Strengthen your Coding Team to Support Organizational Success Jackie King, MSHI, CPC, COC, RH-CBS

Transcription

1 Strengthen your Coding Team to Support Organizational Success Jackie King, MSHI, CPC, COC, RH-CBS

2 Agenda Office (Outpatient) Coding Overview HCC Risk Scoring Appropriate Modifier Usage Provider Queries Educating Providers (and Staff) on Documentation Improvement Performing Coding Audits to Uncover Learning and Revenue Opportunities

3 HIPAA Code Sets CPT - What did you do? CPT is currently identified as Level I of the Healthcare s Common Procedural Coding System (HCPCS). Created by the AMA (and their documentation rules aren t licensed to others who also publish manuals) Most codes are updated January 1st each year but vaccine product codes can be updated twice a year. HCPCS II - What did you do and/or what supplies were used? HCPCS-II is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level II of the HCPCS. Created by CMS as a supplement to Level I CPT codes. Many temporary codes (e.g. Q0091) and permanent codes with different update schedules. Supplies, DME, many specific CMS preventive medicine services are found here. ICD-10-CM - Why did you do perform a service? Overseen by the Cooperating Parties (AHA, AMA, CMS, NCHS). New codes become effective on October 1 each year.

4 CPT Code Reporting Aids CPT Assistant, September 2018, Volume 28, Issue 9, page 3

5 Components of an E&M Service CPT Category I History Exam Medical Decision Making KEY COMPONENTS Nature of Presenting Problem Counseling Coordination of Care Time CONTRIBUTORY COMPONENTS.

6 Selecting a E/M Level of Service Based on Time. For visits that involve more than 50 percent counseling or coordination of care, time can determine the level of coding. For example, if a 25-minute office visit with an established patient involved more than 15 minutes of counseling and coordination of care, time could be used to support CPT code even if the Key Components result in a Sample verbiage: Total visit time = 35 minutes with greater than half of the time spent counseling/coordinator care. 20 of 35 minutes spend counseling/coordinating care.

7 CPT Category II Codes CPT Category II codes are tracking codes which facilitate data collection for the purposes of performance measurement. The use of the tracking codes for performance measurement will decrease the need for record abstraction and chart review, and thereby minimize administrative burdens on physicians and other health care professionals. These codes are intended to facilitate data collection about quality of care by coding certain services and/or test results that support performance measures and that have been agreed upon as contributing to good patient care. Some codes in this category may relate to compliance by the health care professional with state or federal law. The use of these codes is optional. The codes are not required for correct coding and may not be used as a substitute for Category I codes.

8 CPT Category II code examples Patient History 1000F = Tobacco use assessed (CAD, CAP, COPD, PV) (DM) Patient History 1031F = Smoking status and exposure to 2 nd hand smoke in the home assessed (asthma) see also 1032F- 1039F Patient History 1125F and 1126F = Pain severity assessed (present vs. not present) Physical Examination 2000F = Blood pressure measured (CKD and DM)

9 Outpatient ICD-10-CM Coding General Guidelines Coders cannot use probable, suspected, rule-out, likely, etc. in outpatient. (*This differs from inpatient coding where these conditions are coded as if they exist during the stay). Code the conditions to the highest degree of certainty for that encounter. List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided In some cases, the first-listed diagnosis may be a symptom when a diagnosis as not been confirmed. These codes that describe signs or symptoms are acceptable when a diagnosis has not been confirmed by the provider. Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80- Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment

10 What are HCCs? Hierarchical Condition Categories or HCCs are groups of similar diagnoses that consume similar resources. They are conditions known to be a clinical disease burden. Similar to MS-DRGs, each HCC is assigned a specific weight that impacts each patient s risk score. HCCs are grouped in disease hierarchies (i.e. Diabetes Mellitus is grouped in several HCCs depending on whether the disease has complications or is controlled/uncontrolled, etc.) and are often chronic disease conditions. HCCs were developed as a way of accounting for and expressing the health status (i.e. major risk factors) of any particular Medicare enrollee, focusing on the greater costs and longer term care associated with patients needing care for chronic conditions.

11 Source: der/noapplication/f2/s2/t4/pw_g pdf?refer=ehpprovider Matching ICD-10-CM codes to HCCs risk scores

12 HCC Overview Common gaps and key steps in capturing HCCs

13 CMS Requirements for HCC Code Assignment All principal and secondary diagnoses codes be reported to the highest level of specificity. The medical record validates the diagnoses codes that have been reported by the Physician. All diagnoses must be re-documented on an annual basis - during a face-to-face encounter with the beneficiary in order to be reported on the claim for HCC assignment.

14 Modifiers Key to compliance and profitability Where are they found? ( Appendix A in the CPT manual) Pure Coding modifiers (ex. -26, -50, -TC) vs. Billing modifiers (ex. -25, -51, -90) Who needs to know them? It is highly recommended modifiers only be entered by the coding staff who have access to the patient chart and can verify its contents. Best practice indicates billing staff does not attach modifiers to claims. Billing personnel attaching modifiers without coding input can be construed as fraud behavior.

15 You can use Modifier -25 in 2 different ways: Significant or A new patient presents with head trauma, loss of consciousness at the scene, and a 2.1 cm scalp laceration. The physician determines the laceration requires sutures and performs a simple repair. 9920(x)-Due to the loss of consciousness, the physician also performs a full neurological examination with an history, examination, and medical decision making documented. The possible neurological damage from the head trauma extended beyond the laceration that was repaired. The full neuro exam, history and medical decision making are significantly separate and well documented to support the modifier 25. CMS: National Correct Coding Initiative Policy Manual. Chapter 1 General Correct Coding Policies, E, Modifiers and Modifier Indicators. Correct codes: 9920(x)-25, Separately identifiable 9921(x) An established patient seen for 6- month evaluation of hypertension who asks the provider to address left knee pain which developed after recently playing basketball. The evaluation of the knee problem is included in the procedure below, however the evaluation of the hypertension was performed regardless of the knee pain being present, making the use of modifier 25 appropriate aspiration from, or injection into, a major joint Correct codes:9921(x)-25, 20610

16 Reporting Removal of Impacted Cerumen Know when separately reportable vs with an E/M with Modifier- 25 Know which of these codes must be performed by a full provider Removal impacted cerumen using irrigation/lavage, unilateralnursing staff may perform as long as cerumen impaction is documented by the provider Removal impacted cerumen requiring instrumentation, unilateralmust be performed by the provider only and cerumen impaction must be documented in the medical record. Since these are unilateral codes - for bilateral procedure, report with modifier -50 on one line item for proper coding with double the fee, though some carriers might want it on 2 lines for billing.

17 Modifier -59 Basics Two codes in a code pair edit often by definition represent different procedures. The provider cannot use the -59 modifier for such an edit based on the two codes being different procedure codes. However, if the two procedures are performed at separate sites or at separate patient encounters (sessions) on the same date of service, the modifier -59 may be employed. This is a last resort modifier let s look at the definition in Appendix A of CPT

18 Modifier -59 Basics Modifier 59: Distinct Procedural Service Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. (Appendix A of CPT ) CMS has defined four new HCPCS modifiers XE, -XS, -XP, -XU to specifically identify subsets of Distinct Procedural Services (-59 modifier) as follows: XE: Separate Encounter, XP: Separate Practitioner; XS: Separate Structure; XU: Unusual non-overlapping Service (These are FYI as many carriers didn t initially load these into their system and may not have yet)

19 The CMS Global Surgical Package $ $ Pre-operative Intra-operative Post-operative Minor - day of surgery (Modifier 25 is applicable) Major - day of and day before surgery (Modifier 57 Decision for Surgery-is applicable) Minor adds - 0 or 10 days of follow-up Major adds - 90 days post-op +1 day pre-op +1 day of surgery 92 TOTAL global days Modifier 24- Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period is applicable

20 Physician Queries A physician query is a method of communication used by coders to request clarification of patient diagnoses or procedures from the physician. The generation of a query should be considered when the health record documentation is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent. ( Guidelines for Achieving a Compliant Query Practice [2019 Update] ).

21 Compliant Query Practices Compliant queries should follow these guidelines: Be clear and concise Contain clinical indicators from the health record that: Are specific to the patient and episode of care Support why a more complete or accurate diagnosis or procedure is sought Support why a diagnosis requires additional clinical support to be reportable Present only the facts identifying why the clarification is required Avoid queries that: Fail to include clinical indicators that justify the query or justify the choices provided within a multiplechoice format Encourage the provider to a specific diagnosis or procedure (leading queries) Indicate the impact on reimbursement, payment methodology, or quality metrics ("Guidelines for Achieving a Compliant Query Practice [2019 Update]" )

22 Educating Providers and Staff on Documentation Improvement Clinical Documentation Pitfalls Missing documentation Lack of medical necessity Not knowing when time impacts coding Lack of specificity for disease or injury coding Lacking key component documentation Lacking (or untimely) signatures Unaware of CPT Guidelines

23 Educating Providers and Staff on Documentation Improvement Focus on the need to manage who can enter in the reasons for the patient s visits into the EHR: Does cc: get pulled in from your scheduling system? Who has access to those EHR fields? Does your system combine the CC and HPI? Who performs HPI/ROS/PFSH What about previously documented history? Know what must be documented by provider (Chief Complaint and HPI) Ancillary staff documentation is acceptable for ROS and PFSH as long as there is reference to such information in the provider note.

24 The Medical Record According to CMS, (c)(1) All patient medical record entries must be legible, complete, dated, time and authenticate in written or electronic form by the person responsible for providing or evaluating the service provided. CMS states providers should submit adequate documentation to ensure that claims are supported as billed and that each note must stand alone to support services claimed. When Incident-To billing is employed, know the rules (ex. established patients with established problems and compare scope of services). The medical record is the proof you may need to support payment and prevent claims of fraud/abuse. The medical record also serves as a legal document beyond billing to include malpractice/liability scenarios.

25 Performing Coding Audits to Uncover Learning and Revenue Opportunities Excellent educational opportunity for coding, billing, and clinical staff Improved relations between HIM/billing staff, and physicians, all revenue cycle departments Correct reimbursement to the organization Protect against fraudulent claims and billing activity Identify and correct problem areas before insurance or government payers challenge inappropriate coding Improved operational efficiency Improve data quality for external reporting and internal use Enhancement of current internal auditing efforts

26 THANK YOU!

27 Contact Information Jackie King, MSHI, CPC, COC, RH-CBS ICAHN: ARHPC:

28 References: CMS. National Correct Coding Initiative Policy Manual. Chapter 1 General Correct Coding Policies, E, Modifiers and Modifier Indicators. CPT Assistant, September 2018, Volume 28, Issue 9, page 3 Guidelines for achieving a compliant query practice (2019 update). (2019). Guidelines for Achieving a Compliant Query Practice (2019 Update) / AHIMA, American Health Information Management Association, Retrieved from