Learn Connect Succeed. JCAHPO Regional Meetings 2017

Transcription

1 Learn Connect Succeed JCAHPO Regional Meetings 2017

2 Financial Disclosure Histories That Make Your Physicians and Payers Proud (and Your Patients Happy too) Matthew Baugh, MHA, COT, OCS, OSC Revenue Integrity Coordinator Moran Eye Center I have no financial interests or relationships to disclose. Presented by: Matthew Baugh, MHA, COT, OCS, OSC Friday, March 3, 2017 Course Objectives / Outline Requirements for and differences between E/M (Evaluation and Management) vs Eye visit codes for ophthalmology Elements of a history from a coding perspective with common limiting factors and how to prevent them Course Objectives / Outline How to perform self chart audits on histories How to determine the correct level of coding Did You Know? Histories impact surgeries and procedures too. Course Objectives / Outline Why is the history so important? It continues to be the #1 reason charts are down-coded in an audit! Requirements for E/M and Eye Visit Codes 1

3 E/M vs. Eye Visit Codes Ophthalmologists have two sets of exam codes (office based) from which to choose. Evaluation and Management (99XXX) and Eye visit codes (92XXX). E/M Codes 99XXX E/M & Eye Visit Codes - What sets them apart? Documentation is standardized and nationally recognized by all payers. No frequency edits as to how often a level of code may be billed. Eye Codes 92XXX Documentation may vary by state and by payer. Frequency edits for non-medicare payers. Example: CPT code may only be billed once within a 12-month period. No frequency edits for Medicare payers. Unrestricted diagnosis coverage. Official audit form. No official audit form. Typically used for medical exams. Limited list of covered diagnosis codes that may vary by payer. Typically used for vision exams depending upon the payer rules. Eye Visit Codes Histories for Eye visit codes Eye Code History Requirements Intermediate Examination and Comprehensive Examination and History Components? Can include: CC and HPI ROS PFSH History Evaluation and Management History Requirements Remember: The #1 reason charts are down-coded in an audit 4 components of a complete History 1. Chief complaint 2. HPI 4. PFSH YOU are instrumental in history taking and elements of the exam 2

4 1. Chief Complaint The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factors for the reason for the encounter. Is the reason for today s exam. Drives which elements of the exam are performed. Does not necessarily have to be in the patient s own words. If there are multiple reasons for the encounter, list them in order of medical necessity. 1. Chief Complaint Should meet the documentation requirements of the payer, and Should also tell the physician what he/she needs to know. The primary diagnosis should relate to the chief complaint. 1. Chief Complaint Coding Clues: A chief complaint is required for all levels of service. Do not use the term follow-up or F/U without expanding upon the reason for the follow-up. 2. History of Present Illness (HPI) Chronological description of the development of the patient s present illness (CC) from the first sign or symptom to the present. 2. History of Present Illness 1. Location: Right eye, left eye, both eyes? 2. Quality: Is the nature of the problem constant, acute, chronic, improved or worsening? 5. Duration: How long has the issue been a problem? 6. Context: Associated with any activity? 2. HPI for Established Patients Or, for established patients, you can also document the status of three chronic or inactive conditions. 3. Severity: On a scale of 1-10 Mild, moderate, severe 7. Modifying factors: What efforts have been made to improve the problem? 4. Timing: Worse in am or pm? Onset? 8. Associated signs and symptoms: Is the problem causing blurred vision, twitching, headache? 3

5 Coding Clues: At least 10 organ systems must be reviewed (out of 14 possible) for comprehensive exams (99204, 99205, 99214, 99215) Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. Constitution Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Fever, weight loss, cancer Sudden loss or change, distortion, double vision, itching, redness, discharge, swelling of lids Sinus infection, dry mouth, deafness High blood pressure, circulation problems, cholesterol treatment, heart attack Asthma, emphysema, TB Gastrointestinal Musculoskeletal Neurological Endocrine Hematologic/lymphatic Allergic/immunologic Acid Gerd, hepatitis Arthritis Stroke, MS, HOH Diabetes, thyroid Infection Seasonal allergies, hay fever 3 additional systems: 1. Genitourinary 2. Integumentary 3. Psychiatric Note: May add more or less questions in each category based on specialty practice. When medically necessary, the data may be referenced and updated at each visit. ROS no change since (date). ROS no change except since (date). For EHR: - Update ROS and record in chart note. - Typically shows current ROS. - Exclude if not reviewed at that visit. 4

6 4. Past, Family, and Social History (PFSH) Past history documentation may include information regarding: - Prior illnesses and injuries - Prior operations - Prior hospitalizations - Current medications - Allergies 4. PFSH Family history documentation may include information regarding: - Disease of family member that may be hereditary or place the patient at risk, such as diabetes, amblyopia, retinal detachment, AMD, and glaucoma - Specific diseases related to problems identified in the CC or HPI 4. PFSH Social history documentation should include information regarding: - Use of drugs, alcohol, and tobacco 4. PFSH May also include: - Current employment/student status - Developmental history - Marital status - Driving status - Other relevant social factors - Language preference 4. PFSH 4. PFSH All three of the histories must be present for a new patient or consultation. Two of three histories must be present for an established patient. Information should be referenced and updated at each visit. - PFSH no change since (date). - PFSH no change except since (date). 5

7 History Is there any reason not to have a comprehensive history for each new patient encounter? - This is your best effort for not having the chart down-coded. Note: A comprehensive history on every established patient may inflate the level of examination documented. Difference in reimbursement for Level 4 E/M compared to Comprehensive Eye Code (Medicare) New Patient = +$15 Return Patient = - $17 Test Your Knowledge Test Your Knowledge #1 Eye visit codes require standardized documentation and are nationally recognized by all payers. True False Test Your Knowledge #2 Which of the following is not an element of HPI for E/M codes: A. Severity B. Timing C. Duration D. Cause Test Your Knowledge #3 Which of the following is not one of the key components of History for an E/M code: A. HPI B. CC C. ROUS D. PFSH Test Your Knowledge #4 Which of the following is not true about Review of Systems (ROS): A. Must be obtained from a physician B. Obtained by asking a series of questions or questionnaire C. A reason must be documented if unobtainable D. There are a total of 14 systems that can be reviewed 6

8 Elements of History from Coding Perspective with and How to Prevent Them Histories and Coding 1. Chief Complaint (CC) At least one distinct CC is required It is either there or it is not Primary diagnosis reported on the billing sheet should be linked to the main CC in the history potion of the exam. Reminder that every diagnosis that the patient has does not need to be listed in the history or diagnosis portion of the billing sheet. Sometimes more is just more. 1. Chief Complaint (CC) Not clearly stated Prevention Do not leave room for ambiguity Limiting factor is often the patient that does not have a CC Everything is good and no new changes Prevention Detective work Order of operations CC after elements of the exam? 1. Chief Complaint (CC) Routine eye exam or annual eye exam? Prevention Identify the payer Medical vs. vision 1. Chief Complaint (CC) Will the payer pay for a routine or annual? Medicare Part B does not cover routine eye exams Is there a medical reason for the exam? Histories and Coding 2. History of Present Illness (HPI) Brief HPI = 1 to 3 elements documented Extended HPI = 4 to 8 elements documented Other option for Extended HPI for established patients only is the documentation of the status of 3 or more existing (chronic or inactive) conditions. 7

9 2. History of Present Illness Number of HPI elements clearly documented Prevention Always document at least 4 elements Vision is (#1 Quality) in (#2 Location) at (#3 Timing) when (#4 Context), for (#5 Duration) Histories and Coding 3. Review of Systems (ROS) None Problem Pertinent ROS = 1 (Eyes) Extended ROS = 2 to 9 systems reviewed Complete ROS = 10 or more systems are reviewed Vision is blurry (1) in right eye (2) at night (3) when reading (4) for the past three months (5) 3. Review of Systems Number of correctly reviewed ROSs when an ROS is marked positive in order to receive credit documentation must be provided stating what is being done to resolve the problem Prevention Education for understanding and then provide necessary documentation Examples for your review: Patient says he or she has asthma, supporting documentation could note that the patient carries an inhaler. 3. Review of Systems Incorrect use of all others negative You should not document fewer than 10 systems and then indicate all others negative in order to meet the requirement. The same is true with an electronic medial record and its own all others negative statement. If you just ask about eyes and diabetes and nothing else that is only two systems. Additional Coding Tips - ROS 3. Review of Systems Complete a comprehensive ROS on each new patient. To save time, offices can mail, or fax a systems questionnaire to the patient for completion before the new patient visit. Give to them at check in? For established patients, you may not always need a comprehensive ROS Histories and Coding 4. Past, Family, and Social History (PFSH) None Pertinent History = only 1 of the 3 is documented Complete History = all 3 of the histories are documented 8

10 4. Past, Family, and Social History (PFSH) Incorrect histories reviewed All 3 histories must be present for a new patient or consultation. At least one of the 3 histories should be documented for established (review of current medications) Prevention Education for understanding and correct documentation Test Your Knowledge Test Your Knowledge #5 There are three possible coding levels of the Chief Complaint (CC). True False Test Your Knowledge #6 The more documentation that you have = better documentation. True False Test Your Knowledge #7 Which of the following is true concerning the coding levels for HPI: A. Extended = at least 4 elements B. Extended = at least 3 elements C. Extended = Documenting the status of 3 or more chronic or inactive conditions for an established patient D. Extended = Documenting the status of 3 or more chronic or inactive conditions for a new patient Determine the Correct Level of Exam 9

11 Eye Codes All Eye visit codes require history but they are not a determining factor of which code to use intermediate new patient comprehensive new patient intermediate established patient comprehensive established patient Evaluation and Management (E/M) Codes Histories are a determining factor of the level of exam Determined by the level of each of the 4 history components Review of Histories and Coding (for E/M Codes) 1. Chief Complaint Present or not? 2. HPI Brief (1 to 3) Extended (4 to 8)? None Problem Pertinent (eyes are only reviewed) Extended (2 through 9) Complete (10 or more) Review of Histories and Coding (for E/M Codes) 4. Past, Family, Social History No PFSH present Pertinent (1) Complete (all 3 for New or 2 or for Established patient) Review of Histories and Coding (for E/M Codes) Determine Level of History = 1. Circle type of HPI, ROS, and PSFH. 2. Circle the farthest option to the right when a type of element is listed at two levels. 3. Type of history is determined by the column with a circle that is farthest to the left. Level of History Components and Type of History HPI Brief Brief Extended Extended ROS None Problem pertinent Extended Complete PFSH None None Pertinent Complete Type of History Problem Focused Problem Expanded Detailed Comprehensive 10

12 New Patient E/M Codes (9920X): If the Level of History is: Problem Focused = the highest possible code is Expanded = the highest possible code is Detailed = the highest possible code is Comprehensive = the highest possible code is (99205) The Level of Exam is directly related to the Level of History (Limiting Factor) for New Patients Established E/M Codes (9921X): If the Level of History is: Problem Focused = the highest possible code is Expanded = the highest possible code is Detailed = the highest possible code is Comprehensive = the highest possible code is The level of exam is NOT directly related to the level of history (not the only Limiting Factor) for Established Patients Determination of E/M code is also based on : Examination and Medical Decision Making For the purpose / scope of this presentation we are looking specifically at how histories help determine the level of exam Test Your Knowledge Test Your Knowledge #8 What is the level of history based on the type of HPI, ROS, and PFSH for the following example? a) CC/HPI: Annual Exam, blurry vision ou, distance and near all the time especially at night. b) ROS: Eyes are positive and no other systems are marked c) PFSH: patient smokes Level of Exam based on Histories Level of History Components and Type of History HPI Brief (1 3) Brief (1 3) Extended (4 8) Extended (4 8) ROS None (0) Problem Pertinent (1) Extended (2 9) Complete (10 or more) PFSH None None Pertinent (0) (0) (1) Complete (2 for Established) (3 for New) Type of History Problem Focused Problem Expanded Detailed Comprehensive 11

13 Test Your Knowledge #8 a) Problem Focused b) Problem Expanded c) Problem Detailed d) Comprehensive Test Your Knowledge #9 Patient in last example is a new patient. The highest level of E/M code is: a) b) c) d) Test Your Knowledge #10 What is the Level of History for the following HPI, ROS, and PFSH? a) CC/HPI: Glaucoma check OU. b) ROS: Eyes and Endocrine are positive with no other documentation. c) There is a positive check mark next to PFSH. Level of Exam based on Histories Level of History Components and Type of History HPI Brief (1 3) Brief (1 3) Extended (4 8) Extended (4 8) ROS None (0) Problem Pertinent (1) Extended (2 9) Complete (10 or more) PFSH None None Pertinent (0) (0) (1) Complete (2 for Established) (3 for New) Type of History Problem Focused Problem Expanded Detailed Comprehensive Test Your Knowledge #10 a) Problem Focused b) Problem Expanded c) Problem Detailed d) Comprehensive Test Your Knowledge #11 Patient in last example is an established patient. The highest level of E/M code is: a) b) c) d)

14 Test Your Knowledge #12 Patient in last example is an established patient. Possible EYE CODEs for this patient are: a) b) c) d) Did You Know? Your Histories can impact how surgeries and procedures are billed out? Example Cataract Surgery What is one major documentation requirement by all payers for Cataract Surgery? Documented in the HPI or progress note of the exam. If not present claims can be denied and or recoupment during an audit. More than just a symptom! Example Injections and Exams Can an intravitreal injection and exam be billed out on the same day? Why or Why not? Documentation? Modifier? Any minor procedure (lasers, biopsies, plugs) or just injections? Proud Physicians Proud Physicians Proud Payers Happy Patients Physicians are proud of their technician staff when they receive all the information that they need to take care of the patient from the documented histories and do not have to worry about the histories being the limiting factor for the level of exams. What are your Patients telling your Physicians about you and your history taking? 13

15 Proud Payers Understanding what the requirements are for different levels of history and realizing how this impacts the overall level of exam will help you to minimize coding mistakes (up coding and under coding) which will in turn minimize rejected or returned claims. Happy Patients Pertinent histories will help patients efficiently receive the care that they need at the right level of service. Questions 14