Junaid Khan Report August 2014

Title 22 Payments

We had about 60 responses to the initial query about the lack of payment for second assistants from Noridian the Medicare vendor. The problem was nearly universal.

CASTS leadership has had multiple points of contact with Noridian, including a meeting with its director Bernice Hecker MD. We informed them of the unique role of Title 22 in the state of California in requiring a second assistant. Our understanding at this point is that Noridian will be open to paying for the second assistant as long as its role is documented properly. We have heard some feedback from members who are now starting to get paid for a second assistant. Below is a sample composite template on how to document appropriately the role of the first and second assistants, based on some of the responses we have received form members. A follow up meeting was held between CASTS leadership and Noridian at the Medicare Carrier Advisory Committee meeting in San Francisco last month. The following the statement was issued after that meeting. Not completely satisfying, but something we can work with. An alternate proposal for billing the vein harvest as co-surgeon was discussed and though this might lead to slightly higher short term compensation, but I did not think this was a good long term solution, ie if/when the vendor changed again and since it did not resolve the non cabg cases.

Dr. Hecker submitted the following statement:

“Esteemed Colleagues, Noridian has received a number of appeals (redeterminations) related to denials for reimbursement of services of a second assistant during open heart surgery. At the redeterminations level, we have been able to make several individual determinations favorable to the appellant based on additional information submitted. This process, however, remains a mutually time-consuming, resource-intensive interim solution. Moreover, a number of claims have remained denied due to the absence of documentation supporting the need or even a role for the second assistant other than fulfillment of a state requirement which is unrelated to medical necessity. We have sought advice from CMS, providers and specialty societies across our states, legal staff, and all on this email but have not yet been able to identify a solution(s) or other resolution to this situation. From our perspective, and that of essentially all with whom we have spoken, Title 22 may need to be re-addressed in light of current national practice and the requirements of Medicare and other payers. In the interim, careful documentation of the specific roles of the assistants is fundamental to payment. We are not allowed to change the Medicare law, but we will do whatever we are allowed to do to assist you.

My regards to each of you,”

Bernice Hecker MD, MHA, FACC, Executive Medical Director, Medicare, Parts A&B, Jurisdiction E (CA, HI, NV, Guam, Samoa, CNMI)

Suggested wording for operative reports:


The 2nd assistant performed saphenous vein harvest and preparation, followed by closure of the incision.  Simultaneously, the first assistant assisted with cannulation and placing the patient on cardiopulmonary bypass. The first assistant remained throughout the construction of all proximal and distal anastomoses, and weaning the patient off bypass. When the 2nd assistant finished closing the leg, he/she moved to the chest, to assist with suctioning, retraction, and exposure.  Once the patient was off bypass, the 2nd assistant assisted with closure of the wound.

Sternotomy AVR & MVR

The 1st assistant was present from the time of cannulation for cardiopulmonary bypass, to the completion of valve implantation (or repair) until the patient was successfully weaned off cardiopulmonary bypass.  The 2nd assistant was present throughout the entire operation, and assisted with retraction, suction, and exposure.  The 2nd assistant also held the valve prosthesis during suture placement into the sewing ring to expedite implantation and reduce ischemic time.


SB830, enhancing public reporting to include PCI, continues to make its way through the state legislature committee structure. CASTS was asked to and did provide a letter of support for the legislation.

It was held up due to budgetary concerns, ie cost. We are working with CA-ACC to try to help reduce the cost by importing currently available data from cath labs. More to follow. Dr McMillan is leading the charge for CASTS on this topic.



The CASTS reporting website has been completely revised and updated.  The draft version is at www.californiacardiacsurgery.com/CCSIP-2012. The hospital needs to pay a fee to see comparative data.  At present this is the only source of comparative data for California heart hospitals.  It is rigorously documented and offers a source of information in advance of public reporting, which will take a few years to get off the ground.  CASTS would like to enlist hospital participation in QI collaboratives, offering access to the website and regional meetings for an annual fee. We would like your support in the endeavor. Please enlist your data managers’ and hospital administrators’ help in supporting this initiative.  The annual fee is really a small amount, so far only a few hospitals have paid. This is the easiest way to secure the financial viability of CASTS.

Public Reporting of PCI and Valves Moves Along (SB 830)

James MacMillan attended a hearing in Sacramento last week at which Senate Bill 830 was presented and discussed.  Dr. MacMillan submitted a letter of support and made a presentation to the committee hearing.  He described the changes that have occurred in cardiovascular procedures since the beginning of public reporting of CABG more than ten years ago.  The incidence of CABG has decreased, and there are now 4 times more PCI’s than CABG procedures performed in California.  Heart Valve procedures have increased relative to CABG, now representing more that half of the cardiac surgeres performed at most hospitals.  Outcomes for CABG and valve surgery have improved, and recent data shows that PCI accounts for more deaths and complications than cardiac surgery.  His presentation was well received and there appears to be little opposition to the expansion of public reporting.

CASTS update March 2014

CASTS board members had an informal luncheon meeting at the STS in Orlando.  The primary topic of conversation was related to the update of the mandatory public reporting law SB 680.  The update, known as SB 830, is in draft form and currently being prepared by James MacMillan of CASTS and Bill Bommer of CAACC.  The legislation will allow reporting of PCI and Valve outcomes beginning in 2015.  CASTS is also preparing an update to its reporting site www.californiacardiacsurgery.com which will provide an examples of information that may be presented in future public reports.  The new reports are designed similar to those in New York, which provide aggregated isolated valve and valve-CABG groups as well as CABG and PCI.   The reports will be available at the end of March to qualified users.

CASTS in Sacramento with ACC regarding SB680 and CCORP reporting

We had a very productive meeting today with Senator Galgiani and her chief of staff, Ross Warren. Nilas Young, Chief of Cardiac Surgery at Davis Medical School, Junaid Khan, President of CASTS, Bill Bommer, Professor of Cardiology at Davis, and James Macmillan were present. They have submitted a spot bill which is quite good, but needs some additions which they invited us to submit. We all agreed on the strategy of portraying this effort as an update to SB 680 to account for changes in practice patterns and new procedures, ie PCI reporting.

Public Reporting of CABG-Valve Data

Thanks to all for responses to the notice that the CCORP will begin reporting CABG-valve cases sometime in the near future (the earliest would be the end of 2014). Of about 20 surgeons who responded, most agreed with Fred Grover’s parting recommendation that no further cardiac surgery reporting be undertaken without reporting of PCI. While this is not surprising, some also pointed out that we surgeons have been in the forefront of public reporting and should continue to support it. Unfortunately the law (SB 680) that established CABG reporting included ALL CABG, not just isolated CABG. Further, from a statistical point of view, the greater number of outcomes (deaths) provides improved significance to the reports. Clearly the law needs to be updated and this time around the CASTS must play a more active role in the legislative process.

A few quotes from the responses:

“Reporting needs to happen now, with cardiology and cath lab stats–there needs to be “skin in the game” and take advantage of their stronger lobbying power.”

“…until cardiologists agree to report their interventions, cardiac surgeons should simply tell their hospital administrations, that they will no longer act as back up for interventions that are undertaken without accountability.”

“I also agree with Dr. Grover’s wise remark not to participate in any State sponsored reporting until the Cardiologists are forced being accountable of their work. I see too many PCIs with poor intermediate and long term outcomes. The standing recommendation to refer a patient for CABG with 3 vessel disease and significant LV dysfunction is violated on a daily basis.”

“We need to develop a strategy to get a law to get PCI publicly reported. This will also require funding. Perhaps the CA ACC could step up. We can fight the extended CABG reporting, I predict without success. Instead, I recommend making the case for PCI reporting. The concerns that lead to the original law to report CABG is totally applicable to lead the quest to report PCI.”

“……if the ultimate intent of the reporting is to elevate the level of cardiovascular health care delivery then it must include defining what has appeared by some observers (myself included) to be an egregious inappropriate excess…reporting pci results is essential …. if mechanisms to force the issue are necessary then they should be used…double standards are hard to defend.”

“I disagree with Fred Grover. Cardiac surgery public reporting for cabg has reduced operative mortality since introduction. Expanding to valves and cabg valves would undoubtedly have a similar influence. Our specialty has had unusual strength of character and integrity making our leadership by example more powerful than debate.”

“The caveat for me is that this next level has to be more than just a linear extension of the mechanics of studying CABG to valve/CABG. There is more that we need from the data management since we have learned how it drives surgical, post surgical and nonsurgical behavior. Although I agree with Dr. Grover’s wish to have PCI also reported, I disagree that we should wait for that to happen before we move further forward. CABG data has dramatically improved outcomes even though the public does not know how to interpret these numbers. They none the less have been beneficiaries.”

“Historically, cardiac surgeons were initially dragged into a position of accountability insofar as risk-adjusted outcomes data for CABG surgery. Now, after three decades, the profession is admired by its peers and by the public for its foresight and clarity of purpose . The accurate reportage of our results has had beneficial effects in terms of better outcomes and has served as a useful guidepost for our patients in selecting whom they want as a surgeon. I can only see benefits in extending this accountability to the practice of valve/cabg surgery and possibly eventually robotic surgery.”

“We need to use this energy to point out the value of CASTS. I will certainly work on my state senator and assemblyman to get some legislation going. Also CMA can help push it once it gets going. The Consumers Union would be hypocritical if they didn’t support it also.”

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