NATIONAL Medicare Medicaid Third party payers STATE Medicaid ACA plans COMPLEX & FLUID What You Need to Bill Master s Degree and Certification by a Na

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1 Coding & Documentation: Fiscal Responsibility in a Changing Healthcare World Lynn Rapsilber DNP APRN ANP-BC FAANP Co-Owner NP Business Consultants, LLC Session 409 Saturday April 22, 2017 Objectives Learn the nuances of coding and documentation for APRN Services Identify audit triggers and coding conundrums Understanding MACRA and implications in value based reimbursement Health Care Dollars are Shrinking Attune to: Costs of Care Revenue Stream Factors related to efficiencies Cost of Care Varies by: Location Patient population Type of Services Location Hospital Office Clinic FQHC Urgent Care Home Telehealth Rural Urban Population Neonatal Pediatric Adult Geriatric Women s health Psychiatric Acute vs Chronic Preventative Episodic Chronic disease Behavioral health REGULATED Type of Services Revenue Stream

2 NATIONAL Medicare Medicaid Third party payers STATE Medicaid ACA plans COMPLEX & FLUID What You Need to Bill Master s Degree and Certification by a National Certifying Body ANCC, AANP, etc. National Provider Number Provider Number Third Party Payers Provider Panels National Provider Number (NPI) Provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Standard unique identifier for health care providers and health plans CMS developed the National Plan and Provider Enumeration System (NPPES) to assign these numbers customerservice@npienumerator.com toll-free Contracting & Credentialing Need a contract in order to submit claims Apply Individual or Multiple Attestation form Practice Requirements Vary by States Requirements Vary State by State Full Practice Reduced Practice Restricted Practice 2017 AANP Nurse Practitioner State Practice Environment Almost there Certified Contract Credentialed Ready to see patients Previsit Considerations Contract Credentialing Can the patient be seen

3 Participating / In Network / Out of Network Schedule the appointment Visit process Schedule the appointment Check insurance card Confirmation call Check eligibility Patient arrives for visit Recheck Eligibility Provide Services Document Services Code Services Submit Claim Payment Reconciliation Patient Visit Complete Now you must Document & Code for what you do.. Why is Coding so Important? Results: payments inc by 43% $77 billion to $110 billion E&M inc by 48% $22.7 billion to $33.5 billion Established code most often used increased by 17% from Results: 2014 $6.7 billion lost in incorrect coding 55% of all claims Consultation codes were billed at the highest level and miscoded 95% of the time Errors in upcoding 26% of claims by one level Errors in downcoding 15% of claims by one level MDs & NPs & PAs equally erred Recommendations Education of HCPs on E&M coding and documentation Review E&M for high coding HCPs Review E&M for undercoding Elimination of Consultation codes in 2010 Review claims paid in error Revised Annually Systemic Listing Coding of Procedures and Services Specific to MDs, PAs and NPs CPT: Current Procedural Terminology ICD-10: International Classification of Diseases

4 Classifies Diseases by Assigning Numeric Codes Only Choices are from the ICD-10 Submitted Electronically Link ICD-10 to CPT = Medical Necessity Medical Necessity Defined By statute, Medicare may only pay for items and services that are: "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member", unless there is another statutory authorization for payment. ICD-10 International List of Causes of Death, was adopted in WHO created ICD in 1948 and published the 6th version, ICD-6, that incorporated morbidity for the first time. The WHO (1967) stipulated using the most current ICD revision for mortality and morbidity statistics. ICD-10 was endorsed in May 1990 United States until October 1, 2015 to adopt Coming 2018 ICD-11 ICD-10: Why is it Different? ~ 14,000 codes to ~ 69,000 codes Updated to be consistent with clinical practice Greater clinical detail & specificity Better data for care quality Better statistics Better studies Reduction of paperwork Less queries Decreased denials Increased productivity, financial and administrative Public health data improved ICD-10 Increased site specificity & laterality Episodic care for injuries (initial, subsequent, sequela) Intraoperative/postprocedural complications Combo codes: etiology, related conditions, other medical conditions/complications Documentation ICD-10 Fracture Details Episode Initial Subsequent Sequela Laterality Right / Left

5 Bilateral Level of healing Normal / Delayed Malunion / Non-union Combination Codes Two diagnoses Commonly associated Examples K57.21 diverticulitis of large intestine with perforation and abscess E Type 2 DM with severe nonproliferative diabetic retinopathy with macular edema I atherosclerotic heart disease of native coronary artery with unstable angina pectoris There s an ICD-10 for that!! V97.33: Sucked into jet engine. Y92.253: Hurt at the opera. Y93.D1: Accident while knitting or crocheting. Y92.146: Swimming-pool of prison as the place of occurrence of the external cause. W220.2XD: Walked into lamppost, subsequent encounter. W55.41XA: Bitten by pig, initial encounter. Z63.1: Problems in relationship with in-laws. Patient care Coding Billing for services Compliance plan Education is the key! Documentation is key driver Other Resources HCPCS (hicks picks) Level II Medicare Codes Drugs, Supplies, Vaccines, Services Adjunct to CPT Billing in Hospital No Reimbursement for NP Reimbursed by DRGs Length of Stay Determines Amount of Revenue Hospital Makes Bed Turnover the Key Medical Record Documentation is Key Medical Record Should Reflect What was Done and Why Paper or EMR EMR Templates Macros CMS EMR should not replace the need for good documentation from the provider. CMS Rules for Documentation Medical Record Complete and Legible

6 Patient Encounter MUST Include: CC, Relevant Hx, Assessment, PE, Clinical Interpretation of Testing, Dx, Treatment Plan, Data to be Reviewed Identify the Provider Rationale for Testing Should be Apparent at Time of Service CMS Rules for Documentation Diagnoses and Conditions (Past and Present) must be Readily Accessible Health Risks Identified Documentation of Responses to Treatment, Follow-up and Progress CPT/ICD-10 Supported in Documentation Data Sequential Addendum Dated to Day Entered NOT DOS Documentation Guidelines Established 1995 AMA, CMS Revised 1997, guide/downloads/95docguidelines.pdf guide/downloads/97docguidelines.pdf Resource-Based Relative Value Scale Identifies Work Effort Through RVU (relative value unit) Hsiao 1988 * Replaced Fee for Service Hsiao, W.C.,Braun, P, Dunn, D, et al JAMA. 1988;260(16): doi: /jama Converting an RBRVS to a Dollar Amount (Work RVU x Work GPCI) + (Practice Expense RVU x Practice Expense GPCI) + (Malpractice RVU x Malpractice GPCI) x Conversion factor x Practitioner Payment Rate = Allowed Amount RVU = relative value unit GPCI = geographic practice cost indices It is all changing.. No longer paid by what you do (procedures) Paid by how you do it (outcomes) Value Based Reimbursement MACRA: Medicare Access and CHIP Reauthorization Act NPs will be key players Detailed later in the presentation How to Pick a Code? Evaluation and Management

7 Foundation of Fiscal Responsibility New Patient vs Established Patient 3 Key Components History Examination Medical Decision-making Counseling Coordination of Care Nature of Presenting Problem Time Key Components History Examination Medical Decision-making Very Important Levels 2 Problem focused 3 Expanded Problem focused 4 Detailed 5 Comprehensive Evaluation and Management New Patient New to the practice Not seen in 3 (three) years Hospital patient Need all three components to bill: History, Exam, Medical Decision making Evaluation and Management Established Patient Someone who the practice has an ongoing relationship with Hospital patient Need two out of three key components Look at all three and take the two with the highest amount of work effort History CC: Chief Complaint HPI: History of Present Illness ROS: Review of Systems PFSH: Past, Family, Social History Evaluation and Management Constitutional Eyes Ears, nose, throat, mouth Respiratory Gastrointestinal Genitourinary Elements of ROS

8 Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/ Immunologic Location Quality Severity Duration Timing Context Modifying Factors Associated signs/symptoms HPI Description Past/Family/Social History Past History: the patient s history of illnesses, operations, injuries, treatments, medications. Family History: a review of medical events in the patient s family, including diseases which may be hereditary or place the patient at risk. Social History: an age appropriate review of past and current activities. Ex: marital status; sexual history; tobacco, alcohol, and drug use history; job/career status. Components of History Evaluation and Management Examination 4 Levels Problem Focused Expanded Problem Focused Detailed Comprehensive Guidelines (1995,1997) determine # systems examined Examination Multi system Single system Cardiology Neurology Musculoskeletal Hematology/Oncology Ear Nose and Throat Genitourinary Psychiatry Respiratory Skin Evaluation and Management

9 Evaluation and Management Medical Decision-Making 4 Levels Straightforward Low Complexity Moderate Complexity High Complexity Based upon # of diagnoses # management options Data to review Risk of complication, morbidity, mortality Medical Decision-Making Number of Diagnoses or Treatment Options Self-limiting or minor (stable, improved or worsening) (1) Established Problem (stable, improved) (1) Established Problem (worsening) (2) New Problem; no additional work-up (3) New Problem; additional work-up required (4) Medical Decision Making Amount and Complexity of Data to be Reviewed Review and/or order lab tests (1) Review and/or order radiology tests (1) Review and/or order medicine tests (1) Discussion of test results with performing provider (1) Decision to obtain old records and/or history form someone other that pt (1) Review and summarize old records and/or obtain info other than pt, or discuss case with other HCP (2) Independent review of image, test, tracing or specimen (not just read the report) (2) Preventative Care Obesity Counseling Smoking Cessation Prolonged Services Coding by Time Final look at Medical Decision Making Coding Conundrums Shared E&M Visits Evaluation and Management plus Procedure Modifiers Incident to PREVENTATIVE CARE Age specific/ new vs established/ comprehensive exam based upon age Vaccines Smoking Cessation

10 Cardiovascular Disease Screening Diabetes Self-Management, Supplies, and Services Medical Nutrition Therapy Mammogram PAP Smear Fecal Occult Blood Testing Flexible Sigmoidoscopy/ Colonoscopy Glaucoma Bone Mass Density Prostate Screenings Preventative + Abnormal If abnormality found Perform components of E&M Bill for both E&M and preventative Use Modifier 25 ie: physical with c/o abd pain for abdominal pain **Subject to co-pay A Word About Co-pays. Co pay Wide range values Must collect Fraud Relationship Insured Insurance company Middle man Medicare Physicals IPPE Initial Preventative Physical Exam Annual Wellness Visit Subsequent Wellness Visit Recommend separate documentation to capture all the components Medicare Well Visit Includes Personalized Prevention Plan 9 elements History: medical /family Risk for depression Functional ability/level of safety Physical Exam with BMI, visual acuity Current providers of care Cognitive impairments Written screening plan for next 5-10 yrs

11 Risk factors/interventions Education regarding prevention/referrals Medicare Covers Smoking Cessation Smoking Cessation Counseling: smoking and tobacco use cessation visit 3-10 minutes Has s/s needs Dx tobacco disorder smoking and tobacco cessation counseling > 10 minutes For those who smoke or have a disease or illnesses related to smoking Those taking RX FDA approved Covers two attempt per year Max 8 sessions per 12 month period < 3 minutes is included in E&M visit Obesity Counseling GO447 Medicare Obesity: BMI > 30 kg/m2 Covers intensive behavior therapy Screen BMI, nutritional assessment Promote wt loss through high intensity diet/exercise Behavior health risk/factors Treatment goals/methods Agreed upon goals Follow-up contacts (in person or phone) Obesity Counseling Competent/alert when counseled Covers: One face-to-face every week for first month One face-to-face every other week months 2-6 One face-to-face every month for months 7-12 if pt meets 3 kg wt loss over the first 6 months Coding By Time Counseling and Coordination of Care More than 50% of Face to Face in Discussion Patient, Family or Legal Guardian MUST BE DOCUMENTED!!! = 15 minute = 25 minutes = 40 minutes Document as a fraction of the time spent Coding By Time Greater than 50% of the face-to-face time was spent discussing the above. 20/25 minutes was spent. Shared E&M Visits

12 Hospital: Inpatient/Outpatient/ER MD and NP see a patient, each providing a portion of the care Hospital inpatient only Not incident to.. Office only Service is billed under the MD or NP NPI number Documentation must be separate/ MD done something. (doesn t mean co-sign) i.e. NP pre-rounds on patients am / MD sees pm and changes plan. Evaluation and Management Plus Procedure Must be a Separate, Identifiable Evaluation and Management by the Same Provider on the Same Day Examples Follow-up Diabetes (99214) + Cryosurgery for Seborrheic Keratosis Evaluation and Management + Chemotherapy Administration * modifier 25 to E&M Incident to Medicare Patients NP Bills with MD Provider # Reimbursed at 100% MD Rate TOO GOOD TO BE TRUE!! IT IS!!!!! Incident to Specific Criteria to Bill Direct Supervision by MD MD Needs to be Accessible NP MUST be Employed by MD MD MUST Perform the Initial Service MD MUST have Active Participation in Patient Care Patient CANNOT have a New Problem Incident to Problematic OIG Actively Reviewing Use of Incident to!! Incident to If you see something Say something.. You are accountable for what you code & bill!!! Medicare Fraud Fraud is defined by CMS as the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to him/her self or some other person. Medicare Fraud/ Common Pitfalls Audit Triggers Bill for Appointment patient failed to keep Non-covered Services Billed as Covered (false claims) Coding does not meet Medical Necessity Incident to Billed When MD NOT Present Documentation does not Support Level of E&M Billed

13 Use only One E&M Code for ALL Visits MACRA 2015 Quality payment Program (QPP) Two paths to payment Merit-Based Incentive Payment System (MIPS) Advanced Alternative Payment Models (APMS) Three Key Dates Reporting Data Payment Begins Review Determination Who is eligible? Physicians Physician Assistants Nurse Practitioners Clinical Nurse Specialists Certified Registered Nurse Anesthetists Participation in MIPS Inclusion Established Medicare Provider > 100 Medicare patients per year > $30,000 in Part B Medicare allowable charges Exclusion First year as a Medicare Provider < 100 Medicare patients per year < $30,000 in Part B Medicare allowable charges per year If you qualify to report in APM MIPS DATA Measures Quality (similar to PQRS) Advancing Care Information (ACI) (similar to MU) Improvement Activities (IA) (new) Cost (similar to VBM) Quality Measures (60%) Replaces PQRS and quality part of VBM Report on 6 Quality Measures Submit data for 50% of your patients who are eligible to measure Examples of Quality Measures Title: Diabetes: Hb A1C Poor Control (>9%) Description: % of pts yo with DM HbA1C >9% during measurement Title: Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation Description: % of pts 18 and older with Dx COPD who had spirometry results documented Title: Breast Cancer Screening Description: % of women yo who had a mammogram to screen for Breast Cancer Title: Ischemic (IVD): Use of Aspirin or other antiplatelet Description: % of pt 18 and older DX AMI, CABG, PCI in 12 mos or active IVD who documented use of aspirin or other antiplatelet Examples of Quality Measures Title: Use of High Risk Medications in the Elderly Description: % of pts 66 and older who were ordered 2 high risk medications. Reported as a) % of pts with one high risk med; b) % pts who were ordered at least 2 high risk medications Dementia: Caregiver Education and Support

14 Description: % of pts, regardless of age, with Dx dementia whose caregiver is provided with education on disease management and behavior changes AND referred to addt l sources of support within 12 month period Title: Annual Hepatitis C (HCV) screening for Pts who are active IVD users Description: % of pts, regardless of age, who are active IVD users who are screened for HCV infection within the 12 month reporting period Advancing Care Information Measure Base Score similar to Meaningful Use 4 required minimum threshold (Meet = 50 points; Miss just 1 =0 points) Security Analysis E-Prescribing Provide Patient Access Health Information Exchange Performance Score (range 0-90 points) 7 measures Provide Patient Access ** double wt Health Information Exchange ** double wt View/Download/Transmit health information by the pt thru pt portal Patient-specific Education Secure Messaging Medication Reconciliation Immunization Registry Reporting Advancing Care Information Measure In addition to Base and Performance Earn Bonus points 1. Additional Registry Reporting Bonus 5 points if attest to being active in public health or clinical data registries Does not include state immunization registries 2. Improvement Activities Bonus 10 points if attest to completing at least one clinical practice improvement activity using HER Access thru 24/7 to eligible HCPs/Population Mgmt/Care Coordination bilateral information exchange/integrated Behavioral & Mental Health integrated PCBH model/ Health Equity social determinants of health Cost Measures Delayed until 2018 reporting 0% of MIPS final score for first year 2019 Takes the place of Value-Based Modifier (VBM) No additional reporting to receive a score Advanced Alternative payment models Earn more to take more risk *** ACO*** Expected to expand over next several years Incentivizes HCP to provide high quality, cost effective care Meet 4 Criteria CMS Innovation Center, Shared Savings, or Federal demonstration program Use a certified EHR Base payments for services quality measures comparable to MIPS Medical Home Model expanded under Innovation Center Payments MIPS is budget neutral All monies saved will be redistributed to those who qualify for an increase

15 Congress set $500 million per year for 5 years as part of MACRA Data 2017 >CMS reviews 2018 > MC payment 2019> range -4% reduction to +12% increase Data 2018> 2019 > 2020> range -5% reduction to +15% increase Data 2019> 2020 > 2021> range -7% reduction to +21% increase Data 2010> 2021 > 2022> range -9% reduction to + 27% increase OIG Concerns with QPP quality Payment Program OIG identified two vulnerabilities that are critical for CMS to address in 2017 Impact the potential program's success: (1) providing sufficient guidance and technical assistance to ensure that clinicians are ready to participate in the QPP (2) developing IT systems to support data reporting, scoring, and payment adjustment. For more information CMS Centers for Medicare and Medicaid Services Final Rule tive-payment-system-mips-and-alternative-payment-models-apm Thank you lrapsilber@optonline.net Questions?