American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

July 2013 ACS Advocate


Is momentum building in Congress to overturn the maligned sustainable growth rate (SGR) formula (SGR)? In this month’s issue of The ACS Advocate:

  • We provide an update on efforts two key congressional committees are making to reform the Medicare physician payment system and details on the College’s ongoing involvement in the process.
  • Although the implementation of ICD-10 is a year away, now is the time to begin verifying that your documentation is ICD-10 ready.
  • Find out why a Supreme Court judge barred a health care expert from testifying in a medical liability case.

Inside this issue...

At the Federal Level

Physician Payment Reform | ICD-10 Required Clinical Documentation | ICD-10 FAQs | Surgical Coding Workshops | Stark Exception and Anti-Kickback Safe Harbor | Inpatient Prospective Payment System | eRx Hardship Exemption Deadline June 30  

At the State Level

Fluoroscopy Supreme Court Ruling | Independent Practice | Expert Witness Supreme Court Ruling | Provider Shield Legislation 

PAC and Grassroots News

ACSPA-SurgeonsPAC Making an Impact

Other News of Interest

At the Federal Level

ACS continues to advocate for physician payment reform

In February, the Republican-majority staffs of the House Energy and Commerce and Ways and Means Committees jointly released framework that would serve as the foundation for repealing the SGR and reforming Medicare’s physician payment system. The illustration below delineates efforts both committees are making to seek repeal and the American College of Surgeon’s (ACS) involvement.  


Senate Finance

House Energy and Commerce

House Ways and Means

Does the Committee have a Medicare physician payment reform proposal?


Legislative Language


Has ACS testified before the Committee on Value-Based Update?




The House Committee on Energy and Commerce released its long-awaited legislative draft proposal to reform Medicare’s physician payment system on May 28. The legislative text contains language that calls for repealing the SGR and replacing it with an improved fee-for-service system that offers providers a chance to opt out in favor of alternative ways of delivering care and participation in new payment and delivery models. However, the text is still incomplete and leaves several unanswered questions and blank spaces. Legislators have been looking to health care provider groups and other stakeholders to provide feedback and fill in those gaps. In June, the ACS responded to the committee’s request for feedback, maintaining that any new payment system must be based on the complementary objectives of improving outcomes, quality, safety, and efficiency while simultaneously reducing the growth in health care spending. 

On June 5, the committee held a hearing on the legislative draft proposal and prioritizing quality in a modernized physician payment system. Another legislative draft is expected to be released by the committee some time before the August congressional recess.

On the Senate side, the Finance Committee sent out a request for feedback on several questions regarding the Medicare physician payment system. In late May, the ACS responded with a number of recommendations on how to reduce health care spending in the current system while improving quality and paving the way for physicians to move into new payment models. The College has responded to Congress’ repeated efforts to tap the medical community for feedback on numerous issues regarding the physician payment system with suggestions for implementation of the ACS Value-Based Update, a patient-centered model that is based on the dual goals of improving quality and reducing growth in health care spending.  

Extended reading: Sustainable growth rate repeal: The bandages are running out

Clinical documentation requirements of ICD-10 for providers

Is your practice prepared for the transition to ICD-10? The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) is a medical classification list by the World Health Organization used for the coding of diseases, signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. After October 1, 2014, ICD-10 codes must be used on all Health Insurance and Portability and Accountability Act (HIPAA) transactions, including outpatient and inpatient claims. Otherwise, claims and other transactions will be rejected and will need to be resubmitted.

Familiar clinical concepts in ICD-10

Although some concepts in ICD-10 may be new to coders, physicians already are documenting much of the required information, including: initial encounter, subsequent encounter, or sequelae; acute or chronic condition; right or left side; normal healing, delayed healing, nonunion, or malunion. Examples, ICD-10 codes will now indicate laterality (right or left side of the body) allowing physicians to capture laterality and other concepts in a standardized form.

Verifying your documentation is ICD-10 ready

ICD-10 will require that physicians make some changes to their clinical documentation practices. It is important to conduct an initial review of documentation with coding and billing staff. Doing so will help you understand how ICD-10 will affect your practice. In addition, understanding the scope of the ICD-10 transition will reduce the likelihood of overlooking areas that need updates for ICD-10.

To begin, surgeons should look at their clinical documentation for the most used ICD-9 codes in their practice and work with coding and billing staff to select the appropriate corresponding ICD-10 codes. Identifying these codes will reinforce the information to highlight when documenting patient diagnoses for ICD-10.

Examples of common general surgery codes crosswalked from ICD-9 to ICD-10

ICD-9 code Descriptor ICD-10 code Descriptor
550.90 Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent) K40.90 Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent
574.20 Calculus of gallbladder without mention of cholecystitis, without mention of obstruction K80.20 Calculus of gallbladder without cholecystitis without obstruction
553.21 Incisional hernia K43.0 K43.1 K43.2
  • Incisional hernia with obstruction, without gangrene
  • Incisional hernia with gangrene
  • Incisional hernia without obstruction or gangrene
V12.72 Personal history of colonic polyps Z86.010 Personal history of colonic polyps
540.9 Acute appendicitis without mention of peritonitis K35.80 K35.89
  • Unspecified acute appendicitis
  • Other acute appendicitis

Note. All specific references to ICD-9 and ICD-10 codes and descriptions are © 2012 World Health Organization.

The Centers for Medicare & Medicaid Services. Official CMS industry resources for the ICD-10 transition. Available at: Accessed March 5, 2013.

Frequently asked questions about ICD-10

The Centers for Medicare & Medicaid Services (CMS) released three new FAQs about submitting ICD-10 claims and how to split the claims for services prior to the transition to ICD-10. The transition will take place on October 1, 2014.

  • How do I report ICD-10 codes on claims when the dates of service span from before 10/1/2014 to on or after 10/1/2014? (#8246)
  • If I submit or process a transaction with an ICD-9 code for a date of service after October 1, 2014, am I HIPAA compliant? (#8248)
  • How long after the October 1, 2014, ICD-10 compliance date must I continue to report and/or process ICD-9 codes? (#8252)

Attend one of the three remaining 2013 surgical workshops

The ACS offers a series of workshops throughout the year to meet the growing demands of your busy schedule. Because Current Procedural Terminology (CPT) codes for general surgery are updated each year, it is essential that physicians and their staffs attend a coding course annually to obtain the proper training and information necessary to accurately interpret and report medical procedures and services. 

New in 2013: Integumentary Guidelines Updated • Bariatric Surgery Coding • Esophagoscopy Coding, Tracheotomy Coding, Bronchoscopy Coding • Hernia Coding • Breast Coding

2013 workshops

  • Nashville, TN, August 22–23, Lowes Vanderbilt Hotel
  • Las Vegas, NV, October 24–25, Westin Las Vegas
  • Chicago, IL, November 7–8, Hyatt Chicago Magnificent Mile

In addition to describing what’s new in 2013, the two-day sessions also include updates on effective billing and collection processes designed to reduce inaccuracies and delayed reimbursement, as well as techniques for improving communication and productivity. Participants will receive a coding workbook for use in their practices.

Physicians can earn a maximum of 6.5 AMA PRA Category 1 Credits™ for each day. American Association of Professional Coders members can earn a maximum of 6.5 credits for each day. Register today for the next workshop. ACS members and their staffs are eligible for discounted registration.

Liability protections for health care providers

With the ACS' support, Rep. Marsha Blackburn (R-TN) and Jim Matheson (D-UT) in April introduced the Good Samaritan Health Professionals Act, which will ensure health professionals who provide voluntary care in response to a federally declared disaster are able to do so without the worries of liability claims.

The medical profession has a long history of providing assistance in times of disaster, especially when the needs of victims overwhelm the services that are available locally. In earlier years, the Volunteer Protection Act was established to encourage such actions, but failed to address liability protections for health care providers who cross state lines to aid disaster victims. The ACS advocacy staff is working with a Senate champion on the introduction of companion legislation in that chamber. The efforts of surgeons attending the ACS Advocacy Summit played an integral role in finding an advocate in the Senate.

ACS advocates for extension of Stark Exception and anti-kickback safe harbor

On June 7, the ACS submitted two letters, one to the CMS and a similar letter to the Department of Health and Human Services Office of Inspector General (OIG), regarding extending a federal physician self-referral statute (Stark Law) exception and comparable anti-kickback safe harbors for donation of electronic health records (EHR) software to physicians. The current exception and safe harbor for EHR donation will expire on December 31, 2013. The ACS has requested that this Stark Law exception and anti-kickback safe harbor for EHR donation continue as long as physicians can be penalized for failure to comply with the EHR Incentive Program.  

The Stark Law prohibits physicians from making referrals for certain Medicare-reimbursable services to an entity with which the physician (or an immediate family member) has a financial relationship, unless an exception applies. The entity is also prohibited from submitting Medicare claims for those referred services, unless an exception applies.

The Anti-Kickback statute imposes criminal penalties on individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce or reward the referral of business reimbursable under any of the Federal health care programs. Safe harbor provisions specify certain payment and business practices that are not subject to these.

ACS responds to Inpatient Prospective Payment System proposed rule

On June 14, the ACS responded to the CMS Inpatient Prospective Payment System (IPPS) proposed rule. In the rule, CMS proposes to set forth new criteria for identifying when an inpatient admission should be ordered. Specifically, CMS would presume that an inpatient admission was reasonable and necessary if the patient spent two midnights in the hospital or if the patient received a service that was on the inpatient-only list. Although the ACS does not oppose this proposal as it applies to retroactive review by a Medicare review contractor, the ACS is concerned that the proposal fails to address the difficulty that physicians face in determining whether a patient should be designated as an "inpatient" or "on observation" at the time of decision making. 

Additionally, the ACS has requested that CMS delay finalizing a proposal to include labor and delivery days in the calculation of hospital Medicare use because it may decrease Graduate Medical Education payments to hospitals. The ACS also commented on measures proposed for inclusion in the Hospital Value-Based Purchasing Program, the Hospital Inpatient Quality Reporting Program, the new Hospital-Acquired Conditions Reduction Program, and the Prospective Payment System Exempt Cancer Hospital Quality Reporting Program.  

The IPPS proposed rule was published in the Federal Register on May 10, and its provisions if finalized, will apply to services provided between October 1, 2013, and September 30, 2014.

Quality Corner

Medicare incentive programs update

Apply today for an eRx hardship exemptions. The deadline is June 30.

Sunday, June 30, is the deadline to submit applications for significant hardship exemptions from participation in the 2014 Electronic Prescribing (eRx) Incentive Program penalty. Eligible providers must apply for a significant hardship exemption to avoid a 2 percent reduction in 2014 Medicare Part B payment. Health care professionals who applied and met the deadline for an eRx significant hardship exemption for any previous year—including the January 30 deadline for the 2013 eRx exemption—and received CMS approval must reapply for 2014. Follow this step-by-step guide created by the ACS to apply. Applicants for the exemption must use Internet Explorer 9. Apple users should contact the CMS eRx help desk at 866-288-8912.

Other resources: CMS significant hardship exemption application site| eRx final rule

At the State Level

Iowa Supreme Court rules on fluoroscopy

The Iowa Supreme Court recently issued an opinion on a case appealed from the Polk County District Court related to the supervision of nurse practitioners when providing fluoroscopy. The Iowa Board of Nursing had adopted rules permitting advanced registered nurse practitioners to conduct fluoroscopies, but the physician community filed suit to stop this scope of practice expansion. As part of its opinion, the Court found the Board of Nursing had the authority to adopt these rules.

Independent practice for nurse practitioners

In May, Nevada became the most recent state to grant independent practice to nurse practitioners.  Under the new statute, advanced practice registered nurses will be able to prescribe schedule II drugs, may be required to carry liability insurance, and will no longer practice under a protocol with a physician.

Medical liability: Expert witness ruling in New Jersey

Earlier this year, the New Jersey Supreme Court issued a ruling in a medical liability case pertaining to expert witness qualifications.  Under New Jersey law, plaintiff’s expert witnesses must be board certified in the same specialty as a board-certified defendant. In this case, the Supreme Court of New Jersey ruled that an internist who specializes in hyperbaric medicine, critical care medicine, and pulmonary diseases is ill qualified to testify against an emergency physician and a family physician. The court found that plaintiffs cannot establish the standard of care through an expert who practices outside of the defendant physicians’ medical specialties and barred the expert from testifying to the standard of care.

Georgia adopts provider shield bill

In May, Georgia became the first state to enact provider shield legislation. Under the new statute, a barrier is created between physicians and public or private payor guidelines that could have been used as evidence in medical liability lawsuits. Evidence related to the public and private payor guidelines will be inadmissible in court and cannot be used as the standard of care and as a presumption of negligence in a medical liability lawsuit. 

PAC and Grassroots News

ACSPA-SurgeonsPAC by the numbers

Did you know?

  • Since 2007, staff and Fellows have attended more than 1,000 political events.
  • Since moving into the office on F Street, NW, in Washington, DC, located steps from Capitol Hill, the College has hosted more than 50 events for members of Congress or congressional candidates.
  • Since 2010, the ACS Political Action Committee (ACSPA-SurgeonsPAC) staff and Fellows hosted more than 50 political events.
  • Numerous Fellows have delivered ACSPA-SurgeonsPAC checks in their local Congressional districts.
  • 13 members of Congress attended the 2013 Advocacy Summit.
  • The 2011–2012 Congressional election was the highest earning cycle? In that cycle, the ACSPA-SurgeonsPAC received $1.368 million in contributions, contributed $758,000 to 93 candidates and incumbents, and made contributions to various leadership PACs and political party committees. The success rate was more than 92%.

To learn more about the ACSPA-SurgeonsPAC, get involved. View additional facts.

Other News of Interest

  • The following ACS members have been elected to serve in American Medical Association (AMA) leadership positions:
    • Maya Babu, MD, neurosurgery resident, Rochester, MN, was elected to the resident/fellow trustee position on the AMA Board of Trustees.
    • Andrew Gurman, MD, FACS, hand surgeon, Altoona, PA, was reelected as Speaker of the House of Delegates (HOD).
    • Liana Puscas, MD, FACS, otolaryngologist, Durham, NC, was elected to the AMA Council on Medical Education.

The elections were completed during the annual AMA HOD meeting in June. Read detailed information on the actions of the AMA HOD.

  • CMS plans to conduct pre- and post-payment audits for EHR programs. Review the criteria and learn how an audit could affect you.
  • In May, ACS advocacy staff and Lee Morisy, MD, FACS, general surgeon, Memphis, TN, and ACS representative to the American Hospital Association (AHA), attended the AHA Editorial Advisory Board (EAB) for Coding Clinic for ICD-9-Clinical Modifications in Baltimore, MD. The EAB assists hospitals and networks in collecting and reporting standardized quality data. Also in May, Dr. Morisy was appointed to represent the ACS on the AHA’s EAB for Coding Clinic for Healthcare Common Procedure Coding System committee.  
  • The AMA released its sixth annual National Health Insurer Report Card (NHIRC), a review of health insurers and their patterns for processing and paying medical claims. The AMA also unveiled its new, Administrative Burden Index, a component of the NHIRC, to rank commercial health insurers according to the level of unnecessary cost they contribute to the billing and payment of medical claims.

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