarding the state licensing application process and application. State laws vary greatly, from one state to the other, so what is required in one state may not be required in another.
3. Apply for a National Provider Identifier (NPI) from Centers for Medicare and Medicaid Services (CMS). This unique Physician identifier is a standard set by CMS and is required for reimbursement for products and services provided to patients.
4. Review the 26 Supplier Standards from the Medicare Enrollment Application and complete the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Medicare Enrollment Application. Once you are accepted as a DMEPOS supplier, you can bill Medicare for equipment provided to Medicare recipients.
5. Contact a DME accreditation program. An accreditation from a CMS-approved compliance program is needed in order to be accepted to the DMEPOS program. These compliance companies ensure that DME suppliers are following the 26 Supplier Standards. 
6. Submit the state application and prepare for inspection, if applicable. You may pay any applicable application and inspection fees alongwith your application.
7. Prepare for compliance inspection. The compliance company will send you items that they will inspect, but the list is not all-inclusive. Upon completion of the compliance inspection, you will receive the results and become accredited.
8. Submit DMEPOS application with all of the required documentation. Once your application is approved, you will receive your Medicare supplier number.
   

PQRI 2011

The Physician Quality Reporting Initiative (PQRI) is a program to improve the quality of reporting in the healthcare industry. The program is now considered to be permanent and therefore the program name has been amended to the Physician Quality Reporting System (PQRS). PQRS reporting is based on individual measures which are associated to a specific patient group by diagnosis, ailment, age, or clinical action taken by the reporting therapist. All Medicare Part B FFS (fee for service) patients are eligible, but must meet inclusion criteria for each measure. 

There are three methods of reporting your clinical data to CMS:  Claims, Registry and EHR-based.  Choosing your reporting method is very important in reaching your 1% incentive goal.  

Claims-based Reporting
With claims-based reporting, measures are tied to clinical practice reported on claims with CPT codes that link to measures.


To qualify for your 1% incentive, you must report on at least 3 measures ( atleast 3 individual measures or atleast 1 measure group ) and report on 50% of eligible patients (this is a reduction from the 80% requirement of 2010).

Advantages of claims-based reporting:

1. You are in control of your own data from completion to submission
2. Cost effective – no added cost
3. Only 50% reporting requirement
4. OK for smaller practice or if Medicare is a small portion of your payer mix

Disadvantages of claims-based reporting:

1. Must have someone in the clinic who will own this project: complete audits, know all the ins/outs of PQRS, keep record of the % completed
2. Auditing process can be tedious and potentially a productivity loss for an employee
3. We must complete and submit the proper forms in proper format for the eligible patients
4. Workload could be significant if large % of your patients are Medicare or part of a large clinic

Registry-based Reporting
With registry-based reporting, the eligible professional or group practice submits the data electronically to the registry, who then captures and stores the measure related data. The registry is then responsible for submitting the individual measure or measures group information to CMS on behalf of eligible professionals.  Registries provide CMS with calculated reporting and performance rates at the end of the reporting period.  Registries must pass stringent reporting method criteria annually and be qualified to participate.
 
To qualify for your 1% incentive, you must report on at least 3 measures ( atleast 3 individual measures or atleast 1 measure group ) and report on 80% of eligible patients or report.
 
Advantages of registry-based reporting:

1. Form creation and submission is done by registry
2. No need for auditing due to the EMR enforcing measure criteria and selecting eligible patients
3. Staff productivity maintained
4. Higher potential for meeting the reporting criteria and receiving your 1% incentive bonus
5. Using a EMR registry gives you added insight and assistance with choosing most appropriate measures
6. Measures are updated automatically each year as information is provided by CMS

Disadvantages of registry-based reporting: 

1. There is a cost involved; but it is nominal ( around 300 $ per provider ) and definitely provides an ROI when staff time, paper/office supplies, and decreased stress levels are calculated
2. 80% reporting requirement, but with the EMR in place, 100% data collection should be the expectation
3. Data collection enforcement with all eligible patients – no choice but to report on each patient

The 1% incentive may not seem like much, if you have to spend staff time and effort to get the proper codes into billing, complete audits to ensure your clinic is meeting its minimum criteria, and manually submitting claims to CMS. Although there is a cost associated with using a registry, the savings on staff time and maintaining productivity alone is substantial.

EHR-based Reporting
Eligible professionals who choose to report on EHR measures need to select at least three EHR measures to report on to be able to qualify to earn a PQRI incentive payment.To qualify for the incentive, the correct quality action or performance exclusion will need to be reported on at least 80 percent of the eligible cases identified for each selected measure.


A case is eligible for PQRI purposes when the codes match the denominator inclusion criteria and are listed as PFS covered services according to the PQRI EHR Measure Specifications. Each measure has a reporting frequency or timeframe requirement for each eligible patient seen during the reporting period for each individual eligible professional.

Ensure all patient-care and visit-related information are documented in your EHR system. Ensure you identify and capture all eligible cases per the measure denominator for each measure you choose to report. Review all the denominator codes that can affect EHR-based reporting to make sure the correct quality action is performed and reported for the eligible case.

Create the required reporting file, which would be uploaded from your EHR system. A PQRI-qualified EHR would have been programmed already to generate this file. Submit final EHR reporting files with quality measure data by the data submission deadline.
 

Advantages of EHR-based reporting:

1. Cost effective – no added cost
2. EHR enforces measure criteria and selects eligible patients
3. Staff productivity maintained
4. Measures are updated automatically each year by EHR as information is provided by CMS

Disadvantages of EHR-based reporting:

1. Must have adequate training on the EHR to manage the PQRI process
2. Must generate and submit the EHR-PQRI reporting files
3. 80% reporting requirement, but with the EMR in place, 100% data collection should be the expectation

Colonoscopy Billing Guidelines

A Colonoscopy is an exam that allows a doctor to closely look at the inside of the entire colon. The doctor is looking for polyps or signs of cancer. Polyps are small growths that over time can become cancer. The doctor uses a thin (about the thickness of a finger), flexible, hollow, lighted tube that has a tiny video camera. This tube is called a colonoscope.

Colonoscopy Codes

CPT Code
Description
45378
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)
45379
Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body
45380
Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
45381
Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance
45382
Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45383
Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45384
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45385
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

45378 – Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without collection colon decompression (separate procedure).  Because this code is diagnostic and a separate procedure, it should never be reported with any other colonoscopy code.  Per the CPT manual, when a diagnostic endoscopy is followed by a surgical endoscopy, the diagnostic endoscopy is considered part of the surgical endoscopy and is not to be separately reported.  Only when the provider performs a diagnostic colonoscopy with brushings, washings and/or decompression and nothing else (no biopsies, excisions, etc.) should this code be reported.

45380 – Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple. The physician performs colonoscopy and obtains tissue samples.  This code can only be reported once regardless of the number of biopsies.  According to CPT Assistant, July 2004, this code is also used to describe polypectomy with cold biopsy forceps.  A cold biopsy with forceps is not the same as hot biopsy forceps and it is not a snare technique, therefore codes 45384 and 45385 would not be appropriate.  If the physician does remove a polyp or other lesion with a different technique and then takes a biopsy on a separate lesion, this code may be reported in addition with modifier -59. 

45381 – Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injections(s), any substance. The physician injects a substance into the submucosa, directed at specific areas through the scope while viewing the colon. (E.g. saline, India Ink).  This code is not to be used for injections used to control bleeding.  45381 may be reported in addition to other procedures with modifier -51 or -59. 

45382 – Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g. injections, laser, stapling, plasma coagulator).  This code is used when a physician controls bleeding in the colon due to a condition such as diverticulosis.  This code is not used to report control of bleeding caused by a procedure performed during the same encounter.  For example, there may be small amount of bleeding after a polyp is excised.   This would not be reported because control of bleeding is integral to therapeutic or surgical procedures.  However, if the physician treated a bleeding condition and then removed a polyp at a different location, the services may be reported together with modifier -59. 

45383 – Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amendable to removal by hot biopsy forceps, bipolar cuatery or snare technique.  This code is used when a physician ablates tumors, polyps or other lesions by laser or other method (e.g. fulguration).   

45384 – Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cuatery.  Hot biopsy forceps (also called monopolar cautery forceps) have “jaws” that are between 1 and 2 mm in size and can open up to about 1 cm wide to encompass a small polyp or lesion. The physician then applies cautery to ablate the base of the polyp (or other lesion) so it can be retrieved and sent to pathology for analysis. 

45385 – Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.  Snaring involves “lassoing” a polyp or lesion with a wire loop and shaving it off the bowel wall.  The snare may or may not be heated.  Any snare technique including cold snare, hot snare, and bipolar snare would be reported with this code.  The snare technique is the most often used technique and is best when removing both sessile polyps (those attached by a large base) and pedunculated polyps (those attached by a stalk).

Coding Multiple Procedures

When more than one procedure is performed using the same technique, report only one code.  For example, if the physician removes multiple polyps throughout the colon with snare technique, 45385 can be reported only once. 

However, if multiple polyps or lesions are removed with different techniques, you may report each separately.  For example, a physician removes a polyp with snare technique in the rectum and then biopsies a lesion in the transverse colon, you may report 45385 and 45380-59. 

In the absence of a CCI edit, always list the procedure with the highest RVU first.

Sigmoidoscopy Billing Guidelines

During a Sigmoidoscopy, a doctor closely looks at the lower parts of the colon, called the sigmoid colon and the rectum, for signs of cancer or polyps. Polyps are small growths which can over time become cancer. The doctor uses a thin (about the thickness of a finger), flexible, hollow, lighted tube that has a tiny video camera. This tube is called a sigmoidoscope.

The colon comprises three main parts: the ascending colon, the transverse colon, and the sigmoid colon—sometimes called the descending colon. The sigmoid colon is the last one-third of the colon. Flexible sigmoidoscopy enables the doctor to see only the sigmoid colon, whereas colonoscopy allows the doctor to see the entire colon. 

CPT Code
Description
45330
Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
45331
Sigmoidoscopy, flexible; with biopsy, single or multiple
45332
Sigmoidoscopy, flexible; with removal of foreign body
45333
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45334
Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45335
Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
45337
Sigmoidoscopy, flexible; with decompression of volvulus, any method
45338
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45339
Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45340
Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures
45341
Sigmoidoscopy, flexible; with endoscopic ultrasound examination
45342
Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)
45345
Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)

Emergency vs Critical Care

Emergency Care

Emergency care, with respect to trauma or critical patients, is the recognition of the critical condition, then appropriate stabilization and initial management of these issues. Emergency care gets the patient who is almost dying to 'in critical condition', by correcting the immediate problems, and and managing it.

Emergency care deals with Disaster management (major role) primarily, and have to face a wide variety of patients with varied problems in an uncontrolled environment. Emergency care is confined to short term management of the patient's condition.

Critical Care 

Critical care is the long term management of these patients after they leave the Emergency care.

Critical care takes the patient in critical condition and gets them into stable condition where they can be managed on the general medical floor. They do this by taking hold of certain physiologic parameters and managing it. They also manage the life threatening conditions which take days to treat.