The Cardiovascular Group (CVG) comprises 16 cardiologists—four of whom implant EP devices—and serves five hospitals and eight satellite campuses throughout the greater Atlanta, Ga., area. In the fourth quarter of 2009, the group began integrating data from implantable cardiac devices—remotely transmitted from their patients’ homes—directly to its EMR. While CVG had been reaping the benefits of remotely interrogating EP devices via St. Jude Medical’s Merlin.net Patient Care Network since late 2008, which included increased reimbursement revenues, reduced overhead costs and decreased manual processes, the benefits were enhanced when those data became integrated with the practice’s EMR (GEMMS ONE).
As a high-volume facility, CVG implanted approximately 1,530 cardiac devices (including pacemakers, implantable cardioverter-defibrillators [ICDs] and biventricular ICDs [CRT-Ds] from all manufacturers) between 2008 and 2010 (see figure, page 11). Previously, patients with implanted cardiac devices were required to visit the office for device interrogations, which were typically conducted quarterly. However, when the practice implemented Merlin.net, two of those annual device interrogations could occur remotely via the Merlin@home wireless transmitter. St. Jude Medical’s ICD, CRT-D, CRT-P and traditional pacemaker technologies are tracked using RF telemetry that remotely monitors patient devices on a daily basis, which enables caregivers access to patients seven days a week, 365 days a year, and leads to a reduction in delays between event and clinical intervention. Recent research suggests remote monitoring leads to:
- A 50 percent relative reduction in the risk of death1;
- Improved survival rates: 13 percent for ICDs and 15 percent for CRT-Ds1; and
- An 80 percent reduction in time to clinical intervention2.
The paradigm shift of remotely following asymptomatic patients allowed CVG to spend more time with symptomatic patients, as well as to expand its business. In addition to the time saved by physicians and staff through remote monitoring, utilizing Merlin.net for device interrogations can result in greater economic value. CMS reimburses approximately $29 to $35 more for monitoring remote interrogations over a three-month period, compared with individual quarterly office visits for patients with pacemakers or ICDs/CRT-Ds. From 2008 to 2010, CVG billed for 2,645 in-office device interrogations for pacemakers and ICDs across all its manufacturers, generating revenue of approximately $170,6003 (see figure, page 11). For example, if you took a comparable physician practice with the same volume that was not employing remote interrogations, and applied an additional $30 to half of those 2,645 visits, as if it had been using Merlin.net, the total revenue for that same period would have been about $210,300, or a 23.3 percent increase.
In 2009, its first full year of using Merlin.net, CVG generated about $46,300 in revenues from device interrogations for St. Jude Medical’s devices alone, which boosted its an annual revenue to $71,668 in 2010—a year-over-year increase of 64.6 percent (see figure below).
|Cardiovascular Group Remote Interrogations for St. Jude Medical Devices|
|Quarterly Procedural Growth||321%||108%||-54%||-14%||65%||45%||30%|
|2009 Q-o-Q Procedural Growth||250%||38%||-4%||170%|
|2009 Q-o-Q Revenue Growth||161%||35%||-5%||169%|
|Annual Revenue: $46,317||Annual Revenue: $71,688|
|Includes technical/professional CPT codes for St. Jude Medical ICDs and pacemakers (93294, 9329526, 93296 & 93295)|
All revenue has been normalized to 2010 Medicare Physician Fee Schedule in Atlanta (June 1-November 2010), which is 200-300 percent lower than average practice revenues.
Practice management considerations
The Merlin.net integration with the GEMMS ONE Device Manager occurred soon after the EMR rollout. Prior to this integration, individual patients could have two or three paper records for both clinical and device information. Even though the nursing staff was utilizing Merlin.net, their process was to print out all clinical events, which were stored as PDF files. Then, the staff would scan the files and attach them to the patient’s record, as well as manually enter device data into the record.
By seamlessly integrating patient interrogated reports and data between these two systems, the clinicians at CVG have one centralized electronic record with all their patients’ cardiology and electrophysiology data, resulting in a “tremendous reduction in physical reports,” says Niraj Sharma, MD, an electrophysiologist at CVG.
While the manual paper process took 24 hours for data to be entered into the patient record, the same automated process now takes about 15 minutes, says Elaine Coker-Smith, LPN, a triage nurse at CVG. Shortly after a patient transmits his or her information via Merlin@home, the nursing staff can access the data on Merlin.net, which brings any patient-activated interrogations to the attention of the CVG staff, she says. The nursing staff routinely checks the alert system portal in Merlin.net to monitor any abnormal findings.
Additionally, the current automated method provides patients with additional confidence in the monitoring of their conditions, as the transmitter will check the individual on a daily basis, as opposed to only during regularly scheduled quarterly check-ups. Merlin.net also gives the patient the freedom to travel because the Merlin@home transmitter can transfer data back to CVG from anywhere in the U.S.
“The new workflow is not interruptive, as the technology now simply prompts the nurses to export data directly to the EMR through the same Merlin.net interface we had previously been using,” says Coker-Smith.
Due to the automated process, the practice reduced staffing levels by two FTEs, who transcribed the data pulled from device interrogations into the patients’ record. This equated to a savings of approximately $55,000 annually, as each FTE earned $12 to $14 an hour (see figure below).
|2010 Earnings After Merlin.net/GEMMS ONE EMR Integration|
|Medicare Charges1||2008 Medicare Charges||2010 Quantity||2010 Medicare Charges||Total Increase|
|Replacing Two In-Clinic Checks with Remote Reimbursement||$40.77–$80.50||$0||1,376||$71,668||$71,668|
|Clinic Staff Savings||$55,000|
|Office Visits - New||$40.09–$195.52||$41,850||695||$102,447||$60,597|
|Device Implantation (Pacemaker, ICD & BV-ICD)||$445.19–$977.14||$299,595||537||$366,000||$66,405|
|Health IT Incentives2||$18,000|
|Revenue Increase: $290,715|
|1 All revenue has been normalized to 2010 Medicare Physician Fee Schedule in Atlanta (June 1-November 2010), which is 200-300% percent lower than average practice revenues.|
2 Because GEMMS ONE EMR is certified by the Drummond Group, which is an Office of the National Coordinator of Health IT Authorized Testing and Certification Body (ONC-ATCB), CVG is planning to submit for meaningful use funding under the HITECH Act, and anticipates receiving funding in the first or second year of the program.
2010 is the first year that Merlin.net was integrated with the GEMMS ONE EMR, compared with 2008 which is prior to the implementation of Merlin.net
As a result, clinical decision making—measured from the time of transmission to the time a nurse or physician reviews the data—is far swifter, especially for asymptomatic atrial fibrillation patients, Sharma says.
“The time for a physician to make a clinical decision has been reduced from days to hours or even minutes,” Coker-Smith adds. “Physicians are no longer required to be in a particular physical location to receive the paper charts. Now, once they are alerted to a problem, physicians can access the data in an electronic chart through any secure internet connection.”
Due to the Merlin.net/GEMMS ONE Device Manager integration, the billing process also has been expedited. Physicians can electronically sign off on reports, allowing them to get instantly adjudicated through the EMR via a billing portal to the payor.
Coker-Smith, who manages billing, says the billing cycle due to electronic sign-off is “exponentially shorter,” resulting in a faster turnaround time for reimbursement. Previously, reimbursements could be prolonged or bottlenecked due to the requirement of a physicians’ physical presence for a signature.
Directing caregivers to patients
“Beyond the economic benefits, the automation in processing interrogations affords our clinical and business teams more time to deal with face-to-face patient interactions, rather than paper shuffling which doesn’t add value to the patient’s experience,” says David Donnelly, CEO at CVG. Due to the reduced routine check-ups in the office, the practice has been able to accept more new patients, as well as reduce wait times. Previously, new patients had to wait about three weeks for an appointment, and now, the average wait time is approximately a week. “Our schedules remain equally as busy, but we are able to take on new patients,” Sharma says.
In fact, CVG was able to expand its capacity to address community disease treatment needs. The practice billed for 431 new EP-related office visits in 2010 compared to 2008, a 164 percent increase. Likewise, the electrophysiologists are able to perform additional EP and ablation studies, which are necessary to diagnose and treat critically ill patients and reimburse at a higher rate. The practice earned about $362,600 in 2010 for these procedures—almost $40,000 more than the previous year. Also, the need for ablations is expected to grow exponentially in the coming years, due to the burgeoning atrial fibrillation patient population. Therefore, electrophysiologists will need to have their time freed for these procedures.
“While we didn’t initially know what benefits would result from Merlin.net integration with our GEMMS ONE EMR, we now have discovered the benefits of expedited processes and reduced overhead costs,” Sharma concludes
|2008-2010 Cardiovascular Group Billing Records for all EP Device Manufacturers|
|CPT||Medicare Rates*||Quantity||Medicare Charges*|
|Office Visits - Consults||99242–99245||$48.94–$136.48||4,849||$652,384.48|
|Office Visits - New||99202–99205||$69.35–$195.52||1,187||$179,993.07|
|Office Visits - Established||99212–99215||$40.09–$136.48||19,760||$2,168,128.94|
|Office Visits Total:||25,796||$3,000,506.49|
|Office Monitoring Patients||93288||$40.77||962||$39,220.74|
|Office Monitoring Patients||93289||$69.53||159||$11,055.27|
|Devices - PM||33207||$509.30||81||$41,253.30|
|Devices - PM||33208||$550.54||583||$320,964.82|
|Devices - ICD||33249||$977.14||537||$524,724.18|
|Devices - ICD Rev.||33223||$445.19||70||$31,163.30|
|Devices - BV-ICD||33224||$535.10||30||$16,053.00|
|Devices - BV-ICD||33225||$482.71||224||$108,127.04|
|Studies - EP||93620||$636.70||702||$446,963.40|
|Studies - Ablations||93650||$584.96||65||$38,022.40|
|Studies - Ablations||93651||$889.78||544||$484,040.32|
|Studies - Ablations||9365122||$889.78||37||$32,921.86|
|Studies - Ablations||93652||$968.78||29||$28,094.62|
|Remote - ICD||93295||$70.37||1,924||$135,391.88|
|Remote - ICD||9329526||$70.37||107||$7,529.59|
|Remote - ICD||93296||$34.70||1,791||$62,147.70|
|Remote - Pacemaker||93294||$35.91||9||$323.19|
|Remote - Pacemaker||93296||$34.70||1,791||$62,147.70|
|Remote Interrogations Total:||5,622||$267,540.06|
|GRAND TOTAL: $5,511,024.00|
|*All revenue has been normalized to 2010 Medicare Physician Fee Schedule in Atlanta (June 1-November 2010), which is 200-300% percent lower than average practice revenues.|