Presented by Teresa Thompson, CPC TM Consulting, Inc

Transcription

1 Presented by Teresa Thompson, CPC TM Consulting, Inc

2 I have no disclosure to report

3 Disclosure information No relevant relationships disclosed

4 Tips for Improving Your Revenue Coding Conservatively is it an issue? Co-pays are they collected Verification of insurance benefits and deductibles Fees that are not current review Diagnosis not appropriate to encounter Not coding all services hospital consults, subsequent care, procedures Timeliness of submission 4

5 Revenue Management Scheduling of patients charging for n/s? Procedures, allergy testing, oral challenges, rapid desensitization Staff overload overtime? Lack of research for best price antigens, supplies New procedures and equipment not recognized as payable by carriers Nitric oxide expired gas determination Multiple hours for oral challenges??? 5

6 Fee Schedules Read your contracts thoroughly before signing Know your reimbursement rates Will the rates change related to ACA? Ask if the carrier follows CMS guidelines What about mid level providers???? What bundling program is used are they available on the carrier website Preventive a covered benefit? 6

7 Fee Schedules What is the legal payment time for your state Does the carrier change your codes? When should you contact your insurance commissioner or medical society? What is proper for appealing claims? 7

8 Maximizing for a greater profit Review, posting & processing of EOB to patient account payment correct Following guidelines published per carrier Regular auditing & monitoring of all phases Are all charges being collected What is percentage of uncollected charges Continual education and training of all staff

9 Results? Profitable practice Patient satisfaction Staff accountability, pride and support

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11 Introduction Instructions for Use of the CPT Codebook.When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same sub-specialties as the physician A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service but who does not individually report that professional service

12 Introduction Request To Update the CPT Nomenclature Application Submission Requirements

13 Introduction General Criteria for Category I Codes- new or revised All device and drugs necessary for performance have received FDA clearance or approval when such is required for performance of the procedure or service The procedure or service is performed by many physician or other qualified healthcare professionals The procedure or service is performed with frequency consistent with the intended clinical use The procedure or service is consistent with current medical practice The clinical efficacy of the procedure or service is documented in literature that meets the requirements set forth in the CPT code change application

14 Introduction Category III Criteria The procedure or service is currently or recently performed in humans; and One of the following additional criteria has been met The application is supported by at least one CPT or HCPAC advisor representing practitioners who would use the procedure or service The actual or potential clinical efficacy of the specific procedure or service is supported by peer reviewed literature whish is available in English There is at least one Institutional Review Board-approved protocol of a study of the procedure or service being performed; a description of a current and ongoing United States trail outlining the efficacy of the procedure or service or other evidence of evolving clinical utilization

15 2014 Evaluation & Management Codes Interprofessional telephone/internet Consultations An assessment and management service which a patient s treating physician or other qualified healthcare professional requests the opinion and /or treatment advice of a physician with specific specialty expertise to assist the treating physician in the dx and/or mgmt of the patient s problem without the need for the patient s face to face contact with the consultant

16 2014 E/M Codes The timing may make face to face service with the consultant not feasible. Codes should not be reported if there is a transfer of care before the assessment Are appropriate if the transfer happens after the initial interprofessional telephone/internet consultation

17 2014 E/M Codes Patient may be a new or an established patient with a new problem or an exacerbation of an existing problem Requires no face to face encounter with the last 14 days or in the next 14 days (or next available appointment) these are codes are not reported. Greater than 50% of the service time must be devoted to the medical consultative verbal/internet discussion

18 Interprofessional telephone/internet consultations Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review

19 Interprofessional telephone/internet consultations minutes of medical consultative discussion and review minutes of medical consultative discussion and review minutes or more of medical consultative discussion and review

20 2014 CPT Changes cerumen removal requiring instrumentation, UNILATERAL (For bilateral procedure, report with modifier 50) RVU 2.92 Watch your payments for changes to RVU values since it is now a unilateral code CMS is not recognizing the code currently as a bilateral code

21 2014 CPT Changes For cerumen removal that is not impacted or does not require instrumentation, eg, by irrigation only, see E/M service codes which may include new or established patient office or other outpatient services

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23 Medicare Publication December 10, 2013 CMs has published the RVU values for 2014 Medicare Administrative Contracts have fee schedules on their websites Conversion factor for $ until March 31, 2014 Extension of Medicare Physician Work Geographic Adjustment Floor - 1.0

24 Medicare The final rule also includes several provisions regarding physician quality programs and the Physician Value-Based Payment Modifier. In 2016, the CMS will put the finishing touches on proposals to apply the modifier to groups of physicians with 10 or more eligible professionals, and to apply upward and downward payment adjustments based on performance to groups of physicians with 100 or more eligible professionals.

25 Medicare Only upward adjustments based on performance (not downward adjustments) will be applied to groups of physicians with 10 to 99 eligible professionals. Physician Quality Reporting System (PQRS) for 2014, including a new option for individual eligible professionals to report quality measures through qualified clinical data registries.

26 Medicare Physicians and other eligible professionals can report a measure once to receive credit in all quality reporting programs in which that measure is used. Data collected in 2012 for groups reporting certain PQRS measures under the Group Practice Reporting Option will be publicly reported on the CMS Physician Compare Web site in 2014.

27 CMS Changes for Meaningful Use Stage 2 would be extended through 2016; and Stage 3 would begin in 2017 for health care providers who have completed at least two years in Stage 2 of the program. According to a blog post by Robert Tagalicod -- director of CMS' Office of E-Health Standards and Services -- and acting National Coordinator for Health IT Jacob Reider, the revised timeline would offer a variety of benefits, such as: Allowing for more analysis of stakeholder feedback on Stage 2 progress and outcomes; The availability of more data on Stage 2 adoption and measure calculations;

28 CMS Changes for Meaningful Use Allowing for more consideration of possible Stage 3 requirements; Providing additional time for preparation for Stage 3 requirements; and Giving vendors adequate time to develop and distribute certified EHR technology ahead of Stage 3 and to incorporate usability and customization lessons. In the fall of 2014, CMS is expected to release a notice of proposed rulemaking for Stage 3 and ONC will release the corresponding NPRM for the 2017 Edition of ONC Standards and Certification Criteria, according to the blog post. The NPRMs will offer additional details on the new proposed timeline. The final rule on Stage 3 of the meaningful use program is expected to be released in the first half of 2015.

29 OIG Cloned EHR Records CMS said it will develop guidelines to ensure that copy-and-paste "is used appropriately." It noted that it intends to work to develop "a comprehensive plan to detect and reduce fraud in EHRs OIG Work Plan will be published in January

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31 Allergy practices and Audits Number of Test performed Number of Doses charged Medical Necessity for allergy testing and an E/M on the same calendar date Incident to services with mid levels

32 Incident To Guidelines Applicable to ALL government entities medicare, medicaid, Champus, Federal employees ---- Incident to - physician has established a plan of care for an employee to follow. Physician must be on site when the service is provided NP, PA may not supervise diagnostic test under incident to guidelines and bill the service under the physician.

33 OIG Work plan for2014 Evaluation and management services Inappropriate payments. We will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. We will also review multiple E/M services associated with the same providers and beneficiaries to determine the extent to which electronic or paper medical records had documentation vulnerabilities. Context Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the billing code for the service on the basis of the content of the service and to have documentation to support the level of service reported. (CMS s Medicare Claims Processing Manual)

34 OIG Work Plan 2014 Imaging services Payments for practice expenses Billing and Payments. We will review Medicare Part B payments for imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate.

35 OIG Work plan 2014 Physicians and suppliers Noncompliance with assignment rules and excessive billing of beneficiaries Billing and Payments. We will review the extent to which physicians and suppliers participated in Medicare and accepted claim assignment during We will also assess the effects of their participation and claim assignments on the Medicare program (such as noncompliance with assignment rules) and on beneficiaries (such as excessive billing of beneficiaries share of charges). Context Physicians participating in Medicare agree to accept payment on assignment for all items

36 OIG Work plan for 2014 Physicians and suppliers Noncompliance with assignment rules and excessive billing of beneficiaries Billing and Payments. We will review the extent to which physicians and suppliers participated in Medicare and accepted claim assignment during We will also assess the effects of their participation and claim assignments on the Medicare program (such as noncompliance with assignment rules) and on beneficiaries (such as excessive billing of beneficiaries share of charges). Context Physicians participating in Medicare agree to accept payment on assignment for all items

37 OIG Work plan for 2014 Improper Medicare payments for beneficiaries with other insurance coverage Medicare as Secondary Payer. We will identify Medicare payments made for services to beneficiaries who have certain types of other insurance coverage to assess the effectiveness of Medicare s controls to prevent such payments. We will determine whether selected non- Medicare health plans properly reported insurance coverage information to Medicare as required. Context The provisions underlying the objectives are in the Social Security Act, 1862(b), and the Medicare, Medicaid and SCHIP Extension Act of 2007, 111. (OAS; W ; various reviews; expected issue date: FY 2014; work in progress)

38 RAC Reviews and Audits RAC scope includes pre-payment fraud, waste and abuse efforts not limited to credit balance audits, incorrect billing and processing errors, and lack of medical necessity. Post payment RAC work includes data mining, medical records review, identifying overpayments

39 RAC Reviews and Audits Connelly Consulting Incorrect billing of Evaluation and Management Claims Physician Evaluation and Management Services During Same Day Global Period Place of Service Errors for Physician claims for service performed in an ASC or outpatient Hospital Place of Service Errors for Physician claims for service performed in Hospital Inpatient setting Duplicate Claims - Physician (Carrier) CMS Modifier 59 Know when you can use it appropriately Excessive Units-Untimed Codes

40 RAC and other payer audits Focusing on allergy doses and testing E/M on the same date as a testing Some allergist have been reviewed back for three years from Medicaid or Medicare. CMS may go back seven years for review Cloned records in the EHR.

41 ALLERGIST CODING CURVE National National % % % % % % % % % % 41 41

42 ALLERGIST CODING CURVE National % % % % % 42 42

43 Preparation for a RAC Audit 1. Know Where Previous Improper Payments Have Been Found: Look to see what improper payments were found by the Recovery Auditors: Demonstration findings: Look to see what improper payments have been found in OIG and CERT reports: OIG reports: CERT reports:

44 What Can Providers do? 2. Know If You Are Submitting Claims With Improper Payments: Conduct an internal assessment to identify if you are in compliance with Medicare rules Identify corrective actions to promote compliance Appeal when necessary Learn from past experiences

45 Response to RAC Request Tell your Recovery Auditor the precise address and contact person they should use when sending Medical Record Request Letters: Call Recovery Auditor take names Use Recovery Audit Programs Websites When necessary, check on the status of your medical record (Did the Recovery Auditor receive it?): Use Recovery Audit Programs Websites

46 Appeal when Necessary The appeal process for Recovery Audit denials is the same as the appeal process for Carrier/FI/MAC denials Do not confuse the Recovery Audit Programs Discussion Period with the Appeals process If you disagree with the Recovery Auditor s determination: Do not stop with sending a discussion letter File an appeal before the 120th day after the Demand letter.

47 Learn From Past Experiences Keep track of denied claims Look for patterns Determine what corrective actions you need to take to avoid improper payments.

48 Audit Response Know your risk Seek counsel if you are high risk Review your records Have a third set of unbiased eyes read the notes Respond in a timely manner Communicate with the payer performing the review. Negotiate

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50 Ancillary services Allergy testing Interpret the test because the code includes interpretation and report as part of the code. Have name and/or initials of the supervising provider on the test Nebulizer treatments, MDI instruction Separate document CT Scans, radiographs If billing for it as a separate service, there should be a report as a separate document in the chart. Scopes Separate procedure note

51 Ancillary Services Immunotherapy make sure billings for CMS are per cc limit per billing are 10 cc s Make sure there is documentation of the recipes for each patient. Document on the allergy injection record the beginning of a new vial. Document review of allergy injection record. If more than normal number of injections, make sure medical record supports the necessity of the higher number of vials manufactured.

52 Aerosol Demo/Eval pt utiliz Bronchodilation responsiveness Bronchospasm Eval - Prolonged Laryngoscopy - flexible, dx Nasal endoscopy Nasopharyngoscopy Non pressured Inhalation trmt less than 1 hour Continuous inhalation tx with RX> 1hr Continuous inhalation tx with Rx ea addt'l 1hr Oximetry, single Oximetry, multiple Pulmonary Stress Test, Simple Respiratory Flow Volume Loop Spirometry, base Vital Capacity, total (separate P.) Nitric oxide expired gas determination 95012

53 ALLERGY TESTING Puncture/Prick allergenic extract # Intradermals allergenic extract # Allergy test Prick and ID - venoms # Allergy test Prick & ID biologicals & drugs # Skin end point titration Delayed ID testing # Patch Test # Inhalation bronchial challenge with antigens Ingestion challenge test initial 120 minutes Ingestion challenge test: ea additional 60 min 95079

54 ALLERGEN IMMUNOTHERAPY Allergen-Mult. Dose # Doses Allergen - Single Dose # Venom Antigen - 1 single stinging Venom Antigen - 2 single stinging Venom Antigen - 3 single stinging Venom Antigen - 4 single stinging Venom Antigen - 5 single stinging Whole Body - biting insect Rapid Desensitization #Hr 95180

55 INJECTIONS Allergy Injection Allergy Injections Allergy Inj + Antigen Allergy Inj + Antigen Xolair Injection OTHER INJECTIONS Antibiotic Inj ( ) Immun. admin. Single with counseling Immuno admin, ea add'l. with counseling 9056` Flu Vac under 3yr pre free Flu Vac under 3yr Flu Vac 3yr +, split virus V04.81 V Flu Vac intranasal IV Med Admin push Infusion Therapy 1st hr ea. add'tl hr Pneumovax V03.82 V Therapeutic Inj

56 SUPPLIES/ MISCELLANEOUS Lab Handling Nasal Smears Solumedrol Syringes J2930 A4206 Special Reports Triamcinolone Xolair Portable peak flow meter (A4614) Peak flow expir. flow physician service Nebulizer & supplies J3301 J2357 S8096 S8110 A

57 Diagnosis Coding The diagnoses need to be specific ICD-10 is here Remember place the diagnosis with the most acuity first Acute precedes chronic Co-morbidities you need to address how the comorbidity affect the allergy/asthma issues List the co-morbidities after your dx If you code it make sure it is in the documentation Medical necessity is defined with diagnosis codes

58 Chart Auditing How to analyze your chart notes Chief Complaint make sure your note leads the reader down the appropriate path CC Patient is here for retesting for allergies HPI Make sure your HPI is for today s encounter. HPI Make sure it is clear what information is for today. Previous information is ok but only for your information. HPI The provider is required to obtain the information for the HPI.

59 Past, family and social history make sure it is applicable to the patient for your questions. ROS if the patient is filling out the information or your staff, make sure there is documentation to support the providers review of the information obtained.

60 Chart Auditing How to analyze your chart notes Exam 2014 tell the reader what you see Normal is ok but describe templates Make sure templates match the rest of the note for complaints You may use either the allergy specific or the general medical exam (1995 or 1997 guidelines)

61 Difference between a and a Comprehensive hx Comprehensive hx Comprehensive exam Comprehensive exam Moderate medical High medical decision making decision making

62 Moderate Medical Decision making (need two at same level or higher) Number of Diagnosis Amount of Data Lab 3 or more 3 or more Radiographs Medical records Medicine tests not billed Risk Moderate: Prescription drug management, undiagnosed new problem, one or more chronic conditions with mild exacerbation, progression or side effects of treatment

63 High Medical Decision Making need two at the same level or higher Number of diagnosis Amount of data Risk High: 4 or more 4 or more Drug therapy requiring intensive monitoring for toxicity One or more chronic illness with severe exacerbation, progression or side effects of treatment Acute or chronic illness or injuries that pose a threat to life or bodily function

64 Medical decision cheat sheet Two diagnosis doing well on RX allergic rhinitis and asthma; allergic rhinitis and conjunctivitis 2. one diagnosis worse on RX dermatitis not responding

65 Medical Decision making cheat sheet Three diagnosis doing well allergic rhinitis, asthma, anaphalysis to foods; or allergic rhinitis, asthma, dermatitis One new problem requiring an RX - urticaria requiring a RX One diagnosis doing well and one diagnosis not responding or worse. Both diagnoses are RX treatment allergic rhinitis worse, asthma stable

66 Medical decision making cheat sheet New problem pt acutely ill and needs labs, radiology studies, review of chart notes consultation with another health care provider. OR pt presents with additional workup planned and is high risk

67 Time Time is appropriate if more than 50% is counseling and coordination or care Document total face to face time Percentage is greater than 50% of the encounter Document the discussion with the patient.

68 CONSULT-HOSPITAL CONSULT-3 of NEW PT- 3 of HISTORY CHIEF COMPLAINT Required Required Required Required Required HX of PRESENT ILL Brief(1-3) Brief(1-3) Extended(4+) Extended(4+) Extended(4+ REVIEW OF Problem Extended Complete Complete SYSTEMS Pertinent (1) (2-9 System) (10 + system) (10+ system) PAST HX Pertinent-1 Complete-1ea Complete-1ea FAMILY HX Pertinent-1 Complete-1ea Complete-1ea SOCIAL HX Pertinent-1 Complete-1ea Complete-1ea Perform/ Perform/ Perform/ Perform/ Perform EXAM document document document document document 1 organ sys 2-4 organ sys 5-7 organ sys. 8 organ systems 8 organ systems MED. DEC MAKING (2 of the 3 must be met or exceeded) MGMT OPT. & DX. Minimal (1) Minimal (1) Limited (2) Multiple (3) Extensive(4) AMT DATA &COMPLEX Minimal(1) Minimal (1) Limited (2) Moderate (3) Extensive(4) RISK OF COMPLICAT. Minimal Minimal Low Moderate High

69 ESTABLISH PT 2 OF HISTORY CHIEF COMPLAINT Required Required Required Required Required HX PRESENT ILL. Brief Brief Extended Extended SYSTEM REVIEW Prob. Pertinent Extended Complete PAST HISTORY Pertinent-1 Complete: FAMILY HISTORY Pertinent-1 Choice of 2 SOCIAL HISTORY Pertinent-1 ele PFS Hx. Perform/ Perform/ Perform/ Perform/ EXAM document document document document 1-3 systems 4-6 systems 5-7 systems 8 systems MED. DEC MAKING MGMT/OPTION DX Minimal (1) Limited (2) Multiple (3) Extensive(4) AMT DATA/COMPLEX Minimal(1) Limited(2) Moderate(3) Extensive(4) RISK OF COMPLICAT. Minimal Low Moderate High

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72 Questions??? Thank you,