Getting Paid for What You Do! Coding 2010

Transcription

1 Getting Paid for What You Do! Coding 20 Children s Mercy Health Network 11/17/09 Richard H. Tuck, MD, FAAP 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. OBJECTIVES 1. Recognize value of Coding to your practice 2. Apply correct CPT and ICD Guidelines to patient management 3. Review current Documentation Guidelines What s New for 20? CODES - New CPT/ICD Codes VALUE-RBRVS New RVU s and CF PAYER PAYMENT- AAP Private Sector Advocacy Program State Pediatric Council National Class Action Law Suits PATIENTS- Covered Benefit Consumer Driven Health Care CONTRACTS - Pay for Performance Reimbursement Environment Declining Dollars for Pediatricians Rising Costs to Insurance Companies and of Managed Care Increasing Costs of Delivering Care Breaking Down of Academic Shield Work smarter, Not harder IMPORTANCE OF ACCURATE APPROPRIATE CODING INCREASED REIMBURSEMENT DECREASED LIABILITY IMPROVED INFORMATION FLOW 1

2 Pediatricians and CPT Use only a few codes Code at lower levels Don t code for procedures and testing Why? Lack experience with CPT Undervalue worth of Pediatric Services Lack knowledge of Procedural and Testing Coding Fear of audits or oversight Ignore in Academic salaried environment Coding for Children s Mercy Health Network Accurate Information is Power All information flow is CPT and ICD derived Supporting Evidence Based Guidelines Win / Win relationship Pay 4 Performance for the Network/Physicians Improved Health Care outcomes for Contracted Plans Hedis Criteria Published Quality of Care Indicators HCPCS: CPT: Basic Coding Systems Complete coding system for all services furnished Healthcare Common Procedural Coding System. Coding for services furnished Current Procedural Terminology ICD-9-CM: Coding for diagnosis/reason for services International Classification of Diseases, 9 th Revision Clinical Modification RBRVS: Assigns a relative reimbursement for CPT codes Resource Based Relative Value Scale Using and Reporting ICD-9-CM Codes Code to the highest degree of specificity Code to the highest degree of certainty for the encounter such as symptoms, signs, abnormal test results, Probable, suspected,questionable, or rule out should not be coded List the ICD-9-CM code that is identified as the main reason for the service first. Next list any current coexisting conditions. Chronic disease treated on an ongoing basis may be coded Do not code for conditions that were previously treated and no longer exist ICD Coding to support Quality Pay for Performance Code appropriately for primary diagnosis Code for comorbidities Code for complications Code for of ICD Coding for Special Needs Patients Code throughout the continuum of care in the medical home Code determines complexity ity supports management according to evidence based guidelines Supports higher levels of and more CPT codes for additional services provided 2

3 Inpatient Diagnosis Coding Inpatient coding Admission diagnosis can be rule out, suspected, probable Final diagnosis = diagnosis at discharge Inpatient Diagnosis Coding Seeking maximally coded audit resistant diagnoses Principal diagnosis established by hospital coder. If more than one, there is a better diagnosis Hospital coders want as many diagnoses as possible Include Comorbid Complications critical for increased DRG reimbursement Discharge diagnosis should account for lab and services ordered (medical necessity) Current Procedural Terminology Category I Guidelines and procedures listed by separate sections Evaluation/Management Anesthesiology Surgery Radiology Pathology and Laboratory Medicine All physicians may code from any section where services are found. er relative values are in the procedural sections! CPT Coding Basic Principles of Use 1. Physician should select diagnosis and procedure codes Coding confirmed by the coding team 2. Document patient services to support codes Good Care and Compliance 3. Use separate codes for different encounters 0% 75% 50% 25% 0% Appropriate Coding Appropriate Coding Under coding Over coding EM ESTABLISHED OFFICE- Expected EM EST OFFICE

4 EM ESTABLISHED OFFICE- Actual EM ESTABLISHED OFFICE- Pediatrics EM EST OFFICE 0 EM EST OFFICE EM ESTABLISHED OFFICE- Specialty EM EST OFFICE CPT Coding Basic Principles of Use 1. Physician should select diagnosis and procedure codes Coding confirmed by the coding team 2. Document patient services to support codes Good care and Compliance 3. Use separate codes for different encounters 4. Learn to use modifiers, procedure, and add-on codes 5.Design a superbill/computerized routing sheet SUBSPECIALTY SPECIFIC CPT and ICD codes What s so important about documentation? Medico-legal shows the information you had to evaluate and treat the patient a record of your patient management Billing allows third-party payors to evaluate the amount of physician work and medical decision making involved in the patient s care Quality Patient Care Auditing / Documentation 95, 97 Guidelines Think in ink! Code to meet your documentation If it s not in the chart, it wasn t done Address handwriting, required signatures Dictate (look for evidence of physician review) Templates/ Clinical forms Computer Assists Electronic medical records Beware of Documentation Upcoding Must be medically necessary! 4

5 Documentation for Special Needs Patients Complete documentation of of your SNP visit Include all conditions being managed at that visit Complications Comorbidities Coding alone is not enough! If you didn t document it, you didn t do it or consider it If your patients are sicker, show it in your documentation and coding! Evaluation and Management Codes 7 Components The SCIENCE of Coding Key Examination Medical Decision Contributory Counseling Coordination of Care Nature of Presenting Explicit Time Only to assist physician in selection So why are you here? Includes Chief complaint (CC) of present illness (HPI) Review of systems (ROS) Past, family and/or social history (PFSH) Type (212) (213) (214) (215) HPI Brief (1-3) Brief (1-3) Extended (4+) Extended (4+) ROS N/A Brief (1) Extended (2-9) Complete (+) PFSH N/A N/A Pertinent (1) Complete (2/3 or 3/3) The rule you choose determines the physical exam type Type of exam focused (99212) problem focused (99213) (99214) (99215) 5-7 BA or OS 8 OS 95 rules 1 body area (BA) or organ system (OS) 2-4 BA or OS 97 rules 1-5 elements from 1 BA/OS >6 elements from 1 BA/OS 2 elements from 6 BA/OS or 12 elements from >1 BA/OS 2 elements from 9 BA/OS Medical Decision Number of possible diagnoses and/or management options Amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed Risk of complications,morbidity and/or mortality, associated with the patient s presenting problem, diagnostic procedures, and management options 5

6 Decision Straight forward (212) ity (3) Moderate ity (4) ity (5) Medical Decision Number of Diagnoses Minimal Limited Multiple Extensive Amount of Data Min. or None Limited Moderate Extensive * elements met or exceeded Risk of Complication Minimal Moderate Time An explicit factor to assist in selecting the most appropriate level of E/M services When counseling and/or coordination of care are more than 50% of the face to face encounter, then time is the key controlling factor. Utilize prolonged services codes (time based) *Documentation in the medical record is a must Key Concepts Outpatient E/M Coding Time spent is face to face One E/M code per day Few exceptions: -25 modifier Prolonged services codes Attending physician must see the patient and fulfill / document criteria supporting code used Procedures and other services should be coded separately May require modifiers (-25 on the E/M code) Codes Exam Decision Time FF Key # Office Visits New Patient Straight forward Straight forward complex Moderate complex complex 60 Codes Exam Decision Time FF Key # Office Visits Established Patient Not Required Not Required Not Required Straight forward Mod The ART of Coding The FEEL Established Patient Nurse Visit Easy, Brief s Average, Usual s OH NO! Just Ran a Marathon 6

7 Non Face-To-Face Physician Services Telephone Calls Reviewing Records/Reports Completing Forms Managing, Modifying Care Plans Case Management Telephone Services 2008 New and Improved Times included in code descriptors allowing correct selection of level Codes have been valued CMS Final Rule for Medicare Fee Schedule 2008 Reporting rules exclude double payment for Telephone care and E/M care Telephone Services CPT Physician to est patient, parent or guardian 2009 Medicare 5 minutes of medical discussion ($12.62) No related E/M service within previous 7 days No related E/M service in next 24 hours or next available appointment minutes ($24.89) minutes ($38.33) Provide Consultations! Reimbursement is 25-42% higher than corresponding new patient office visit codes, and Documentation requirements for, Exam, and MDM are the same! Consult codes are problem-based and can be used for new or established patients REASON: Consultations 5 R s Medically necessary Keyword = Request REQUEST: By another physician or other appropriate source RENDER: REPORT: RETURN: May initiate diagnostic and/or therapeutic services By written report back to the requesting source Patient back to requesting physician/source Referral 7

8 Office Consultation/ New or Est Inpatient Consult / New or Est. Code Code Exam Decision Time FF Straightfd 15 Straightfd 40 Mod Exam Decision Time/unit Straightfd 20 Straightfd Mod 80 1 Key # Key # Key Concepts - Inpatient E/M Coding Code for services only the day the patient is seen (face to face) One E/M code per day ( few exceptions 25 Modifier) Time spent is unit/floor time Attending physician must see the patient and fulfill and document criteria supporting code used Procedures should be coded separately (few exceptions Newborn /Critical care codes) Code Exam Decision Time/ Floor Key # Initial Hospital Care/ New or Est or or Straightfd or ity Mod ity ity 70 The ART of Coding Code Subsequent Hospital Care The FEEL Established Patient Straightforward Average, Usual s OH NO! Exam Decision Time/ Floor Straightfd/ ity 15 Mod ity 25 ity 35 Key # 8

9 Hospital Discharge Discharge day management of minutes or less Discharge day management of more than minutes Normal Newborn Care Neonatal/Pediatric Intensive/Critical Care Codes RE N U M B E R E D! RE LO C A T E D! Effective January 1, 2009 Normal Newborn Care Initial Hospital Other Setting Subsequent Hospital Same day Admit/Discharge Discharge minutes Discharge > minutes Attendance at delivery Delivery Resuscitation Unchanged Unchanged Newborn/Intensive Care Renumbered After January 1, Newborn Care/NB Resuscitation Report with Subsequent Intensive Care Recovering Neonate Report with Ped Critical Care Pt Transport Report with Inpt Neonatal/Ped Critical Care Report with Prolonged Services ( ) Code series defining prolonged services by: Site of service Direct or without Direct patient contact Time Reported in addition to other physician service, including E/M services at any level Total time for a given date, even if the time is not continuous Time must be of minutes or more Direct Patient Care Face to Face Face to Face Before or after Face to Face Before or after Face to Face Prolonged Services Outpatient first hour > min each add min > 75 min first hour > min each add min > 75 min Inpatient first hour > min each add min > 75 min first hour > min each add min > 75 min 9

10 Modifiers Services altered by specific circumstance Tells insurer this visit is different - 25 Significant separately identifiable E/M Service by the same physician on the same day - 26 Professional component - 32 Mandated Services - 51 Multiple Procedures - 52 Reduced Services - 59 Distinct Procedural Service - 76 Repeat procedure by same physician Single E/M Code per day Multiple outpatient and/or inpatient E/M codes upcoded to a higher single code Ex: Observation to Admit Outpatient OV to later Admit ER visit to later Admit Must use site of face to face service for upcoded service Pediatricians Cognitive Specialists Cognitive Services CPT Evaluation and Management Services er RBRVS Relative Values Most questioned by payers Procedures Potential increase in revenue Insurance system with historical procedural base Least questioned by payers PROVIDE MORE PROCEDURES! SPECIFIC TO YOUR SUBSPECIALTY CODE FOR PROCEDURES! (Not Included In Global Critical Care Codes) Office procedures Vaccinations Minor procedures Lab and x-ray services Medical services Screening procedures Special services Code for Those Procedures! Provide more services with procedures (nonfacility): RVU/2009 Medicare Foreign body removal/ear (00) 3.02/$8.92 Foreign body removal/nose 0 (00) 5.47/$ FB removal/subcutaneous 120 () 3.33/$120. Incision&Drainage/Simple 060 () 2.72/ $98. Wart removal (1-14) 171 () 2.70/ $97.38 Wart removal (15 or >) () 3.20/ $ Wound repair/dermabond () 3.87/$ Subluxation of radial head () 2.89/ $4.23

11 Optimizing Reimbursement Through CPT Coding Utilize Time Time spent in counseling and coordination of care greater than 50% of the visit time Ex: (15 min) to (25 min) Otitis media requiring extensive counseling ADHD follow-up visit Document time spent and counseling issues Documentation/ ICD 9 CM ICD coding should support higher levels of coding (medical necessity) to Code multiple diagnoses Document chronic condition when an acute problem is presented Diabetes mellitus Prematurity and related problems Code for extensive medical services Optimize standard office visit services Hx, PE, ity Time $ OV < Prev Med < Consultation Utilize prolonged services codes For excess time spent beyond E/M code PROVIDE MORE PROCEDURES! CODE FOR PROCEDURES! DOCUMENT! DOCUMENT! DOCUMENT! Coding for Quality Pay for Performance Win/Win/Win! 11

12 AAP Your CODING CONNECTION Coding & Reimbursement Resources National AAP Coding Hotline: or 800/ ext 4022; free service to members and their office staff Coding publications: Coding for Pediatrics, Pediatric Coding Companion, Quick Reference Guides, ICD-9-CM Flipchart, RBRVS Brochure, AAP News Coding Corner A Hundred Years From Now It will not matter what my bank account was, the sort of house I lived in, or the kind of car I drove But the world will be different Because I was important in the life of a CHILD 12