Coding Opportunities and Challenges. Richard H. Tuck, MD, FAAP. Richard H. Tuck, MD 1/1/12

Transcription

1 Coding 2013 Opportunities and Challenges Richard H. Tuck, MD, FAAP Richard H. Tuck, MD 1/1/12

2 Disclosure I have financial relationships or interests with proprietary entities producing health care goods or services related to the content of this CME activity. I am Consulting Editor of Pediatric Coding Alert for Eli Health Care. I serve on the speakers bureau for Sanofi Pasteur. My content will not include discussion/ reference of commercial products or services. I do not intend to discuss an unapproved/ investigative use of commercial products/devices.

3 IMPORTANCE OF ACCURATE APPROPRIATE CODING INCREASED PAYMENT DECREASED LIABILITY IMPROVED INFORMATION FLOW

4 What s New for 2013? CODES - New CPT/ICD Codes VALUE- RBRVS New RVU s and CF PAYER PAYMENT- AAP Private Sector Advocacy Program State Pediatric Councils National Class Action Law Suits PATIENTS- Covered Benefit Consumer Driven Health Care YOUR CONTRACT- Pay for Performance Clinical Integration, ACOs

5 CODING CHANGES 2013

6 2013 CPT Changes Revision inclusion/ exclusion provider/professional type instructions Observation services assigned typical times Interfacility transport supervision care codes Neonatal/pediatric critical care guideline changes Complex care and transitional care services codes Vaccine code changes New psychotherapy codes Pharmacologic management revised

7 2013 CPT Changes Revisions to cardiology section Allergy instructions and codes revised New codes for pediatric polysomnography Infusion and IV push examples Revision of vision screening code

8 Other Qualified Health Care Professional Almost all CPT code descriptors and specific instructions revised to consistently reflect the inclusion/exclusion of provider type Also revised to consistently reflect inclusion of a qualified health care professional when word physician is included

9 Observation or Inpatient Care Services (Including Admission and Discharge Services) Code History Exam Decision Making Detailed or Comprehensive Detailed or Comprehensive Straightfd or Low Complexity Comprehensive Comprehensive Comprehensive Comprehensive Mod Complexity Time/ Floor High Complexity Key # 3 of 3 3 of 3 3 of 3

10 Non Face to Face Physician Online evaluation and management service provided by a physician to an established patient or guardian, health care provider not originating from a related E/M service in previous 7 days, using the internet of similar electronic communications network

11 Pediatric Critical Care Patient Transport To report the control physician non face-to-face suprervision of interfacility transport of critically ill/injured patient < 24 months of age Includes two way communication prior to transport, during transport with team, not with facility Time from first contact with team, ends when care handed over to receiving facility team

12 Pediatric Critical Care Patient Transport Supervision by control physician of interfacility transport, < 24 months of age, first 30 minutes (do not report <15 minutes) Each additional 30 minutes Over 24 months of age, or any age if not critically ill or injured

13 Neonatal Intensive Care and Pediatric/Neonatal Critical Care Services 99468,99469 Neonatal/Pediatric Critical Care Reported by a single individual physician, per hospital stay, in a given facility If readmitted, report for first day of readmission reported in addition to (delivery attendance), (resuscitation)

14 Pediatric/Neonatal Critical Care Services Two separate institutions: Referring individual physician to use time-based critical care codes (99291,99292) Receiving physician to use initial day critical care codes if child <6 years if age If transferred to lower level of care different physician same facility, transferring physician does not report per day critical care, receiving physician report subsequent intensive or hospital care

15 Pediatric/Neonatal Critical Care Services Neonate or infant becomes critically ill day when intensive care services, hospital, or nl newborn services have been performed. Different physician, different group Transferring reports one service only (critical, intensive, hospital care, nl newborn) Receiving reports initial or subsequent critical care Newborn becomes critically ill same day received nl nb care, same physician/group reports initial critical care with -25 modifier on critical care code

16 Initial/Continuing Intensive Care Neonate becomes critical after seen as intensive same day, to different group Transferring physician reports time based critical care or intensive care, not both Receiving physician reports initial or subsequent critical care based on age Neonate becomes critical after intensive same day same group, report either intensive or critical care

17 More CPT 2013 Changes Pneumocentesis and thoracentesis codes ( ) deleted ( ) replaced, designating same procedures performed with or w/o imaging Laboratory 87910, 87912, New tests using nucleic acid probe for detection for CMV, Hepatitis B

18 Vaccines, Toxoids Influenza vaccines trivalent (current vaccines) 90672, Influenza vaccines quadrivalent (FDA approval pending) deleted (DTP - whole cell pertussis) deleted (Td)

19 Psychiatric Services or Procedures Pharmacologic management, including prescription review of medication, when performed with psychotherapy services (Use in conjunction with 908P10, P20, P30) Can also use with appropriate E/M codes Do not double count time deleted Pharmacologic management with no more than minimal psychotherapy

20 Sleep Services All sleep services ( ) include recording, interpretation, and report -52 modifier if, 6 or 7 hours recording (code specific) or if <4 nap opportunities

21 Sleep Services Polysomnography - any age age > 6 years age > 6 years (with initiation of ventilation) < 6 years < 6 years (with initiation of ventilation)

22 Ocular Screening Instrument based ocular screening (eg photoscreening, automated-refraction, bilateral) Do not report in conjunction with other vision screening automated or semiautomated screening test, quantitative, bilateral

23 Allergy Testing Percutaneous tests (scratch, puncture, prick) Intracutaenous (intradermal) Any combination percutaneous and intracutaneous, with venoms Any combination percutaneous and intracutaneous, with drugs or biologicals

24 Allergy Testing Ingestion challenge test, initial 120 minutes of testing Each additional 60 minutes of testing

25 Complex Care Coordination Services Provided by physicians, other QHCP, and clinical staff Involve care plan directed by physician or other QHCP Address coordination of care by multiple disciplines and community agencies Address services for medical conditions, psychosocial needs, and activities of daily living

26 Complex Care Coordination Services Complex chronic care coordination services; first hour of clinical staff time, directed by physician or other QHCP, no f to f visit, per calender month with one face-to-face visit, per calender month each additional 30 minutes, per calender month

27 Transitional Care Management Services (TCM) Established patient requiring mod or high complexity decision making during transitions from inpatient hospital setting, partial hospital, observation, or skilled/nursing facility to patient s community setting (home, domiciliary,assisted living) TCM commences on date of discharge Continues for next 29 days

28 Transitional Care Management Services (TCM) Transitional Care Management with: Communication with pt or caregiver within 2 business days of discharge Minimum of moderate complexity decision making Face to face visit within 14 calender days of discharge Transitional Care Management with: As above but requiring: high complexity MDM Face to face visit within 7 calender days of discharge

29 Increased RVU s 2012 Preventive Medicine New % Increase Est % Increase % % % % % % % %

30 Increased RVU s 2012 Newborn Care % Increase Initial NB 64% Subs NB 35% SD Ad/Disch 42%

31 2013 ICD Changes? NONE! Freeze on ICD-9 and ICD-10 changes in anticipation of ICD-10 implementation in October 2013, now October 1, 2014

32 ICD-10-CM Will become effective October 1, 2014 NO EXCEPTIONS if you are a covered entity under HIPAA. Currently there is a freeze on new ICD-9-CM and ICD-10-CM codes to prepare for the changeover. AAP webinar February 9, 2012, addresses ICD-10-CM.

33 ICD-10 A CHANGE FOR THE BETTER!

34 Value to Providers More accurately reflects the acuity of the patient population More accurately reflects application of advances in medical knowledge Improved visibility into population health/risks Better defined and automated referrals and approvals More detail for preauthorization medical review

35 Vaccine ICD-10 Coding ICD-10 effective October 1, 2014 Preventive Care V20.2 crosswalks: Z w/o abnl findings Z with abnl findings Vaccine product V codes all crosswalk to one ICD-10 code: Z23, encounter for immunization Vaccination not carried out (V V64.09) crosswalk with Z28.20-Z28.9 codes

36 Transition: What you can do now? Communicate the implementation process with everyone! Look at the current systems/resources that exist Determine workflow and process changes Review your EMR/HER programs to verify they are ICD- 10-CM ready and what steps you have to take to update If you don t have an EMR or billing program look in to one that supports ICD-10-CM Capability to run both codes a bonus Look at costs of the change-over and start planning now

37 Transition: What you can do now? Encourage your physicians to document and use more specific codes Especially those who tend to use unspecified codes or whose documentation leads to an unspecified code Work with those physicians on their documentation and in areas where you know more documentation is needed (e.g. Otitis Media) Remember that all HIPAA covered entities are required to adhere to the transition to ICD-10-CM So do you!

38 ICD-10-CM + Leverage your investment Move beyond mere compliance to achieve strategic advantage

39 ICD-10 GEMs General Equivalence Mappings Tool for converting ICD-9-CM databases to ICD- 10-CM or ICD-10-PCS Backward and forward mapping Move to coding books and encoder systems October 1, 2014

40 AAP ICD-10 Crosswalks

41 Immunizations How are you doing? Challenges? Successes!

42 Immunizations Bill and Document ALL: E/M Visit» Office Visit, Preventive Medicine Immunization Administration» » in 2011 ( deleted) Vaccine/Toxoid» Link to ICD Diagnoses V20.2 Well Child CSHCN Diagnosis + Specific Vaccine V Codes (V06.8- combination vaccines)

43 EXISTING CPT CODES 2000 Vaccine Administration Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) 90474

44 CPT 2011 Effective January 1, 2011 NEW Pediatric Immunization Administration Codes Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component Each additional vaccine/toxoid component (List separately in addition to code for primary procedure)

45 CPT 2011 Effective January 1, 2011 Immunization Administration What is a vaccine component? A component refers to antigen in a vaccine that prevents disease (s) caused by one organism Combination vaccines contain multiple vaccine components IPV one component MMR three components DTaP-Hib-IPV five components

46 Counseling Counseling: Giving the parent the VIS sheet Discussing concerns, pros and cons Management of any reactions Dosing acetaminophen/ ibuprophen Answering any other questions Documentation is a must! Counseled on vaccines and vaccine components

47 Other Qualified Health Care Professional CPT 2012 now defines this as A physician or other qualified health care professional is an individual who by education, training, licensure/regulation, and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports a professional service. These professionals are distinct from clinical staff. A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service. Other policies may also affect who may report specified services.

48 Other Qualified Health Care Professional 2012 What does that mean? Clinical staff (eg, RNs, LPNs) can no longer have codes (immunization administration) reported to represent when they counsel patients or parents/guardians on vaccines. If clinical staff performs counseling, you must report a code from the series as appropriate.

49 CPT 2011 Effective January 1, 2011 NEW Pediatric Immunization Administration Codes To report a single component vaccine, use To report a multiple component vaccine (combination vaccine), use for the first component, and for each additional component in the combination vaccine Example: DTaP-Hib-IPV vaccine: After January 1,2011: 90460, X 4 Link combination vaccines to V06.8

50 Vaccine Administration RVUs Values - Existing codes RVU 2012 medicare RVU 2012 medicare / $ / $ / $ / $ Values - New codes / $ / $12.59

51 CPT 2012 Effective January 1, 2011 NEW Pediatric Immunization Administration Codes Payment comparison PENTACEL Dtap/IPV/Hib ICD V06.8 Old codes: $ , X 2 $48 for 3 separate vaccines New codes: 90460, X 4 $77

52 /1/2011 IA Summary Implemented Deleted Unchanged Use when no counseling is provided Patient 19 years of age Provider not other qualified health care professional In addition to IA, code vaccine toxoid code

53 CDC Update on Vaccine Storage Interim Guidance 40,000 VFC sites Studies showing problems with storage and handling of VFC vaccines Providers are responsible for losses AAP response pending related to increased costs of vaccine delivery

54 Increased documentation CDC Requirements Recording temperature 2X per day Recording each morning min and max temps over previous 24 hours Replace glass thermometers with data logging monitors with thermal buffer/ 24/7 recording Elimination combination refrigerator/freezers Certification of temp monitoring devices Phone enabled monitor to report temperature excursion

55 CDC Requirements Domestic refrigerator only still acceptable Specific storage recommendations Vaccines 2-3 inches from walls Away from direct air flow Water bottles to mitigate temp variation Avoid top shelf

56 QUESTIONS? STUMP THE CODER!

57 Upcoming Strong4Life Provider Trainings November 27 th, 2012 Satellite Blvd Neighborhood Location 6:00-8:00pm November 29 th, 2012 North Point Urgent Care 6:00-8:00pm December 12 th, 2012 Scottish Rite Mini Auditorium 6:00-8:00pm