Report from the Chair of the Board of Governors

January 8, 2010

“If you don't know where you are going, you'll end up someplace else.” Yogi Berra

Leadership Forum Fast Approaching

I look forward to meeting our incoming Governor-Elects, Governors, incoming Board of Trustees members, Council and Committee chairs and our Fellow-in-Training participants at the 2010 Leadership Forum at the Park Hyatt Hotel in Washington, D.C. This year’s program will focus on “Communications.” Richard Greene, a well known political and communications strategist, will be our keynote speaker. Over the last 25 years, Richard has taught presidents, prime ministers, U.S. senators, governors, CEOs, royalty (Princess Diana), actors and others, in 26 countries around the world, how to give presentations and speeches with comfort and authentic passion. He is the author of “Words that Shook the World” and founder of a corporation that trains the next generation of speakers and leaders. I’m confident that we will all benefit from his insights.

In addition to Richard, we will hear presentations from ACC CEO Jack Lewin on the “State of the Union” followed by ACC 2010 vision speeches from ACC President-Elect, Dr. Ralph Brindis and BOG Chair-Elect, Dr. Richard Kovacs. We are also honored to have veteran NASA astronaut Dr. Story Musgrave as the keynote speaker for the Leadership Forum Dinner on January 29.  Dr. Musgrave served a surgical internship at the University of Kentucky Medical Center in Lexington from 1964 to 1965, and continued there as a U. S. Air Force post-doctoral fellow, working in aerospace medicine and physiology, and as a National Heart Institute post-doctoral fellow, teaching and doing research in cardiovascular and exercise physiology. Dr. Musgrave was selected as a scientist-astronaut by NASA in August 1967. He completed astronaut academic training and then worked on the design and development of the Skylab Program.  He has participated in the design and development of all Space Shuttle extravehicular activity equipment including spacesuits, life support systems, airlocks, and manned maneuvering units and was instrumental in the deployment of the Hubble telescope and subsequent repair operations. Dr. Musgrave is the only astronaut to have flown missions on all five Space Shuttles and the last of the Apollo-era astronauts on active flight status to retire^. Prior to John Glenn's return to space in 1998, Dr. Musgrave held the record for the oldest person in orbit, at age 62. He retired from NASA in 1997. We look forward to an exciting and informative leadership conference.

ACC Launches New Imaging Initiative Called FOCUS 

In an effort to help health care providers implement Appropriate Use Criteria and ultimately reduce inappropriate imaging, the ACC this month is launching a new national quality improvement initiative called FOCUS (Formation of Optimal Cardiovascular Imaging Utilization Strategies). FOCUS is a quality improvement and innovation community designed to help cardiac imaging providers self-assess and gain quantitative feedback on their level of appropriate use, as well as share successes and strategies associated with AUC implementation.

Through participation in the FOCUS community, participants will have access to a shared list of tools and best practices that can then be integrated into practice. In addition, community members will have access to online educational resources and quality improvement tools and will work together with experts to understand practical ways to optimize the use of AUC in this changing payment environment. Innovation is never easy, and the ACC understands the challenges of engaging in FOCUS at a time of tremendous change. However, physician practices will benefit from FOCUS by demonstrating a dedication to professionalism, quality and resource stewardship.

For more information and to sign up for the FOCUS community, visit www.acc.org/auc. In addition, the ACC is holding a special kick-off Webinar on Jan. 19 from 2 p.m. to 3 p.m. (ET). The Webinar will provide an overview of FOCUS and the resources available. To register, click here. Questions regarding FOCUS should be directed to focus@acc.org. A FOCUS button for Chapter Web sites is also available on the Chapter Affairs Extranet. Stock newsletter and Web site text is also available. Please email Helen Smith (hsmith@acc.org) for more information.

FOCUS Quick Facts

• Key Goals:
  • Reduce Geographic Variation in CV Imaging
  • Reduce Inappropriate Imaging by 15% by 2011
  • Reduce Inappropriate Imaging by 50% in Aggregate by 2013

• Professional Advantages:
  • Performance Improvement Module (PIM)
  • Maintenance of Certification (MOC) Credit Opportunities
  • AUC Point of Order/Service Tools
  • Competitive Advantage
  • Opportunities to Inform Future Health Policy and Payment Reforms

We’re Making Headway on the Legal Front

The ACC's legal strategy has been running in parallel to its regulatory and legislative actions. After exhausting all immediate regulatory and legislative options – and with no final action by Congress or CMS to stop the cuts prior to the Jan. 1, 2010 deadline – the College on Dec. 28, 2009 filed a complaint, as well as motions for a preliminary injunction and expedited discovery, against Health and Human Services (HHS) Secretary Kathleen Sebelius, in U.S. District Court in Florida. The complaint alleges that Sebelius, in her capacity as HHS secretary, unlawfully adopted the payment rates for cardiology services in the 2010 Medicare Physician Fee Schedule in a manner that threatens access to patient care and precipitously increases Medicare costs.

According to the complaint, clear and critical defects exist within the Physician Practice Information Survey (PPIS), which was used to justify cuts to Medicare reimbursements rates for cardiology and which directly undermine the viability of community practices. The ACC, along with the Florida ACC Chapter, American Society of Nuclear Cardiology, the Association of Black Cardiologists and the Cardiology Advocacy Alliance, are seeking a preliminary injunction against the implementation of the 2010 Fee Schedule and asking the court to rule it invalid and order HHS to commission a new practice expense survey. The judge has scheduled a hearing on our request for a preliminary injunction for Jan. 13, and we are in expedited “discovery” involving CMS and HHS, AMA, and others. To read the complaint, expert witness testimony and press related to the lawsuit go to the ACC's Campaign for Patient Access Web site: www.campaignforpatientaccess.org. A new FAQ designed to help answer member questions related to the suit is also posted on the site. Feel free to link to these materials from your respective Chapter Web sites.

Unfortunately the cuts included in the final rule are for now official as of Jan. 1. The College has developed a series of documents to help practices navigate the biggest changes, including cardiology coding changes (http://www.acc.org/advocacy/advoc_issues/ACC2010CodingChangesFlyer.pdf ). In addition, the ACC has developed a “Practice Survival Toolkit” to help with important decisions regarding practice management.

On the legislative front, Rep. Charlie Gonzalez (D-TX) introduced legislation prior to the holidays holding cardiology at current 2009 practice expense values. We'll continue to urge continued support for this bill, as well as seek similar legislation in the Senate. Also, before heading home for the holidays Congress approved a temporary freeze on implementing the scheduled 2010 SGR cuts. They will need to act by February to stop these cuts for another year - or even better for good.

More on Consultation Codes 

As part of its 2010 Final Physician Fee Schedule Rule, Medicare has indicated that it will no longer pay for services coded as consultations as of Jan. 1.  Cardiologists provide many consultations and this change has resulted in many questions.  CMS on Dec. 15 released more information on the changes to the consultation codes and how physicians should report services in 2010.  To read the CMS MLN matters on this issue, please visit:  http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf. The ACC has also prepared the following FAQ (pasted below) to help with major questions. This FAQ is also posted on the ACC Web site at http://www.acc.org/practicemanagement.

Q:  Will I be paid for consultations provided to Medicare patients in 2010?

A:  Yes, CMS has instructed physicians to report services that are now reported as consultations as office, hospital, or nursing facility visits depending on the setting.  Since cardiologists provide relatively few services in the nursing facility, we’ll focus on office and hospital services, but the rules for hospitals are the same as those for a nursing facility. 

Q:  Which hospital and office visits should I use?

A:  CMS has indicated that physicians should use the initial hospital visit codes (99221-99223) for services that are provided as consultations in the hospital setting and new or established office codes (99201-99205 and 99212-99215) in the office setting. 

Q:  Aren’t initial hospital visit codes restricted to use by the admitting physician?

A:  Currently, these initial hospital visit codes are restricted to use by the admitting physician.  If more than one physician were to submit an initial hospital visit code in the past, then the one that submitted it earlier would be paid and the second would likely be denied.  However, this decision would change that rule.  Physicians who are serving as consultants may use the initial hospital visit codes. 

Q:  Is there a crosswalk of the consultation codes to the office and hospital codes?

A:  Physicians should select the level of hospital or visit code based on the documentation standards that are described in that section.  In some cases, there is a direct correlation among levels of visits and in some cases there is not.  For purposes of financial planning, ACC has made some assumptions about how services will be reported, but this will be different for every practice. In the hospital setting, there are five levels of inpatient consultation and three levels of initial hospital visits. The two lowest levels of inpatient consultation, which were rarely reported by cardiologists, have no equivalent in initial hospital visits.  However the documentation standards for 99253-99255 and 9221-99223 are equivalent.  The ACC will soon release a potential crosswalk for the codes but reiterates that documentation standards for the visit codes should guide the coding. 

Q:  What is the financial impact of this change?

A:  CMS estimates that the elimination of consultations will result in a 1 percent decrease in payments to cardiologists, but this number depends on your mix of services.  The decrease is not more significant because CMS took the money that had been paid for consultation services and distributed it to the office and hospital visits that will now be used to report them.  This means that the payment for all office and hospital visits will increase as part of this change. For cardiologists who perform a large number of consultations, the financial impact may be very significant. 

Q:  Should I still report consultation services on patients with private insurance?

A:  The ACC is communicating with major private payers to understand their intentions on the use of these services.  Until you hear otherwise from your payers, you should continue to use the existing consultation codes for services provided to patients other than those on Medicare.  The ACC has not yet heard from a private payer indicating that the company will discontinue acceptance of the consultation codes. 

Q:  How will Medicare know what physician admitted a patient?

A:  Medicare has indicated that the admitting physician will be required to report a modifier in addition to the initial hospital visit on his or her claim.  The required modifier will be AI.  Only the physician who admits the patient should use this modifier on his or her claim for an initial hospital or nursing facility visit. 

Q:  If I admit the patient, do I continue to report the AI modifier on subsequent hospital care codes?

A:  No, the AI modifier is only required to be reported once by the admitting physician and should be appended to the initial hospital or nursing facility visit only. 

Q:  I now provide consultations for established patients to review cardiovascular contraindications for surgical procedures.  How will I report these services for Medicare patients in 2010?

A:  For consultation services reported to established patients, physicians will have no choice but to report the established patient office visit codes, which are paid at a considerably lower level than consultations.

Q:  How should I report a service provided to a patient in the emergency room?

A:  Services provided to a patient in the emergency room would have been reported with outpatient consultation codes.  While emergency department visits are most commonly reported by emergency physicians, they are not restricted by specialty.  Physicians provided services in an emergency room should code those services as emergency department visits (CPT codes 99281-99285). 

Q:  How do I report a service provided to a patient in an observation setting?

A:  For a patient in observation setting, a consultation should be reported as an initial or established outpatient visit (99201-99215) if another physician has reported the observation codes. 

Q:  What is ACC’s position on the elimination of consultations?

A:  The ACC strongly opposes the CMS decision to eliminate the recognition of consultations.  As ACC stated in its comments on the proposal when it was released, we believe that a consultation is a distinct service from an office or hospital visit which requires different skills and has a different typical patient.  The ACC also has concerns about the administrative problems that could be caused by requiring different codes for different payers as well as other administrative issues.  However, the ACC is committed to making sure that members understand the issue and are in the best position to avoid denials of payment and be recognized for their work. 

I, and the entire BOG leadership team, look forward to working with all of you in furthering the 2010 ACC vision.

John Gordon Harold, MD, FACC

Chair, ACC Board of Governors