Capturing E/M Services in the HOPD

Transcription

1 Capturing E/M Services in the HOPD AAPC Regional Conference Anaheim, CA Linda Martien, COC, CPC, CPMA September 2016

2 Introduction A part of the Federal Balanced Budget Act of 1997 required HCFA (now CMS) to create a new Medicare "Outpatient Prospective Payment System" (OPPS) for hospital outpatient services It was to be separate but similar to the Medicare prospective payment system for hospital inpatients known as "Diagnosis Related Groups" or DRG's. APC's or "Ambulatory Payment Classifications" are the government's method of paying for facility outpatient services for the Medicare program. APC's apply only to hospitals, and have no impact on physician payments under the Medicare Physician Fee Schedule.

3 What is a Hospital Based Clinic? An outpatient department of the hospital just like lab, x-ray, hospital-based clinic. Examples of HBC: IV therapy Clinic, Wound Clinic, Pain Clinic, Ostomy Clinic, Oncology Clinic,, ambulatory outpatient clinic, transfusion clinic, OB, anticoagulation, scheduled visits in the ER Example Hospital-Owned Physician Directed Clinic: Physician does own E&M, hospital uses own criteria for their E&M. Two different sets of criteria; two different E&Ms.

4 Facility vs. Physician E/M Coding Facility coding guidelines are inherently different from professional coding guidelines. Facility coding reflects the volume and intensity of resources utilized by the facility to provide patient care, whereas; Professional codes are determined based on the complexity and intensity of provider performed work and include the cognitive effort expended by the provider. There is no definitive strong correlation between facility and professional coding and thus no rational basis for the application of one set of derived codes, either facility or professional, to the determination of the other on a case-by-case basis.

5 Hospital Owned Physician Directed Challenges Correct claim submission: Physician bills as hospital based and will receive a reduced fee schedule payment as the administrative fees are covered by the facility. Place of service as office (POS 11) receives the full schedule payment in lieu of the reduced payment. This will ensure the full fee schedule is received on one 1500 form claim.

6 The Rules At this point, there is no national standard for hospital assignment of E&M code levels for outpatient services in clinics and the Emergency Department (ED). CMS requires each hospital to establish its own facility billing guidelines. Further, OPPS lists eleven criteria that must be met for facility billing guidelines. (see APC FAQ). Facility billing guidelines should be designed to reasonably relate the intensity of hospital services to the different levels of effort represented by the codes. Coding guidelines should be based on facility resources, should be clear to facilitate accurate payments, should only require documentation that is clinically necessary for patient care, and should not facilitate upcoding or gaming.

7 Understanding the E/M Process E&M = Hospital-based clinic/er visit charge Revenue code 510 CPT Code / /Clinic/Outpatient Dept. Revenue Code 450 CPT Code /ER APC regulations: As long as the services furnished are documented and medically necessary and the facility is following its own system, which reasonably relates intensity of hospital resources to the different levels of HCPC codes, we will assume that it is in compliance with these reporting requirements as they relate to clinic/emergency department visit codes reported on the bill. (Federal Register vol 65, #68, April 7, 2000, Page 18451)

8 Golden Rules HOPD Charge Capture Always, always bill what was done first, i.e., actual procedure: Injection, IV infusion, laceration repair Then evaluate earning the E&M as a separately identifiable service Each visit look for three unique billable services: Nursing procedure/cpt Surgical/interventional procedure/cpt E&M Not always done, but look for them!

9 Evaluate ER & HBC Billing: E&M Nursing Procedures/CPT Interventional/Surgical Procedures/CPT Know what costs are being billed that relate to the above charges Physician Billing: E&M Interventional/Surgical Procedures/CPT E&M levels can be different, but CPT-4 surgical code should be the same

10 What Charges are Covered? Nursing Procedure Nurse doing the injection Risk of giving the injection Cost of routine supplies Separate and identifiable from the E&M? Surgical Procedure Nurse in assistance Set up, clean up Routine supplies Sterilization/tools Overhead of room Separate and identifiable from the E&M?

11 2007 Forward Final Rules CMS offers 11 guiding principles: 1) The coding guidelines should follow the intent of CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different level of effort represented by the codes

12 Guidelines 2) The coding guidelines should be based on hospital facility resources. The guidelines should be not be based on physician resources 3)..should be clear to facilitate accurate payments and be usable for compliance purposes and audits 4) should meet the HIPAA requirements.

13 Guidelines 5) should only require documentation that is clinically necessary for patient care 6) should not facilitate upcoding or gaming 7) should be written or recorded, well documented, and provide the basis for selection of a code 8) should be applied consistently across patients in the clinic or emergency department

14 Guidelines 9) should not change with great frequency 10) should be readily available for fiscal intermediary review 11) should result in coding decision that could be verified by staff & outside auditors

15 Specifics of Current E/M Guidelines Facility and physician levels are not the same. Create facility-specific leveling system. As long as the facility follows it s own guidelines that includes documentation of the E&M elements = compliance. HOLD on any mandated E&M leveling system. Continue to use internal, auditing, resource based system.

16 Understanding the G Codes Type A ERs Paid with newer G codes with each G code having it s own payment. (APC 609, 613, 614, 615, 616, 617/CC) Open 24/7 and staffed as an ER, plus meets licensure issues as a dedicated ER plus EMTALA (pg 335, CMS 1506) --- NOT IMPLEMENTED Type B ERs Paid with newer G codes; included in HBC payment groupers (lesser payment; APC ) Not open 24/7 / meets licensure issues / EMTALA / during previous calendar year, it provides at least 1/3 of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment. (pg 332, CMS 1506) - IMPLEMENTED

17 Facility E/M Level Capture Facilities do not provide any of the three key components in an E/M service So how do you choose an E/M level?

18 Building E/M Criteria Working with the care team, brainstorm the detailed services for each main category: Triage/medical screening/emtala (ER only) Assessment Emotional Support Teaching Discharge Planning/Status Interventions (= no CPT-4 code) Remember until mandated system, the E&M is whatever the facility says it is, with nursing s documentation

19 Example Assessment Reassess, vital check, visual acuity, reassess post meds Emotional Support Patient, family, prolonged Teaching Crutch training, infection guidelines, walker, new meds, sling Discharge Status To nursing home, f/u, physician, by ambulance Interventions no CPT Enema, observation postmed, IV attempts, IV more than 2 lines, Admit, rape exam, wound cleansing, ring removal, restraint, rectal exam, 2 nurses, flushes, care coordination Miscellaneous Language barrier, behavior issues, coordination of care, holding/waiting bed; holding/waiting for a ride

20 Example Acuity Resource E/M Assessment Reassessment after meds 10 Repeat vital signs 5 pts Visual Acuity 5 points Teaching Ed requiring demo 20 Ed w/2 or more meds 10 Crutch training 5 Post wound care 20 Sling, ace wrap-minor 5 Emotional Support Discharge Status Interventions Continue brainstorming services, assigning points based on risk, acuity and resource consumption. Each visit, the E&M leveling form is used to determine level of E&M to bill.

21 Completing the E/M Acuity Tool Add points and assign to level based on totals All elements of the E&M must be charted Hint: Explore dating and signing the E&M leveling sheet and making it part of the permanent medical record Match charting to E&M form as much as possible

22 Facility ED Leveling Methodology Diagnosis driven Like diagnoses consume like amounts of resources, similar to DRGs Time driven Similar services consume like amounts of resources, similar to APCs Point driven Each service provided is assigned a point value. The total of the points drive the level assigned. Points may NOT be assigned for a service that can be billed separately.

23 Facility ED Leveling Methodology sample Point System 5 POINTS 10 POINTS 15 POINTS 20 POINTS Initial Assessment BP Monitoring Pelvic Exam Admit ICU/CCU Wound Cleanse - simple Apply Clavicle Strap Transport to ICU Apply/Monitor Restraints Topical Meds Foley Cath Sample Enema/Disempaction Cardiac/Thrombolytic Agents Ace Wrap Emotional Support Multiple VS Checks Rape Exam Urine Dip Cardiac Monitoring IV Insertion Multiple IV Infusions Steri-strip Application Accompany to Lab/Rad Newborn Care points ormore or more

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25 Facility ED Leveling Methodology sample Matrix System CPT Could include interventions from previous levels, plus any of: Minor trauma Receipt of EMS/ambulance patient Heparin/saline lock One (1) nebulizer treatment Preparation for lab test described in CPT Preparation for EKG Preparation for plain x-rays on only one (1) area Prescription medication administed PO Foley catheter; In and Out cath C-spine precautions Fluorescein stain Emesis/Incontinent care Medical condition requiring prescription drug management Fever that responds to antipyretics Headache-hx of, no serial exam Head injury-w/o neurologic symptoms Eye pain Mild dyspnea-not requiring oxygen Prep or assist w/procedures such joint aspiration/injection, simple fracture care Mental Health-anxious, simple treatment Routine psych medical clearance Limited social worker intervention Post morten care Direct admit via ED Discussion of discharge Instructions (moderate complexity)

26 Billing Services in Addition to the E/M Program Memorandum A & A = 25 modifier = separate identifiable services. Golden rule: Always get the CPT-4 procedure code. Earn the E&M as the separate service. Inherent nursing in all procedures/cpt-4 codes ER = Triage = separate identifiable = add E&M Clinic = procedure + unplanned outcome of treatment or other medical condition = E&M Ensure the E&M criteria is well charted in addition to the Procedure Code (separate identifiable E&M)

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28 Practice Scenario #1 Patient presents to ED with complaints of nausea, vomiting, fever since last night. The patient is otherwise healthy but very distressed, emotional support provided. Initial assessment is completed by the nursing staff, including vital signs, with prolonged emotional support provided. Patient is seen by ED physician who conducts an expanded problem focused history, expanded problem focused exam and medical decision making of low complexity. She orders labs and an abdominal x-ray, all of which are negative. Tigan suppository given for nausea/vomiting. The patient is discharged home with simple instructions to rest, hydrate, and Tylenol for fever, if continues with Rx for Tigan suppositories for the nausea/vomiting. Assessment: flu

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30 Practice Scenario #1 Initial assessment 30 pts Prolonged support 5 pts Suppository given 5pts Discharge-simple 10 pts TOTAL POINTS 50 PTS E/M LEVEL 99282

31 Practice Scenario #2 A 22-year-old male presents to the ED with right hand pain, after punching another individual during an altercation in a bar. Initial assessment is done and his ring removed due to swelling, using the ring cutter. The patient is clearly inebriated and further injury were undetermined. Patient held in observation until sobered up. C-spine precautions were taken until further evaluations were made. Negative for neuro or spinal injury. He was given Tylenol #3 for pain. X- ray showed a moderately displaced fracture of the 4 th metacarpal. An immobilizing split was applied, as well as a sling. Simple discharge instructions were given. The patient discharged in satisfactory condition. Assessment: right 4 th metacarpal fracture, minimally displaced, reduced with manipulation and splinting.

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34 Practice Scenario #2 Initial assessment 30 pts Ring removed 5 pts Oral med given 5pts C-spine prevent 30 pts Discharge-simple 10 pts TOTAL POINTS 80 PTS E/M LEVEL 99284

35 Practice Scenario #3 A Hispanic speaking patient came in to the wound center for her weekly appointment to treat her chronic non-healing ulcer of the plantar aspect of her left foot. Her son was unable to accompany her today so an interpreter was called. Through the interpreter we learned that on her way across the parking lot she tripped and fell, hitting her head, right elbow and right knee on the pavement. After a thorough assessment, the patient was sent to Radiology for x-rays of all three areas. The x-rays proved to be negative for fractures. The abrasions on her forehead, elbow and knee were cleansed, treated with an antibiotic ointment and bandaged. Once this was completed, attention was turned to the ulcer of her left foot. The ulcer was debrided through the subcutaneous level, dressed and bandaged. The patient was urged to continue to offload the affected foot with her boot. She was discharged in satisfactory condition.

36 Practice Scenario #3 A Hispanic speaking patient came in to the wound center for her weekly appointment to treat her chronic non-healing ulcer. Her son was unable to accompany her today so an interpreter was called. Through the interpreter we learned that on her way across the parking lot she tripped and fell, hitting her head, right arm and right knee on the pavement. C-spine precautions were initiated. After a thorough assessment, the patient was sent to Radiology for x-rays of all three areas. The x-rays showed fractures of the both the distal ulna and radius. All others were negative. Social Services were consulted due to the patient being alone and facing surgery. They coordinated with her family. After examination by an Orthopedic surgeon in the wound center the patient was taken to the OR for repair of the fractures. An IV was started. Her superficial abrasions were cleansed, dressed and bandaged prior to her transfer. She was in stable condition.

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38 Practice Scenario #3 Initial assessment 30 pts Language barrier 10 pts Wound cleansing 5 pts Simple Dressing 5 pts Coordination of res 10 pts IV insertion (1) 20 pts C-spine precautions 30 pts Admit OR 30 pts TOTAL POINTS 140 PTS E/M LEVEL 99285

39 False Claims Reports Lawsuits Involving Hospitals and Health Systems Becker s Hospital Review, July, 2011 Louisville, KY based Norton Healthcare agreed to pay the federal government $782,842 in March to settle allegations that it overbilled Medicare for wound care, infusion and cancer radiation services by adding a separate E&M charge that should have been included in the basic rate. The alleged overbilling, which occurred between Jan Feb 2010 involved outpatient care. The settlement is twice the amount Norton allegedly overbilled. ISSUE: Transmittal A-00-40, A indicates there is inherent nursing in all CPT codes. Therefore, the facility must earn an E&M service when done with a procedure. Unlikely events, other medical conditions being treated, new patient=examples.

40 HOPD E/M Best Practices If no procedure, always look for an E&M ( ) If there is a procedure, the E&M must be earned E&M MUST be a separate, identifiable service Inherent nursing in all procedures (PM A-00-40) Examples of earning E&M in addition to the procedure: Unplanned outcome/event New dx, treatment, meds Other medical conditions Initial treatment

41 Last Thoughts on E/M Charge Capture No separate billable services should be part of the E&M Critical care (99291) - must map to a level 6 through the facility s own system, plus be in compliance with the CPT-4 guidelines, i.e., system failure, etc. If not, move back to 5 TEST and TEST SOME MORE any changes to the E&M leveling system Pull historical utilization, develop bell curve system sorted by like diagnoses. Compare against new proposed leveling system.

42 And Then There Was An Audit Internal self-auditing External assessment Ensure E&M criteria is understood by staff and charted Can the record support the procedure AND the separate identifiable E&M? Note dates of improvement/changes as part of due diligence process

43 Diagnosis Codes (ICD-10-CM) Diagnosis Codes support Medical Necessity! Must match the procedure or service provided Must be sequenced appropriately Must be relevant to the date and type of service Must be consistent with the providers scope of practice

44 Other Providers What happens when a patient sees different doctors who provide the same service on different dates of service? What happens when a patient sees a nonphysician provider (NPP)? What happens when a patient is referred or is a consult? Is there a difference?

45 Modifiers 25 - Appended to the E/M code to indicate a Significant, separately identifiable service by the same physician on the same day of the procedure or other service 51 Multiple procedures, other than E/M services 52 Reduced services 59 (X subsets) Distinct procedural services, independent from other non E/M services performed on the same day. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury 78 Unplanned return to OR by same surgeon following initial procedure for a related procedure during the post operative period (global period) 79 Unrelated procedure by same physician during the post operative period

46 Modifier Decision Tree

47 Summary Many different and complex factors affect reimbursement Know your codes (and modifiers!) Know the situation Know your policies (NCDs/LCDs) Know your payer (contracts) Hospital specific anomalies and practices

48 Resources ome (previously Highmark) (previously Cigna)

49 Thank You! Contact info:

50 CEU #