Office of Billing Compliance: Coding, Billing & Documentation Department of Optometry

Transcription

1 Office of Billing Compliance: Coding, Billing & Documentation 2016 Department of Optometry

2 Why Are We Here? To EDUCATE and PROTECT our providers and organization To provide your department/practice with every tool you need to maximize compliance and get paid what you deserve To update you on the latest CMS/OIG activities related to your specialty To give you confidence in your coding and documentation! 2

3 2016 Code Changes

4 New Codes For 2016 Code Changes - Eye & Ocular Adnexa Implantation of intrastromal corneal ring segments The 2016 CPT code set adds to report a new procedure, intrastromal corneal ring segment implantation. Use to report when the provider implants thin semicircular or crescent-shaped soft plastic rings into channels created in the outer edges of the cornea (the transparent covering on the front of the eye) to correct its shape. The provider performs this procedure to treat keratoconus, a degenerative disease that changes the shape of the cornea and results in distorted vision, or to treat mild to moderate nearsightedness (myopia). 4

5 Revised CPT Codes Trabeculoplasty by laser surgery; Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), cryotherapy, diathermy; Treatment of extensive or progressive retinopathy (e.g., diabetic retinopathy), photocoagulation. The one or more sessions verbiage was removed from these three procedures. 5

6 Revised CPT Codes The following codes contain language changes reflected by underlines: Repair of retinal detachment, 1 or more sessions; cryotherapy or diathermy, including drainage of subretinal fluid when performed; photocoagulation including drainage of subretinal fluid, when performed; Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), including, when performed, implant, cryotherapy, photocoagulation, and drainage of subretinal fluid; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique; 6711 Repair of complex retinal detachment with vitrectomy and membrane peeling including, when performed, air, gas, or silicone oil, tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens; Instrument-based ocular screening (e.g., photo screening, automatedrefraction), bilateral; with remote analysis and report. 6

7 Why Does Documentation Matter? IT S OUR AGREEMENT WITH MEDICARE AND OTHER INSURANCE COMPANIES CORRECT CODING PRACTICE IS PART OF GOOD MEDICAL CARE CIVIL AND CRIMINAL VIOLATIONS ARE HANDED DOWN EACH YEAR FOR FRAUDULENT CODING MILLIONS OF DOLLARS ARE LOST EACH YEAR TO POOR CODING PRACTICES 7

8 8 Visit Coding Decision Optometrists can select either the eye codes or E/M visit codes for their services. Choosing Correct Codes Most Optometrists prefer using the Eye Codes, believing they are easier to use and more audit-proof. That is not necessarily so. If you use only eye codes, not only are you punishing yourself financially, but you also may be found to be upcoding or downcoding under audit. For example, the intermediate eye code for established patients (CPT code 92012) is not always suitable for coding frequent follow-ups such as follow-up examination for corneal abrasion. (The correct code for healing corneal abrasion often usually is E/M code 99212). The Center for Medicare and Medicaid Services (CMS) wants you to code correctly to neither upcode nor downcode. Typically eye codes are billed in the OP setting for visits related to routine eye follow-ups or complaints. E/M codes are usually billed for specific eye injury, complaint or IP services.

9 Nuts and Bolts of E&M Coding THE THREE KEY DOCUMENTATION ELEMENTS MEDICAL DECISION-MAKING HISTORY PHYSICAL EXAM How does medical necessity fit into these components? Knowing the answer to this question will help you to select E/M codes and reduce audit risk. 9

10 Important! The Nature of the Presenting Problem (NPP) determines the level of documentation necessary for the service The level of care (E&M service) submitted must not exceed the level of care that is medically necessary SO... Medical Decision-Making and Medical Necessity related to the NPP determine the maximum E&M service. The amount of history and exam alone do NOT. 10

11 History / Physical Exam / Medical Decision-Making NEW PATIENT = OUT OF ELEMENTS IMPORTANT! ESTABLISHED PATIENT = 2 OUT OF COMPONENTS (MDM PLUS APPROPRIATE HISTORY OR EXAM) 11

12 Medical Decision Making (MDM) DOCUMENT EVERYTHING THAT EFFECTS YOUR SERVICE TODAY!! Step 1: Step 2: Number of possible diagnoses and/or management options affecting todays visit. List each separately in A/P and address every diagnosis or management option from visit. Is the diagnosis and/or management options : New self-limiting: After the course of prescribed treatment it is anticipated that the diagnosis will no longer be exist (e.g. otitis, poison ivy, ) New diagnosis with follow-up or no follow-up: Diagnosis will remain next visit Established diagnosis that stable or worse Amount and/or complexity of data reviewed, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed. Labs, radiology, scans, EKGs etc. reviewed or ordered Review and summarization of old medical records or request old records Independent visualization of image, tracing or specimen itself (not simply review of report) Step : The risk of significant complications, morbidity, and/or mortality with the patient s problem(s), diagnostic procedure(s), and/or possible management options. # of chronic conditions and are the stable or exacerbated (mild or severe) Rxs ordered or renewed. Any Rx toxic with frequent monitoring? Procedures ordered and patient risk for procedure Note: The 2 most complex MDM steps out of the will determine the overall level of MDM 12

13 Medical Decision-Making 1. Number of Diagnoses or Treatment Options One or two stable problems? No further workup required? Improved from last visit? = LOWER COMPLEXITY Multiple active problems? New problem with additional workup? Are problems worse? = HIGHER COMPLEXITY 1

14 Medical Decision-Making 2. Amount/Complexity of Data Were lab/x-ray ordered or reviewed? Were other more detailed studies ordered? (Echo, PFTs, BMD, EMG/NCV, etc.) Did you review old records? Did you view images yourself? Discuss the patient with consultant? 14

15 Medical Decision-Making. Table of Risk Is the presenting problem self-limited? Are procedures required? Is there exacerbation of chronic illness? Is surgery or complicated management indicated? Are prescription medications being managed? 15

16 OPTOMETRY TABLE OF RISK Presenting Problem Diagnostic Procedure(s) Ordered Management Options Selected Min One self-limited / minor problem (subconjunctival Hemorrhage) Low 2 or more self-limited/minor problems 1 stable chronic illness (controlled glaucoma) Acute uncomplicated illness / injury (simple sprain) Mod 1 > chronic illness, mod. Exacerbation, progression or side effects of Tx 2 or more chronic illnesses Undiagnosed new problem w/uncertain prognosis (red eye) Acute illness w/systemic symptoms (facial palsy with corneal exposure) Acute complicated injury High 1 > chronic illness, severe Exacerbation, progression or side effects of Tx Acute or chronic illnesses that may pose threat to life or bodily function (trauma, endophthalmitis, retinoblastoma, malignancies, angle closure) Abrupt change in neurologic status (TIA, seizure) Tonometry PAM Contrast sensitivity Schimir s test MDM Topical Step diagnostic agent : (rose Risk bengal) Ultrasound Color Vision Visual field Lab tests requiring venipuncture Gonioscopy Ophthalmodynamometry Conjunctival culture Oral FA Provocative glaucoma test MRI/MRA Corneal Culture Retrobulbar injection Deep needle biopsy or incisional biopsy Physiological stress tests Vitreous tap Anterior Chamber tap Fine needle biopsy orbital, ocular 16 Rest Elastic bandages Gargles Superficial dressings OTC meds Minor surgery w/no identified risk factors Occlusion Pressure Patch IV fluids w/out additives Prescription meds Minor surgery w/identified risk factors Elective major surgery w/out risk factors Therapeutic nuclear medicine IV fluids w/additives Elective major surgery w/risk factors Emergency surgery Parenteral controlled substances Drug therapy monitoring for toxicity DNR

17 Medical Necessity Ignoring how medical decision-making affects E/M leveling can put you at risk. According to the Medicare Claims Processing Manual, chapter 12, section 0.6.1: Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. That is, a provider should not perform or order work (or bill a higher level of service) if it s not necessary, based on the nature of the presenting problem. 17

18 Medical Necessity The definitions of medical necessity are important, but it s how they get applied in the claims adjudication process that gives them shape. In other words, when it comes to selecting the appropriate level of care for any encounter, medical necessity trumps everything else, including the documentation of history, physical exam. For physicians this could mean that even bullet-proof documentation of these key components will not ensure protection if auditors find that the medical necessity is lacking. 18

19 Medical Necessity The best way to stay within the bounds of medical necessity is to think of each element of the history and physical exam as a separate procedure that should be performed only if there is a clear medical reason to do so. Each component of the history would yield clinically relevant information. First, you would take an extensive history of the present illness (HPI) to further describe the NPP. Ask about the patient s PMH to identify potential risk factors. Ask about FH if it would affect your decisions that visit. Finally, because the spectrum of differential diagnoses for this problem is so broad, you would be justified in performing a complete review of systems (ROS) to uncover clues that may point you in the right medical direction. 19

20 Medical Necessity The same logic applies to performing a comprehensive physical exam on this patient. Because the etiology of the issue or NPP is unknown or unstable, sound medical practice would dictate that a comprehensive exam be performed to help guide diagnosis and treatment. 20

21 Medical Necessity Perform and document only those elements of history and exam that are necessary to take good care of the patient. If the final history and exam fulfill the requirements for the MDM of code too, then this is the code to bill. When the MDM documentation falls short of the requirements for the code, use a lower level code. 21

22 Medical Necessity To ensure that the level of care you select matches the intrinsic medical necessity of the encounter, let the key component of medical decision making be your guide. Because it is based on the number and nature of the clinical problems as well as the risk to the patient, the complexity of your medical decision making may be a reliable surrogate for the vaguely defined concept of medical necessity. Practitioners often estimate the medical decision making early in the encounter before they start to document the history and exam. Let the medical decision making point you toward the appropriate code. 22

23 FOUR ELEMENTS of HISTORY Chief Complaint (CC:) History of Present Illness (HPI) location/quality/severity/duration/timing/context/ modifying factors/associated symptoms Past/Family/Social History (PFSHx) Review of Systems (ROS) 2

24 History 1. Chief Complaint Concise statement describing reason for encounter ( stomach pain,, follow-up diabetes ) Can be included in HPI IMPORTANT: The visit is not billable if Chief Complaint is not somewhere in the note Must be follow-up of 24

25 HPI Status of chronic conditions being managed at visit Just listing the chronic conditions is a medical history Their status must be addressed for HPI coding OR Documentation of the HPI applicable elements relative to the diagnosis or signs/symptoms being managed at visit Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms 25

26 History - PFSHx. PAST, FAMILY, AND SOCIAL HISTORY - Patient s previous illnesses, surgeries, and medications - Family history of important illnesses and hereditary conditions - Social history involving work, home issues, tobacco/alcohol/drug use, etc. - TWO TYPES: PERTINENT: RELATED ONLY TO HPI COMPLETE: / FOR NEW/CONSULTS 2/ FOR ESTABLISHED 26

27 4. REVIEW OF SYSTEMS History - ROS 14 recognized: Constitutional Psych Eyes Respiratory ENT GI CV GU Skin MSK Neuro Endocrine Heme/Lymph Allergy/Immunology THREE TYPES: PROBLEM PERTINENT (1 SYSTEM) EXTENDED (2-9 SYSTEMS) COMPLETE (10 SYSTEMS) 27

28 History PEARLS FOR HISTORY DOCUMENTATION: Must have PAST/FAMILY/SOCIAL history for comprehensive history (ALL THREE) Don t forget 10-system review! You cannot charge higher than a level new or consult visit without COMPREHENSIVE HISTORY 28

29 Eyes EYE 1997 Examination Test visual acuity (Does not include determination of refractive error) Gross visual field testing by confrontation Test ocular motility including primary gaze alignment Inspection of bulbar and palpebral conjunctivae Examination of ocular adnexae including lids (e.g., ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size (e.g., anisocoria) and morphology Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film Slit lamp examination of the anterior chambers including depth, cells, and flare Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus Measurement of intraocular pressures (except in children and patients with trauma or infectious disease) Ophthalmoscopic examination through dilated pupils (unless contraindicated) of : Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor elevation) and nerve fiber layer Posterior segments including retina and vessels (eg, exudates and hemorrhages) Neurological/ Psychiatric Brief assessment of mental status including: Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation) 29

30 1997 Eye Physical Exam Definitions Problem Focused (PF) 97=Specialty and GMS: 1-5 elements identified by bullet. Expanded Problem Focused (EPF) 97=Specialty and GMS: At least 6 elements identified by bullet. Detailed (D) 97=Specialty: At least 12 elements identified by bullet (9 for eye and psyc) GNS= At least 2 bullets from each of 6 areas or at least 12 in 2 or more areas. Comprehensive (C) 97=Specialty: All elements with bullet in shaded areas and at least 1 in non-shaded area. 0

31 Time-Based Coding Medicare will allow payment for face-to-face time counseling patient if documented correctly: I spent 40 minutes with the patient, of which >50 % were spent counseling on No other documentation necessary MUST BE FACE-TO-FACE TIME WITH PATIENT OR FAMILY MEMBERS ONLY!! Also applies for Coordination of Care attending time filling out forms, arranging appointments, facility transfers, etc., when the patient is present 1

32 Time-Based Billing for Counseling or Coordination of Care Outpatient Counseling Time: min min min min min min min min min min min min min min min Inpatient Counseling Time: min min min min min min min min min min min 2

33 Visit Coding Decision Optometrists can select either the eye codes or E/M visit codes for their services. Choosing Correct Codes Most Optometrists prefer using the Eye Codes, believing they are easier to use and more audit-proof. That is not necessarily so. If you use only eye codes, not only are you punishing yourself financially, but you also may be found to be upcoding or downcoding under audit. For example, the intermediate eye code for established patients (CPT code 92012) is not always suitable for coding frequent follow-ups such as follow-up examination for corneal abrasion. (The correct code for healing corneal abrasion often usually is E/M code 99212). The Center for Medicare and Medicaid Services (CMS) wants you to code correctly to neither upcode nor downcode. Typically eye codes are billed in the OP setting for visits related to routine eye follow-ups or complaints. E/M codes are usually billed for specific eye injury, complaint or IP services.

34 Ophthalmology Codes S0620 Routine ophthalmological examination including refraction; new patient (not a Medicare Code) S0621 Routine ophthalmological examination including refraction; established patient (not a Medicare Code) Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits 4

35 S Code Documentation S are defined routine ophthalmological examination, includes refraction. These are HCPCS codes, not CPT, and as a result, most continue use the 99xxx or 92xxx visit codes, combined with 92015, refraction, to report their eye care visits. The word 'routine' in the definition indicates that the visit had no medical reason/chief complaint/presenting problem. Doctors who choose to use the S codes would use them whenever there was no medical reason for the visit, whether the patient has insurance to cover the visit or not. This is further complicated because most of the vision plans that cover the 'non-medical visits' don't accept the use of the S code. An advantage in the S codes is that offices can establish fees for their 99xxx and 92xxx office visits as if they are always used for medical cases, reserving the S codes; in most cases with a lower fee; for the visits without a medical reason. 5

36 General Ophthalmologic Services : New & Established elements of an ophthalmologic exam including: Test visual acuity (does not include determination of refractive error) Ocular mobility (required for comprehensive level) Intraocular pressure Retina (vitreous, macula, periphery, and vessels) Optic disc Gross visual fields (required for comprehensive level) Eyelids and adnexa (required for intermediate level) Pupils Iris Conjunctiva Cornea Anterior chamber Lens Illustration by Art Studio and Gallery of Rudolf Stalder 6

37 7 Comprehensive Examination Includes 9 or more elements and: History, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. A new patient always includes initiation of diagnostic and treatment programs. An established patient always includes initiation or continuation of diagnostic and treatment programs.

38 Intermediate Examination Includes -8 elements and- Intermediate history General medical observations External ocular and adnexal examination If less than elements are provided, then the service must be billed with an E/M code. 8

39 9 Intermediate and Comprehensive Ophthalmological services constitute integrated services in which medical decision making cannot be separated from the examining techniques used. Ophthalmological codes are appropriate for services to new or established patients when the level of service includes several basic routine optometric/ ophthalmologic examination techniques, such as slit lamp examination, keratometry, ophthalmoscopy, retinoscopy, tonometry, and basic sensorimotor examination, that are integrated with and cannot be separated from the diagnostic evaluation. Diagnosis Codes that Support Medical Necessity In addition to the general documentation requirements and the specified number of elements necessary to report a particular level of service, the "reasonable and necessary" requirements for billing Medicare must also be met. Therefore, certain diagnosis codes may not justify the "reasonable and necessary" criteria for reporting a particular level of service.

40 Routine Eye Examinations Medicare does not cover routine eye examinations or refractions For statutory exclusions (services never covered by Medicare) Advanced Beneficiary Notice (ABN) is not necessary HOWEVER For patients with secondary insurance that may cover these services, a claim can be submitted to Medicare to obtain a formal denial of reimbursement Explain Medicare coverage policy to the patient Explain that patient has the choice of having the service Indicate how much the patient will be financially responsible for Append appropriate modifier (GY) if you need to obtain a denial from Medicare to process secondary insurance claim 40

41 Contact Lenses Proper coding for contact lens exams? Patient comes in for routine eye exam and CL fit, code 92004/14 and If a refraction was done also bill Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, both eyes, except for aphakia First follow-up exam after the contact lenses are dispensed is included in the 9210, as its definition includes "medical supervision of adaptation". Patient presents for a routine eye exam, doesn't want CL's at that visit, but decides a month down the road they now want CL's. Code 9210 for the fitting and supervision of adaptation. If medically necessary for a specific patient a limited examination to be sure no eye changes have occurred. 41

42 Optometry Technician vs Optometry Student For billing purposes, a billing practitioner can utilize the below services only, when performed by a technician or student, if referenced in their note: Optometry Technician can perform and document: Visual acuity Intraocular pressure (IOP) Confrontation visual field exam Optometry Student can perform and document: ROS and PFSH in an E/M service 42

43 New Patients Patient not seen by you or your billing group in the past three years (as outpatient or inpatient) 4

44 Florida Medicare Focused Audits

45 Optometrist Current Audit Procedures Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness) Sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure) 9212 Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral 921 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve Gonioscopy (separate procedure) Orthoptic and/or pleoptic training, with continuing medical direction and evaluation Fundus photography with interpretation and report 45

46 CPT Code Desc Justification CC: Blurred Vision Gonioscopy (separate procedure) Computerized corneal topography, unilateral or bilateral, with interpretation and report Sensorimotor examination with multiple measurements of ocular deviation (eg, restrictive or paretic muscle with diplopia) with interpretation and report (separate procedure) Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (e.g., Goldmann visual fields with at least isopters plotted and static determination within the central 0 degrees or quantitative, automated threshold perimetry, Octopus program G-1, 2 or 42, Humphrey visual field analyzer full threshold 9208 programs 0-2, 24-2, or 0/60-2) Fundus photography with interpretation and report 9920 New Office Evaluate angle structures; baseline exam; monitor Examine for corneal surface abnormalities; corneal distortion due to bad images Evaluate phoria in all positions of gaze; no significant change from previous test (THIS IS A NEW PATIENT: DOCUMENT PREVIOUS TEST!) Rule out cause for current symptoms (blurry vision in both eyes) Document and monitor progression of choroidal atrophy 46

47 CPT Code Desc Justification CC: Blurry Vision Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness) Glaucoma suspect or screening; corneal thickness above normal value Computerized corneal topography, unilateral or bilateral, with interpretation and report Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, 921 unilateral or bilateral; optic nerve New Office Comparison study. Central Cone. No significant change compared to prior study. (THIS IS A NEW PATIENT: DOCUMENT PREVIOUS TEST!) Angle and anterior chamber evaluation; monitor progression/changes Evaluate for glaucoma due to large cup/disc ratio 47

48 CPT Code Desc Justification CC: Diabetic Eye Disease Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits Determination of refractive state Computerized corneal topography, unilateral or bilateral, with interpretation and report Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least isopters plotted and static determination within the central 0 degrees or quantitative, automated threshold perimetry, Octopus program G-1, 2 or 42, Humphrey visual field analyzer full threshold 9208 programs 0-2, 24-2, or 0/60-2) Fundus photography with interpretation and report Evaluate corneal health, cause and/or progression of astigmatism, rule out or diagnose keratoconus, rule out causes of decreased visual acuity. Rule out cause for current symptoms (blurry vision in both eyes) Document large physiologic cupping (c/d ratio) 48

49 Lacrimal Punctum Plugs (10 Day Global) Dilation of lacrimal punctum, with or without irrigation Covered if diagnosed with one of the following conditions: Dry eye syndrome of the lacrimal glands (right, left, bilateral, or unspecified) Keratoconjunctivitis sicca, not specified as Sjögren s (right, left, bilateral, or unspecified) Lagophthalmos Chemical burns Ocular pemphigus Severe punctate keratitis Other similar serious anterior segment conditions Documentation of: Complaints that are normally associated with dry eye syndrome. Have a positive Schirmer's test or some other measurement of lacrimal gland deficiency or evidence of corneal decomposition by slit lamp exam. Have undergone two to four weeks of conventional treatment using eye drops, gels, or ointments. Show no evidence of any improvements after conventional treatments. Provider must maintain the following documentation for each claim submitted for reimbursement in the recipient s medical record: Diagnosis code supporting the medical necessity for the procedure. Results of Schirmer s test or equivalent tear break-up time, tear assay, zone-quick and slit lamp exam. 49

50 Common Modifiers Modifier -25 Signifies visit or consultation for a SIGNIFICANT, SEPARATE identifiable E/M service on the same day Example - visit for floaters follow-up/patient also receives an intravitreal injection for Wet AMD. 50

51 Common Modifiers Modifier-24 (Surgery modifier): Unrelated E&M service by the same physician during a post-op period Modifier -59 two services performed at different anatomical sites on the same day on the same patient 51

52 Coding Pearls of Wisdom NUMBER DIAGNOSES IN ORDER OF IMPORTANCE ON CHARGE TICKET Include all diagnoses you addressed!! Some insurance companies (VIVA Medicare) increase cap payments based on # of diagnoses NEVER WAIVE CO-PAYS! (friends, family, MDs or their families, etc.) There are rare exceptions regarding patient s financial hardship but a reasonable attempt to collect must still be documented 52

53 What Initiates a Medicare Audit? Complaints from patients or whistleblowers - nurses, employees, etc. Disproportionate volumes of high level services (Level 4s and 5s) Lack of documentation of medical necessity for services rendered Unrelated specialty procedure billing Uniform level coding (i.e. all Level 4s) 5

54 Teaching Physicians (TP) Guidelines Billing Services When Working With Residents Fellows and Interns All Types of Services Involving a resident with a TP Requires Appropriate Attestations In EHR or Paper Charts To Bill 54

55 Evaluation and Management (E/M) E/M IP or OP: TP must personally document by a personally selected macro in the EMR or handwritten at least the following: That s/he was present and performed key portions of the service in the presence of or at a separate time from the resident; AND The participation of the teaching physician in the management of the patient. Initial Visit: I saw and evaluated the patient. I reviewed the resident s note and agree, except that the picture is more consistent with a corneal tear. Will begin treatment with... Initial or Follow-up Visit: I saw and evaluated the patient. Discussed with resident and agree with resident s findings and plan as documented in the resident s note. Follow-up Visit: See resident s note for details. I saw and evaluated the patient and agree with the resident s finding and plans as written. Follow-up Visit: I saw and evaluated the patient. Agree with resident s note. This is consistent with Nodular episcleritis will start with FML suspension q.i.d. and f/up in 4 days.. The documentation of the Teaching Physician must be patient specific. 55

56 Unacceptable TP Documentation Assessed and Agree Reviewed and Agree Co-signed Note Patient seen and examined and I agree with the note As documented by resident, I agree with the history, exam and assessment/plan 56

57 Evaluation and Management (E/M) Time Based E/M Services: The TP must be present and document for the period of time for which the claim is made. Examples : E/M codes where more than 50% of the TP time spent counseling or coordinating care Medical Student/Optometry Student documentation for billing only counts for ROS and PFSH. All other contributions by the medical/optometry student must be re-performed and documented by a resident or teaching optometrist. 57

58 TP Guidelines for Procedures Minor (< 5 Minutes): For payment, a minor procedure billed by a TP requires that s/he is physically present during the entire procedure. Example: I was present for the entire procedure. If > 5 Minutes Example: I was present for the entire (or key and critical portions) of the procedure and immediately available. 58

59 Diagnostic Procedures RADIOLOGY AND OTHER DIAGNOSTIC TESTS General Rule: The Teaching Physician may bill for the interpretation of diagnostic Radiology and other diagnostic tests if the interpretation is performed or reviewed by the Teaching Physician with modifier 26 in the hospital setting. Teaching Physician Documentation Requirements: Teaching Physician prepares and documents the interpretation report. OR Resident prepares and documents the interpretation report The Teaching Physician must document/dictate: I personally reviewed the film/recording/specimen/images and the resident s findings and agree with the final report. A countersignature by the Teaching Physician to the resident s interpretation is not sufficient documentation. 59

60 Orders Are Required For Any Diagnostic Procedure With a TC / 26 Modifier An Optometrist Can Be The Ordering & Treating Physician The CPT descriptions of documentation requirements for many ophthalmic diagnostic tests include the phrase, "... with interpretation and report." Once the appropriate individual has performed the test, you must document your interpretation of the results somewhere in the medical records. This doesn't have to be anything elaborate. It may merely be a brief phrase indicating if a test is "normal," "stable from a previous test" or "mild superior arcuate defect." 60

61 Florida Medicaid Teaching Physician Guidelines TEACHING PHYSICIANS WHO SEEK REIMBURSEMENT FOR OVERSIGHT OF PATIENT CARE BY A RESIDENT MUST PERSONALLY SUPERVISE ALL SERVICES PERFORMED BY THE RESIDENT. PERSONAL SUPERVISION PURSUANT TO RULE 59G (276), F.C.A, MEANS THAT THE SERVICES ARE FURNISHED WHILE THE SUPERVISING PRACTITIONER IS IN THE BUILDING AND THAT THE SUPERVISING PRACTITIONER SIGNS AND DATES THE MEDICAL RECORDS (CHART) WITHIN 24 HOURS OF THE PROVISION OF THE SERVICE. 61

62 Top Ten Compliance Issues For Documenting in EMR 62

63 Documentation in EMR CMS IS WATCHING EMR DOCUMENTATION Once you sign your note, YOU ARE RESPONSIBLE FOR ITS CONTENT 6

64 Documentation in EMR Every exam component... Every time you copy forward Family/Social History... Every HPI and ROS item you document means YOU PERFORMED THEM ON THAT VISIT... If you document something you did not do... YOU ARE PUTTING YOURSELF AND THE INSTITUTION AT GREAT RISK! 64

65 Top Ten Compliance Rules for EMR 1. Use Copy Forward with caution Each visit is unique Cloned documentation is very obvious to auditors If you bring a note forward it MUST reflect the activity for the CURRENT VISIT with appropriate editing Strongly advise NOT copying forward HPI, Exam, and complete Assessment/Plan 65

66 NOTE 06/05/12 HPI States: She had a metastatic evaluation on Friday and we will review that together today NOTE 06/26/12 HPI States: She had a metastatic evaluation on Friday and we will review that together today. Here for 2 nd neoadj chemo for bilat breast cancer NOTE 08/06/12 HPI States: She had a metastatic evaluation on Friday and we will review that together today. Here for 4th neoadj chemo for bilat breast cancer 66

67 Top Ten Compliance Rules for EMR 2. Don t dump irrelevant information into your note ( the 10-page follow-up note ) Be judicious with Auto populate Consider Smart Templates instead Marking Reviewed for PFSHx or labs is OK from Compliance standpoint (as long as you did it!) 67

68 Top Ten Compliance Rules for EMR. Never copy ANYTHING from one patient s record into another patient s note Self-explanatory 68

69 Top Ten Compliance Rules for EMR 4. Only Past/Family/Social History and Review of Systems may be used from a medical student or nurse s note Student or nurse may start the note Provider (resident or attending) must document HPI, Exam, and Assessment/Plan 69

70 Top Ten Compliance Rules for EMR 5. Never copy documentation from another provider without clearly identifying the original author Can be considered a false claim Not always easy to do better to avoid 70

71 Top Ten Compliance Rules for EMR 6. Utilize Approved Attestations for resident/fellow/mid-level provider notes Important that both providers are identified in the note Auto-Text makes this a 2-click process 71

72 Top Ten Compliance Rules for EMR 7. Be careful with pre-populated No or Negative templates Cautious with ROS and Exam Macros, Check-boxes, or Free Text are safer and more individualized 72

73 Top Ten Compliance Rules for EMR 8. Authenticate all documentation and orders per policy 48 hours for verbal orders 0 days for signed documentation 7

74 Top Ten Compliance Rules for EMR 9. Link diagnosis to each test ordered (lab, imaging, cardiographics, referral) Demonstrates Medical Necessity Know your covered diagnoses for your common labs 74

75 Top Ten Compliance Rules for EMR 10. Individualize every note with a focus on the HPI and Medical Decision Making Results is correct coding with the focus of an E/M selection on medical necessity 75

76 Redemption Tips for Copy and Paste Physicians 76

77 Copy/Paste Philosophy: Your note should reflect the reality of the visit for that day 77

78 Use Specific Dates Don t say Today, Tomorrow, or Yesterday Write specific dates, i.e., ID Consult recommends ceftriaxone through 9/, instead of six more days, which could be carried forward inaccurately Heparin stopped 6/20 due to bleeding will always be better than Heparin stopped yesterday, which can be carried forward in error 78

79 Use Past Tense Neuro status remains stable, will discontinue neuro checks can be copied forward in error Better Neuro checks stopped on 2/24 Added heparin on 4/26 uses past tense and specific date for better accuracy 79

80 Avoid the use of "I Avoid personal pronouns I discussed code status with Ms. Smith and she requested to be DNR could be copied forward by someone else Code status discussed with Ms. Smith and she requested to be DNR will always be acceptable and true 80

81 Delete HPI every day Progressive cumulative daily HPIs become unreadable and cumbersome Temptation exists to add no new information If a previous HPI is needed, it is easily found in the EMR on a past note 81

82 Delete the prior Review of Systems DO NOT COPY FORWARD REVIEW OF SYSTEMS! This leads to contradictions and inconsistency, and danger of documenting something you didn t do HPI Patient reports nausea this morning Templated ROS same day No nausea, no vomiting 82

83 Document the Exam ACTUALLY PERFORMED Always better to document fresh exam every day If copied forward or templated, review the exam closely and make corrections to items you did not perform Credibility is questioned when ear exam is documented every day, or when amputee has 2+ pulses in bilateral lower extremities 8

84 Avoid Routine Daily Labs and Vitals in each note These already exist in the EMR Summarize in the Assessment/Plan These can create unnecessary volumes of pages in notes each day Labs and imaging reports are not necessary for billing 84

85 Do Not Use Pending for Consult Requests Instead, put specific date requested: Cardiology consult requested /22 at 4pm This provides a legal safeguard in case of a poor outcome, as well as being accurate Pending can be copied forward for days in error 85

86 SUMMARY Copy/Paste can be a valuable tool for efficiency when used correctly There are major Compliance risks when used inappropriately, including potential fraud and abuse allegations, denial of hospital days, and adverse patient outcomes Make sure your note reflects the reality and accuracy of the service each day 86

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88 CASE SAMPLES 88

89 HIPAA, HITECH, PRIVACY AND SECURITY HIPAA, HITECH, Privacy & Security Health Insurance Portability and Accountability Act HIPAA Protect the privacy of a patient s personal health information Access information for business purposes only and only the records you need to complete your work. Notify Office of HIPAA Privacy and Security at if you become aware of a potential or actual inappropriate use or disclosure of PHI, including the sharing of user names or passwords. PHI is protected even after a patient s death!!! Never share your password with anyone and no one use someone else s password for any reason, ever even if instructed to do so. If asked to share a password, report immediately. If you haven t completed the HIPAA Privacy & Security Awareness on line CBL module, please do so as soon as possible by going to: training_office/learning/ulearn/ 89

90 HIPAA, HITECH, PRIVACY AND SECURITY HIPAA, HITECH, Privacy & Security Several breaches were discovered at the University of Miami, one of which has resulted in a class action suit. As a result, Fair Warning was implemented. What is Fair Warning? Fair Warning is a system that protects patient privacy in the Electronic Health Record by detecting patterns of violations of HIPAA rules, based on pre determined analytics. Fair Warning protects against identity theft, fraud and other crimes that compromise patient confidentiality and protects the institution against legal actions. Fair Warning is an initiative intended to reduce the cost and complexity of HIPAA auditing. UHealth has policies and procedures that serve to protect patient information (PHI) in oral, written, and electronic form. These are available on the Office of HIPAA Privacy & Security website: 90

91 Available Resources at University of Miami, UHealth and the Miller School of Medicine If you have any questions or concern regarding coding, billing, documentation, and regulatory requirements issues, please contact: Gemma Romillo, Assistant Vice President of Clinical Billing Compliance and HIPAA Privacy; or Iliana De La Cruz, RMC, Director Office of Billing Compliance Phone: (05) Also available is The University s fraud and compliance hotline via the web at or toll-free at (24hours a day, seven days a week). Office of billing Compliance website: 91