Medical Compliance Services Office of Billing Compliance Coding, Billing & Documentation Department of Genetics

Transcription

1 Medical Compliance Services Office of Billing Compliance Coding, Billing & Documentation 2017 Department of Genetics

2 Top Billed Non-E/M Codes CODE PROCEDURES UNITS 9780PR MED NUTR THER, SUBSQ, INDIV, EA 15 MIN PR PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON 1ST HR PR COLLECTION VENOUS BLOOD,VENIPUNCTURE PR MED NUTR THER, 1ST, INDIV, EA 15 MIN PR PROLONGED SERVICE I/P REQ UNIT/FLOOR TIME 1ST HR PR MED NUTR THER, GROUP, EA 0 MIN 4 2

3 Top Billed E/M Codes CODE E&M UNITS 99245PR OFFICE CONSULTATION,LEVEL V PR OFFICE/OUTPT VISIT,EST,LEVL V PR OFFICE/OUTPT VISIT,NEW,LEVL V PR INITIAL INPATIENT CONSULT,LEVL V PR OFFICE/OUTPT VISIT,EST,LEVL IV 7 992PR SUBSEQUENT HOSPITAL CARE,LEVL III PR OFFICE CONSULTATION,LEVEL IV PR OFFICE/OUTPT VISIT,NEW,LEVL IV PR SUBSEQUENT HOSPITAL CARE,LEVL II 10

4 Bell Curves CMS with Commercial 4

5 National CMS / Commercial Bell Curves OP Compared to Department Data Hematology / Oncology New Office Visits Current Practice Dist. % Variance Practice vs. National E&M Code Count National Dist. % % 0.1% 0.49% % 1.10% -1.10% % 9.24% -6.1% % 6.19% % % 5.5% 6.71% Totals % % Established Office Visits Current Practice Dist. % Variance Practice vs. National E&M Code Count National Dist. % % 2.65% -2.19% % 2.65% -1.05% % 1.80% -1.12% % 51.69% -5.02% % 11.21% 69.9% Totals % % New Office Visits ` 94% 5% 6% 0% 0% 0% 1% 0% 9% 6% Practice National 0% % 2% % 1% Established Office Visits ` 2% 81% 52% 17% 11% Practice National 5

6 National CMS / Commercial Bell Curves OP Compared to Department Data Hematology / Oncology Consult Office Visits E&M Code Count Current Practice Dist. % National Dist. % Variance Practice vs. National % 0.1% -0.1% % 1.10% -1.10% % 9.24% -9.01% % 6.19% -0.62% % 5.5% 40.85% Totals % % 0% 0% 0% 1% 0% New Office Visits ` 9% 6% 6% 94% 5% Practice National 6

7 CASE SAMPLES 7

8 Inpatient and Outpatient Evaluation and Management E/M Documentation and Coding 8

9 New vs Established Patient for E/M Outpatient Office and Preventive Medicine What is the definition of "new patient" for billing E/M services? New patient" is a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., procedure) from the physician or another physician in the same group practice(group provider NPI #) (same physician specialty) within the previous three years. An interpretation of a diagnostic test, reading an x-ray or EKG etc., (billed with a -26 modifier only) in the absence of an E/M service or other face-to-face service with the patient, does not affect the designation of a new patient. 9

10 Putting The Puzzle Together 10

11 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. 11

12 The Key Documentation Elements History Focus on HPI Physical Exam Medical Decision Making 12

13 Elements of an E/M History The extent of information gathered for history is dependent upon clinical judgment and nature of the presenting problem. Documentation of the patient s history includes some or all of the following elements: Chief Complaint (CC) & History of Present Illness (HPI) WHY IS THE PATIENT BEING SEEN TODAY Review of Systems (ROS) related to HPI, Past Family, Social History (PFSH) related to HPI. 1

14 Focus on the Present Illness or Reason for the Encounter

15 History of Present Illness (HPI) A KEY to Support Medical Necessity to in addition to MDM HPI is chronological description of the development of the patient s present illness or reason for the encounter from the first sign and/or symptom or from the previous encounter to the present or the status of chronic conditions being treated at this visit. The HPI must be performed and documented by a provider in order to be counted towards the level of service billed. Focus upon present issue or reason for the visit! HPI: Current symptoms or complaints, treatment or medication compliance, stressors etc. 15

16 HPI Elements 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 16

17 HPI Elements Defined: Location: where is the problem located (i.e., body system or organ); Quality: description of type of issue; Severity: on a scale of 1-10 where does the level of pain fall; Duration: how long does it last, how long has it been going on; Timing: has/does anything trigger it, how frequently does it occur; Context: does it occur in relation to anything else (i.e., exercise, eating, etc.) Modifying factors: does anything make it worse or better; Associated signs/symptoms: what other problems are associated with patient symptoms. Per First Coast FAQ: E/M HPI and negative responses Q. Do I get credit for negative HPI elements, e.g., if I ask the patient about modifying factors and say no modifying factors are present would I get credit for this HPI element? A. No, credit is not given for negative responses regarding HPI elements. Page 17

18 Review of Systems (ROS) Constitutional Eyes Respiratory Ears, nose, mouth, throat Cardiovascular Musculoskeletal Gastrointestinal Genitourinary Psychiatric Integumentary Neurologic Allergy/Immunology Endocrine Hematologic/Lymphatic ROS is an inventory of specific body systems in the process of taking a history from the patient. The ROS is designed to bring out clinical symptoms which the patient may have overlooked or forgotten. In theory, the ROS may illuminate the diagnosis by eliciting information which the patient may not perceive as being important enough to mention to the physician relative to the reason for the visit. 18

19 Past, Family, and/or Social History (PFSH) Past history: The patient s past medical experience with illnesses, surgeries, & treatments. May also include review of current medications, allergies, age appropriate immunization status Family history: May include a review of medical events in the patient s family, such as hereditary diseases, that may place a patient at risk or Specific diseases related to problems identified in the Chief Compliant, HPI, or ROS Social history: May include age appropriate review of past and current activities, marital status and/or living arrangements, use of drugs, alcohol or tobacco and education. Record Past/Family/Social History (PFSH) appropriately considering the clinical circumstance of the encounter. Extensive PFSH is unnecessary for lower-level services. Don't use the term "non-contributory for coding a level of E/M 19

20 If History Data is Recorded on Intake Form To receive credit for coding, providers must indicate he/she reviewed the data on the patient questionnaire, either by signature or a statement in the progress note, to include this data in the scoring of the encounter. 20

21 X X X X X X X X X X X

22 History: Step 1 Completed 22

23 EXAMINATION 4 TYPES OF EXAMS Problem focused (PF) Expanded problem focused (EPF) Detailed (D) Comprehensive (C) 2

24 1995: Physical Exam BODY AREAS (BA): Head, including face Neck Chest, including breast and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity CODING ORGAN SYSTEMS (OS): Constitutional/General Eyes Ears/Nose/Mouth/Throat Respiratory Cardiac GI GU Musculoskeletal Skin Neuro Psychiatric Hematologic/Lymphatic 24

25 PHYSICAL EXAM: General Multi-System Examination ( BA/OS) Elements of Examination BA Head, including the face BA Neck: neck (masses, symmetry, etc); thyroid BA Chest (Breasts): inspection breast; palpation breast/axillae BA Abdomen BA Genitalia, groin, buttocks BA Back, including spine BA Left upper extremity BA Right upper extremity BA Left lower extremity BA Right lower extremity OS Constitutional: vitals (sit/stand BP; sup BP; temp; pulse rate; resp; ht; wt) or General appearance OS Eyes: conjunctivae/lids; pupils/irises; optic discs OS Ears, Nose, Mouth/Throat: exam ears/ nose; exam auditory canal/tympanic membrane; hearing assessment; Exam nasal mucosa/septum/turbinates; exam lips/teeth/gums; exam oropharynx/palates OS Respiratory: respiratory effort; percussion of chest; palpation of chest; auscultation of lungs OS Cardiovascular: palpation heart; auscultation; Exam of: carotid; femoral arteries; abd aorta; pedal pulses; Exam extremities for edema/varicosities OS Gastrointestinal: exam of abd; exam liver/spleen; hernia +/-; exam anus, perineum, rectum; stool specimen if appropriate OS Genitourinary: Male: exam of scrotum; exam of penis; DRE of prostate; Female: exam ext genitalia, vagina, urethra, bladder, cervix, uterus, adnexa/parametria OS Musculoskeletal: gait/station; inspect digits/nails; inspect/rom/stability/strength of head/neck, spine/rib/pelvis (Rt upper, Lt upper, Rt lower, Lt lower extremities can be OS also) OS Skin: inspect skin/subcutaneous tissue; palpation skin/subcutaneous tissue OS Neurologic: test cranial nerves; deep tendon reflexes, sensations OS Psychiatric: judgment/ insight; orientation to person/place/time; recent/remote memory; mood & affect OS Hematological/lymphatic palpation of nodes neck, axillae, groin, other 25

26 : GMS and Sub-Specialty Physical Exam GMS: General Multi- System Cardiovascular Musculoskeletal ENT and Mouth Neurological Eyes Genitourinary - Female and Male Respiratory Hematologic/Lymphatic/ Immunologic Skin Psychiatric

27 1995 and 1997 Exam Coding Requirements Problem Focused (PF) = 99212, 99201, : a limited exam of the affected body area or organ system. (1 BA/OS) 97=Specialty and GMS: 1-5 elements identified by bullet. Expanded Problem Focused (EPF) = 9921, 99202, : a limited exam of affected BA/OS and other symptomatic/related OS. (2-7 BA/OS) 97=Specialty and GMS: At least 6 elements identified by bullet. Detailed (D) = 99214, 9920, 992, : extended exam of affected BA/OS and other symptomatic/related OS.(2-7 BA/OS) 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) = 99215, 99204, 99205, 99222, : general multi-system exam (8 or more organ systems) or complete single organ system (a complete single organ system is undefined by CMS). 97=Specialty: All elements with bullet in shaded areas and at least 1 in nonshaded area. GMS: At least 2 elements with bullet from each of 9 areas/systems. 27

28 X X X X X X X X 28

29 Exam: Step 2 Completed 29

30 Medical Decision Making DOCUMENT EVERYTHING THAT EFFECTS YOUR SERVICE!! Include all diagnosis that impact the service. Exchange of clinically reasonable and necessary information and the use of this information in the clinical management of the patient Step 1: Number of possible diagnosis and/or the number of management options. Step 2: Amount and/or complexity of data reviewed, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed. Step : The risk of significant complications, morbidity, and/or mortality with the patient s problem(s), diagnostic procedure(s), and/or possible management options. Note: The 2 most complex elements out of will determine the overall level of MDM 0

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32 MDM Step : # Dx and Management Options Documentation Guidelines Clearly indicate the diagnosis(es) and whether it is controlled, improving, or worsening. Clearly indicate any differential diagnoses: Clearly indicate the treatment plan Clearly indicate any referrals or requested consultations An impression, assessment or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation. The initiation of or changes in treatment should be documented. If referrals are made, or consultations requested the record should indicate to whom the request is made. 2

33 MDM Step 1: # Dx & Tx Options Number of Diagnosis or Treatment Options Identify Each That Effects Patient Care For The DOS Problem(s) Status Number Points Results Self-limited or minor (stable, improved or worsening) Max=2 1 Est. Problem (to examiner) stable, improved 1 Est. Problem (to examiner) worsening 2 New problem (to examiner); no additional workup planned Max=1 New prob. (To examiner); additional workup planned Total 4 1 POINT: 99212, 99201, 99202, POINTS: 9921, 9920, POINTS: 99214, 99204, 9922, POINTS: 99215, 99205, 992, 9922

34 Medical Decision Making

35 MDM Step 2: Amount and/or Complexity of Data to be Reviewed Data Review - Clearly indicate If a diagnostic service is ordered, planned, or performed it should be documented. The review of diagnostic tests should be documented. Direct visualizations of images, tracings, or specimens previously read by another provider 5

36 MDM Step 2: Amt. & Complexity of Data Amount and/or Complexity of Data Reviewed Total the points REVIEWED DATA Points Review and/or order of clinical lab tests 1 Review and/or order of tests in the radiology section of CPT 1 Review and/or order of tests in the medicine section of CPT 1 Discussion of test results with performing physician 1 Decision to obtain old records and/or obtain history from someone other than patient Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider Independent visualization of image, tracing or specimen itself (not simply review of report). Total POINT: 99212, 99201, 99202, POINTS: 9921, 9920, POINTS: 99214, 99204, 9922, POINTS: 99215, 99205, 992,

37 Medical Decision Making 2

38 MDM Step : Table of Risk The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options. DG: Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented. Risk is assessed based on the risk to the patient between present visit and the NEXT time the patient will be seen by billing provider or risk for planned intervention 8

39 Min Low Mod High MDM Step : Risk Presenting Problem Diagnostic Procedure(s) Ordered Management Options Selected One self-limited / minor problem 2 or more self-limited/minor problems 1 stable chronic illness (controlled HTN) Acute uncomplicated illness / injury (simple sprain) 1 > chronic illness, mod. Exacerbation, progression or side effects of treatment 2 or more chronic illnesses Undiagnosed new problem w/uncertain prognosis Acute illness w/systemic symptoms (colitis) Acute complicated injury 1 > chronic illness, severe exacerbation, progression or side effects of treatment Acute or chronic illnesses that may pose threat to life or bodily function (acute MI) Abrupt change in neurologic status (TIA, seizure) Labs requiring venipuncture CXR EKG/ECG UA Physiologic tests not under stress (PFT) Non-CV imaging studies Superficial needle biopsies Labs requiring arterial puncture Skin biopsies Physiologic tests under stress (stress test) Diagnostic endoscopies w/out risk factors Deep incisional biopsies CV imaging w/contrast, no risk factors (arteriogram, cardiac cath) Obtain fluid from body cavity (lumbar puncture) CV imaging w/contrast, w/risk factors Cardiac electrophysiological tests Diagnostic endoscopies w/risk factors Rest Elastic bandages Gargles Superficial dressings OTC meds Minor surgery w/no identified risk factors PT, OT 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 Closed treatment, FX / dislocation w/out manipulation Elective major surgery w/risk factors Emergency surgery Parenteral controlled substances Drug therapy monitoring for toxicity DNR

40 Draw a line down any column with 2 or circles to identify the type of decision making in that column. Otherwise, draw a line down the column with the 2 nd circle from the left. After completing this table, which classifies complexity, circle the type of decision making within the appropriate grid. Final Result for Complexity Step 1 Number diagnoses or treatment options < 1 Minimal 2 Limited Multiple > 4 Extensive Step 2 Amount and complexity of data < 1 Minimal or low 2 Limited Multiple > 4 Extensive Step Highest Risk Minimal Low Moderate High Type of decision making STRAIGHT- FORWARD 99212, 99201, 99202, 9921 LOW COMPLEX 9921, 9920, MODERATE COMPLEX 99214, 99204, 9922, HIGH COMPLEX 99215, 99205, 992, 9922

41 Draw a line down any column with 2 or circles to identify the type of decision making in that column. Otherwise, draw a line down the column with the 2 nd circle from the left. After completing this table, which classifies complexity, circle the type of decision making within the appropriate grid. Final Result for Complexity A B C Number diagnoses or treatment options Amount and complexity of data Highest Risk < 1 Minimal < 1 Minimal or low 2 Limited 2 Limited Multiple Multiple > 4 Extensive > 4 Extensive Minimal Low Moderate High Type of decision making STRAIGHT- FORWARD LOW COMPLEX MODERATE COMPLEX HIGH COMPLEX 41

42 Medical Decision Making: Step Completed 42

43 Using Time to Code an E/M Time shall be considered for coding an E/M in lieu of H-E-MDM when > 50% of the total billable practitioner visit time is counseling/coordination of care (CCC.) Time is only Face-to-face for OP setting Coding based on time is generally the exception & is typically used for: Exacerbation or change in the patient s condition or new diagnosis, Non-compliance with the treatment/plan, Counseling regarding previously performed procedures or tests to determine future treatment options Issues that may not lend themselves to typical E/M encounter. Examples: Behavior/school issues, ADHA Non-compliance with medications or treatments Introduction of new medications or treatments 4

44 Using Time to Code an E/M Required Documentation For Billing: 1. Total time of the encounter excluding separate procedure if billed 2. The amount of time dedicated CCC for that patient on that date of service.. A template statement would not meet the documentation requirements. 4. The documentation MUST be individualized for each patient visit! 5. Check boxes for time and check boxes for CCC are NOT acceptable for coding an E/M service based on time. 44

45 What is Counseling of Care Report on Medicare Compliance August 22, 2016 Counseling of Care Definition The CPT manual makes a distinction between psychotherapy and counseling. Counseling is defined as a discussion with a patient and/or family concerning one or more of the following areas: Diagnostic results, impressions, and/or recommended diagnostic studies; Prognosis; Risks and benefits of management (treatment) options; Instructions for management (treatment) and/or follow-up; Importance of compliance with chosen management (treatment) options; Risk factor reduction; Patient and family education. The CPT manual is not explicit in its definition of coordination of care, but the Agency for Healthcare Research and Quality ( AHRQ ) developed the following definition: Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient s care to facilitate the appropriate delivery of health care services. Organizing care involves marshalling of personnel and other resources needed to carry out all required patient activities, and is often managed by the exchange of information among participants responsible for different aspects of care. *. 45

46 What is Coordination of Care Report on Medicare Compliance August 22, 2016 Selection of the Level of E/M Visit Medicare instructs providers to select the procedure or service that accurately identifies the service performed. If that is an E/M service, the provider determines the extent of the history obtained, the extent of the examination performed and the complexity of the medical decision making. If for some reason, counseling and/or coordination of care dominates (more than 50% of the total time of the encounter) with the patient and/or family (face to face time in the office or other outpatient setting or floor/unit time in the hospital), then time shall be considered the key or controlling factor to qualify for a particular level of E/M service. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (i.e. foster parents, legal guardians). The content of the corresponding patient clinical note should document the nature of the medical counseling and explicitly what topics were discussed in the coordination of care. 46

47 Counseling/Coordination of Care CCC Proper Language used in documentation of time: I spent minutes with the patient and family and over 50% was in counseling about her diagnosis, treatment options including and. I spent minutes with the patient and family more than half of the time was spent discussing the risks and benefits of treatment with (list risks and benefits and specific treatment) This entire minute visit I spent counseling the patient regarding and addressing their multiple questions. Total time spent and the time spent on counseling and/or coordination of care must be documented in the medical record. Documentation must reflect the specific issues discussed with patient present. Document the specific topics that were discussed during the counseling (i.e. diagnosis, prognosis, treatment options, medical management and side effects, etc). 47

48 Time-Based Billing for CCC 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 48

49 Time X X X

50 Completing the Puzzle 50

51 Scoring Medical Records

52 Evaluation & Management Coding Card 52

53 Evaluation & Management Coding 5

54 Prolonged Services 54

55 OP Prolonged Practitioner Services No Resident or Fellow Time Counts! To bill must be > than 0 minutes associated with E/M code time OUTPATIENT: Prolonged E/M or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient E/M or psychotherapy service) If the visit is a counseling visit and time will be the deciding factor, prolonged services can only be added to the highest level of E/M in the category. So if the time is equal to anything less that the highest level, you cannot report a prolonged service code in addition to the E/M. REGULATIONS PER CMS: The medical record must be document by the practitioner to include the dated start and end times of the prolonged service. A counseling visit, when time will be the deciding factor, prolonged services can only be added to the highest level of E&M in the category. 55

56 IP Prolonged Services No Resident or Fellow Time Counts! To bill must be > than 0 minutes associated with E/M code time INPATIENT: Prolonged E/M or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient E/M or psychotherapy service) If the visit is a counseling visit and time will be the deciding factor, prolonged services can only be added to the highest level of E/M in the category. So if the time is equal to anything less that the highest level, you cannot report a prolonged service code in addition to the E/M. REGULATIONS PER CMS: The medical record must be documented by the practitioner to include the dated start and end times of any prolonged service. A counseling/coordinating visit, when time will be the deciding factor, prolonged services can only be added to the highest level of E&M in the category. 56

57 Requirement for Physician Presence You may count only the duration of direct face-to-face contact with the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed, to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable. You cannot bill as prolonged services: In the office setting, time spent by office staff with the patient, or time the patient remains unaccompanied in the office; or In the hospital setting, time spent reviewing charts or discussing the patient with house medical staff and not with direct face-to-face contact with the patient or waiting for test results, for changes in the patient s condition, for end of a therapy, or for use of facilities. 57

58 Prolonged Services Associated With E&M Services Based Counseling and/or Coordination of Care (Time-Based) When an E&M service is dominated by counseling and/or coordination of care (the counseling and/or coordination of care represents more than 50% of the total time with the patient) in a face-to-face encounter between the physician or the qualified NPP and the patient in the office/clinic or the floor time in the scenario of an inpatient service, the E&M code is selected based on the typical/average time associated with the code levels. The time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the E&M code) and should not be rounded to the next higher level. Further, in E&M services in which the code level is selected based on time, you may only report prolonged services with the highest code level in that family of codes as the companion code. 58

59 Prolonged Non Face-to-Face Time Prior to CY 2017, CPT codes 9958 and 9959 (prolonged services without face-toface contact) were not separately payable, and were included for payment under the related face-to-face Evaluation and Management (E/M) service code. Per CMS in the Final Rule 2017 We agreed that these codes would provide a means to recognize the additional resource costs of physicians and other billing practitioners, when they spend an extraordinary amount of time outside of an E/M visit performing work that is related to that visit and does not involve direct patient contact (such as extensive medical record review, review of diagnostic test results or other ongoing care management work). We also believed that doing so in the context of the ongoing changes in health care practice to meet the current population s health care needs would be beneficial for Medicare beneficiaries and consistent with our overarching goals related to patient-centered care. Note: CPT codes 9958 and 9959: Cannot be reported during the same service period as: Complex Chronic Care Management (CCM) services or Transitional care management services CPT codes 9958 and 9959 can only be used to report extended qualifying time of the billing physician or other practitioner (not clinical staff). 59

60 Prolonged Non Face-to-Face Time Report this service if the provider spends time in either preparation or evaluation of the outcome of treatment before or after the face to face encounter with a patient. Clinical Responsibility: For these service, the provider puts extra effort and time into the treatment of the patient. For example, the provider evaluates the patient s previous records in cases where the patient opted to change his provider and the new provider performs extra work to understand and plan the treatment of the patient. The provider can also invest extra time to review the reports and progress after the patient has undergone treatment. Codes 9958 and 9959 are used when a prolonged service is provided that is neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service and is beyond the usual physician or other qualified health care professional service time. Code Status A Medicare Fees National Local 26 TC $11.41 $ $0.00 $0.00 $ $54.55 $58.89 $0.00 $0.00 $

61 Prolonged Non Face-to-Face Time This prolonged service may be reported on the same date (or other date) than the primary service to which it is related (it must be associated with an E/M service.) For example, extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records. However, it must relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management. Codes 9958 and 9959 are used to report the total duration of non-face-toface time spent by a physician or other qualified health care professional on a given date providing prolonged service, even if the time spent by the physician or other qualified health care professional on that date is not continuous. Code 9958 is used to report the first hour of prolonged service on a given date regardless of the place of service. It should be used only once per date. 0 minutes or < not billable Can be billed for 1-74 minutes Code 9959 is used to report each additional 0 minutes beyond the first hour regardless of the place of service. Can bill 1 unit for add-on code for minutes 61 REGULATIONS PER CMS: The medical record must be documented by the practitioner to include the dated start and end times of any prolonged service.

62 Medical Nutrition Therapy (MNT) Medicare will cover 100% of the Medicare approved amount for medical nutrition therapy. The deductible will also not apply and pay no copay or deductible for these services. Medical nutrition therapy is covered by Medicare for people: With diabetes With chronic renal disease Who have had a kidney transplant in the past three years Only RDs can provide and be reimbursed for MNT RDs need NPIs to bill for MNT or to re-assign to a facility or another entity so they can bill for the MNT provided by the RD 62

63 MNT Medicare Billing MNT does not require credentialing for reimbursement MNT must be provided by an RD Referral for initial or follow-up MNT must come from MD or DO Midlevel providers not accepted MNT benefits are always in calendar year MNT can be provided as 1:1 or group CMS link addressing MNT - Guidance/Guidance/Transmittals/downloads/R67CP.pdf 6

64 MNT Medicare Billing hours of MNT is allowed first calendar year 2 hours of MNT is allowed each follow-up year with a follow-up referral MNT is billed in 15-minute units with rounding allowed MNT 1: MNT follow-up 1: MNT group G0270 2nd referral MNT 1:1 G0271 2nd referral group 64

65 MNT - 2nd Referral Same Year Second referral by physician due to change in: Diagnosis Medical condition Treatment regimen (including additional hours needed for renal disease) The second referral MNT codes for additional hours of coverage should be used after the completion of the hours are used No specific limit is set for the additional hours Reference page 9 CMS link 65

66 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 66

67 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 an upper respiratory infection not pneumonia. 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, but lower extremities are weaker, now /5; MRI of L/S Spine today. The documentation of the Teaching Physician must be patient specific. 67

68 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 : Critical Care Hospital Discharge (>0 minutes) or E/M codes where more than 50% of the TP time spent counseling or coordinating care Medical Student documentation for billing only counts for ROS and PFSH. All other contributions by the medical student must be re-performed and documented by a resident or teaching physician. 68

69 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-1.010(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. 69

70 Non-Physician Practitioners (NPP s) or Physician Extenders Who is a NPP? Physician Assistant (PA) Nurse Practitioner (NP) 70

71 NPP Agreements & Billing Options Collaborative agreement between the NPP and the group they are working with is required. The agreement extends to all physicians in the group. If the NPP is performing procedures it is recommended a physician confirm their competency with performance of the procedure. NPPs can bill independent under their own NPI # in all places-of-service and any service included in their State Scope of Practice. Supervision is general (available by phone) when billing under their own NPI number. Medicare and many private insurers credential NPPs to bill under their NPI. Some insurers pay 85% of the fee schedule when billing under the NPP and others pay 100% of the fee schedule. Shared visit in the hospital or hospital based clinic (POS 19, 21, 22, 2) Incident-to can ONLY be provided in an office (POS 11) 71

72 Shared Visits The shared/split service is usually reported using the physician's NPI. When an E/M service is a shared encounter between a physician and a NPP, the service is considered to have been performed "incident to" if the requirements for "incident to" are met and the patient is an established patient and can be billed under the physician. If "incident to" requirements are not met for the shared/split E/M service, the service must be billed under the non-physician's NPI. Procedures CANNOT be billed shared 72

73 Shared Visits Between NPP and Physician Shared visits may be billed under the physician's name if and only if: 1. The physician provides a medically necessary face-to-face portion of the E/M encounter (even if it is later in the same day as the PA/ARNP's portion); and 2. The physician personally documents in the patient's record the details of their face-to-face portion of the E/M encounter with the patient. If the physician does not personally perform and personally and contemporaneously document their face-to-face portion of the E/M encounter with the patient, then the E/M encounter cannot be billed under the physician's name and must be billed under the NPP. The NPP MUST be an employee (or leased) to bill shared. Documentation from a hospital employed NPP may not be utilized to bill a service under the physician. 7

74 Bill Independently and Not Shared Billing Under The NPP NPI Does not require physician presence. Can evaluate and treat new conditions and new patients. Can perform all services under the state scope-of-practice. Can perform services within the approved collaborative agreement. Recommend physician establish competency criteria and demonstration of performance of procedures within the collaborative agreement between the NPP and physician. 74

75 Scribes

76 Scribed Notes Record entries made by a "scribe" should be made upon the direction of the physician or NPP. Writes what the practitioner dictates and does. Cannot act independently or obtain any information independently except to record the ROS and PFSH. They cannot obtain the HPI, any portion of the PE or MDM. AAMC does not support someone dictating as a scribe by an NPP, resident or fellow. Scribing is over the shoulder immediate documenter with no services personally performed by the scriber. A medical student can only act as scribe if they are paid employee of the practice. 76

77 Scribed Notes Documents scribed in the EHR must clearly identify the scribe s identity and authorship of the document in both the document and the audit trail. The following attestation must be entered by the scribe: Scribed for [Name of provider] for a visit with [patient name] [Name of scribe] [date and time of entry]. The following attestation should be entered by provider when closing the encounter: I was present with [patient name] during the time the encounter was recorded. I have reviewed and verified the accuracy of the information, which was performed by me. [Name of provider][date and time of entry]. 77

78 Top Compliance Issues For Documenting in EMR 78

79 Documentation in EMR PAYORS ARE WATCHING EMR DOCUMENTATION Once you sign your note, YOU ARE RESPONSIBLE FOR ITS CONTENT 79

80 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! 80

81 Top Compliance Rules for EMR 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 81

82 Top Compliance Rules for EMR 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!) 82

83 Top Compliance Rules for EMR 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 8

84 Copy / Paste 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 84

85 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/ 85

86 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: 86

87 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: Helenmarie Blake-Leger, Interim AVP of Compliance & Chief Privacy Officer Phone: (05) Iliana De La Cruz, RMC, Executive Director, Professional Billing Compliance Gema Balbin-Rodriguez, Director, Professional 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). Your inquiry or report may remain anonymous Office of billing Compliance website: 87