Medical Compliance Services Office of Billing Compliance Coding, Billing & Documentation Department of Family Medicine

Transcription

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

2 2017 Code Changes 2

3 Medicine: New Vaccine Influenza virus vaccine, quadrivalent (cciiv4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 ml dosage, for intramuscular use

4 CPT 2017 Revised Codes Code Description Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae type b vaccine (Hib-MenCY), 4 dose schedule, when administered to children 6 weeks-18 months of age, for intramuscular use Influenza virus vaccine, trivalent (IIV), split virus, preservative free, 0.25 ml dosage, for intramuscular use Influenza virus vaccine, trivalent (IIV), split virus, preservative free, 0.5 ml dosage, for intramuscular use Influenza virus vaccine, trivalent (IIV), split virus, 0.25 ml dosage, for intramuscular use Influenza virus vaccine, trivalent (IIV), split virus, 0.5 ml dosage, for intramuscular use Influenza virus vaccine, trivalent (cciiv), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 ml dosage, for intramuscular use Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 ml dosage, for intramuscular use Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 ml dosage, for intramuscular use Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 ml dosage, for intramuscular use Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 ml dosage, for intramuscular use Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use 9074 Meningococcal conjugate vaccine, serogroups A, C, Y and W-15, quadrivalent (MCV4 or MenACWY), for intramuscular use 4

5 Top Billed Non-E/M Codes CPT PROC_NAME UNITS Percent 9991PR PREVENTIVE VISIT,EST, INFANT < 1 YR % 90471PR IMMUNIZ ADMIN,1 SINGLE/COMB VAC/TOXOID % 9996PR PREVENTIVE VISIT,EST, % 9985PR PREVENTIVE VISIT,NEW, % 85018CHG HEMOGLOBIN % 9995PR PREVENTIVE VISIT,EST, % 9984PR PREVENTIVE VISIT,NEW, % 90658PR IIV VACCINE SPLIT VIRUS 0.5 ML DOSAGE IM USE % 9994PR PREVENTIVE VISIT,EST, % 90715PR TDAP VACCINE >7 YO, IM %

6 Top Billed E/M Codes CODE E&M UNITS Percentage 9921PR OFFICE/OUTPT VISIT,EST,LEVL III % 99212PR OFFICE/OUTPT VISIT,EST,LEVL II % 992PR SUBSEQUENT HOSPITAL CARE,LEVL III 21.80% 99214PR OFFICE/OUTPT VISIT,EST,LEVL IV 21.51% 99215PR OFFICE/OUTPT VISIT,EST,LEVL V 8 0.1% 99211PR OFFICE/OUTPT VISIT,EST,LEVL I % Total

7 National CMS Bell Curves OP Family Practice New Office Visits Procedure Code Current Annual Frequency Current Practice Dist. National % Dist. % Variance Practice vs. National % 0.91% 8.59% % 14.07% 0.71% % 49.61% 19.78% % 0.48% % % 4.9% -4.9% Totals % % % 80.00% 60.00% 40.00% 20.00% 0.00% % ` Practice State Established Office Visits Procedure Code Current Annual Frequency Current Practice Dist. National % Dist. % Variance Practice vs. National % 2.92% -2.84% %.19% 2.55% % 44.4% 45.60% % 46.58% % % 2.97% -2.82% Totals 5, % % % 80.00% 60.00% 40.00% 20.00% 0.00% % ` Practice State 7

8 National CMS Bell Curves IP Initial Hospital Visits Procedure Code Current Annual Frequency Current Practice Dist. National % Dist. % Variance Practice vs. National % 6.99% -6.24% % 7.97% -7.97% % 55.04% 44.21% Totals % % % 80.00% 60.00% 40.00% 20.00% 0.00% % Practice State Subsequent Hospital Visits Procedure Code Current Annual Frequency Current Practice Dist. National % Dist. % Variance Practice vs. National % 11.68% % % 62.11% % % 26.21% 7.79% Totals % % % 80.00% 60.00% 40.00% 20.00% 0.00% % Practice State 8

9 National CMS Bell Curves Hospital Discharge Day Management Discharge Days Procedure Code Current Annual Frequency Current Practice Dist. National % Dist. % Variance Practice vs. National % 55.46% % % 44.54% 55.46% Totals % % % 80.00% 60.00% 40.00% 20.00% 0.00% Practice State 9

10 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. 10

11 Putting The Puzzle Together 11

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

13 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. 1

14 Focus on the Present Illness or Reason for the Encounter

15 E/M Key Components 1. History (HX)- Subjective information 2. Examination (PE)- Objective information. Medical Decision Making (MDM)- Often linked to medical necessity The billable service is determined by the combination of these key components with MDM often linked to medical necessity. For new patients all components must be met or exceeded and established patient visits 2 of are required to be met or exceeded. Often when downcoded for medical necessity it is determined that documented History and Exam exceeded what was necessary for the visit. 15

16 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. 16

17 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, depression/mania/psychosis screen, safety, compliance, stressors, ETOH/Drugs (inc w/d) 17

18 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 18

19 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, sleeping, etc.) Modifying factors: does anything make it worse or better; Associated signs/symptoms: what other problems are associated with patient symptoms. Page 19

20 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. 20

21 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 21

22 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. 22

23 X X X X X X X X X X X

24 X X X X X X X X X X X

25 History: Step 1 Completed 25

26 Any Questions On History? 26

27 EXAMINATION 4 TYPES OF EXAMS Problem focused (PF) Expanded problem focused (EPF) Detailed (D) Comprehensive (C) 27

28 Coding 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 28

29 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 29

30 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 non-shaded area. GMS: At least 2 elements with bullet from each of 9 areas/systems. 0

31 Examination X X X X X X X

32 Exam: Step 2 Completed 2

33 Any Questions Exam?

34 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 4

35

36 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. 6

37 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,

38 Medical Decision Making

39 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 9

40 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) POINT: 99212, 99201, 99202, POINTS: 9921, 9920, POINTS: 99214, 99204, 9922, POINTS: 99215, 99205, 992, 9922 Total 40

41 Medical Decision Making 2

42 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 42

43 MDM Step : Table of Risk Table Assess Patient Risk Based On: Diagnoses Diagnostics Management Options 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 4

44 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

45 Type of Decision Diagnosis and/or Risk of Complication Low One or 2 self-limited condition(s) or symptom(s). One stable chronic illness or condition. Acute self-limited uncomplicated illness or injury. Risk of complications, morbidity, or mortality is low. Examples Acute gastroenteritis, Pharyngitis/tonsillitis, Epistaxis, Upper respiratory infection, Otitis media Table Pediatric Medical Decision Making Outline, Child/Adolescent* Procedure/Test and/or Data Reviewed Cultures (throat, urine, stool, eye) Tympanometry Stool rotazyme Rapid streptococcus screen Management Options Oral antibiotic therapy Topical therapy Over-the-counter prep therapy Symptomatic management Fever treatment Parent education Oral hydration Intravenous fluid therapy Moderate Three or more self-limited conditions. One or more chronic mild and/or self-limited condition(s) with ongoing activity (active condition), mild to moderate exacerbation, progression, or side effects of treatment. Two or stable chronic illnesses or conditions requiring evaluation. Undiagnosed new illness, injury, or condition with uncertain prognosis. Risk of complications, morbidity, or mortality is moderate.there may be an uncertain prognosis or the possibility of prolonged functional impairment with or without treatment. Imaging studies with contrast Foreign body removal Allergy testing Pelvic examination Mononucleosis test Complete blood count Blood chemistries Hospital admission Specialist referral Parenteral antibiotic therapy Minor surgery Nebulized aerosol treatment Outpatient acute care facility treatment Move intravenous fluid therapy to moderate Examples Acute croup, Chronic eczema, Peritonsillar abscess Acute gastroenteritis with moderate dehydration, Pneumonia, Pyelonephritis, Asthma, persistent, moderate High One or more acute or chronic illness(es) with severe exacerbations. Four or more stable chronic illnesses or conditions requiring evaluation. Acute complicated injury with significant risk of morbidity or mortality. One or more acute or chronic illness(es) or condition(s) that pose(s) imminent threat to life or bodily function. Abrupt change in bodily function (eg, seizure, cerebrovascular accident, acute mental status change). The risk of complications, morbidity, or mortality is high. There is a possibility of significant prolonged functional impairment. Examples Acute epiglottis, Major multiple trauma, Asthma, acute with severe respiratory distress syndrome, Meningitis, Multiple somatic complaints, Rape, Attempted suicide, Renal failure, Child abuse, Seizure, new/prolonged Leukemia, new, Sickle cell aplastic crisis Thoracotomy tube Bone marrow aspiration Biopsy Computed tomography/ magnetic resonance imaging Spinal tap Imaging studies with contrast Parenteral antibiotic therapy (with blood level monitoring). Monitoring may not be required. Cardiorespiratory support. Hospital intensive care unit care. Transfer care to intensivist. Major surgery. Ventilator therapy. Do not resuscitate decision. Total parenteral nutrition. *These guidelines are not approved or recognized by the Centers for Medicare and Medicaid Services (CMS).They are to be used for educational purposes only. 45

46 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

47 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 47

48 Medical Decision Making: Step Completed 48

49 Any Questions on Medical Decision Making (MDM)? 49

50 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 50

51 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. 51

52 What is Coordination of Care Report on Medicare Compliance August 22, 2016 Counseling/Coordination 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. *. 52

53 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. 5

54 What is Coordination of Care Report on Medicare Compliance August 22, 2016 Application: If counseling and/or the coordination of care dominate the patient encounter, the physician has the option to select the level of E/M service based on the average time thresholds associated with each E/M level per the AMA. The physician must document the following elements to ensure the appropriate support for the assignment of the E/M level based on counseling/coordination of care as a contributory factor: Total length of the appointment face-to-face; That more than 50% of the total appointment time was spent in counseling/coordination of care; Documentation of the nature of the counseling and explicitly what topics were discussed in the counseling/coordination of care. 54

55 What is Coordination of Care Report on Medicare Compliance August 22, 2016 Here are examples of when time spent in the counseling/coordination of care might dominate an E/M encounter. This is distinct work from the rendering of psychotherapy for which there are now separate codes: Extended discussion with patient regarding medication compliance issues. Discussion with patient regarding a medication change; above and beyond expected explanations of risks/benefits. Follow-up visit with child, parent and case manager to discuss plan to address child s increasing school avoidance and plans to coordinate with the school. Consultation with patient and spouse regarding the consideration of ECT as a treatment option. Extended discussion with parent and child regarding implementation of increased structure for child in their daily activities and school. Follow-up visit with spouse and patient whose dementia has noticeably worsened and the physician initiates discussion to address prognosis and anticipated future care needs. Psychiatric treatment compliance issues being hindered by patient s ongoing substance abuse; discussion regarding treatment alternatives. * Care Coordination Measures Atlas. January Agency for Healthcare Research and Quality, Rockville, MD. systems/long-term-care/resources/coordination/atlas/index.html. 55

56 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). 56

57 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 57

58 Time X X X

59 Discharge Day Codes Teaching Physician Time Only! CPT 9928: TP s management of patient s D/C took < 0 minutes. CPT 9929: Differs from 9928 because it requires documentation of time > 0 minutes spent managing the patient (final exam, Rx management, POC after D/C). The hospital discharge day management codes are to be used to report: the total duration of time spent by a physician for final hospital discharge of a patient. The codes include, as appropriate, final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, Instructions for continuing care to all relevant caregivers, and Preparation of discharge records, prescriptions and referral forms. EXAMPLE: I saw and evaluated the patient today and agree with resident note. Discharge instructions given to patient and Rx s. To F/U in 5 days in clinic The hospital required discharge summary is not documentation of patient discharge management for billing a 9928 or 9929 unless there is a statement that indicates that the attending personally saw the patient and discussed discharge plans on the day the code was billed. 59

60 Completing the Puzzle 60

61 Prolonged Services 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 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. 61

62 Prolonged Services 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 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. 62

63 Threshold times for prolonged outpatient visit codes 9954 and This chart, issued by CMS, assists in determining when a prolonged service code may be billed, and to select the correct code combination. To use: Locate the appropriate code, then scan across to see if your total time for the service fits the prolonged service thresholds. Note: Add an additional 0 minutes to the threshold times in the far right column to get the threshold time for 9954 and 2 units of Code Typical time for code (min.) Threshold time to bill 9954 (min.) Threshold time to bill 9954 and 9955 (min.)

64 Source for both tables: CMS transmittal 1490 Threshold times for prolonged inpatient visit codes 9956 and 9957 Use this chart, issued by CMS, to help determine when a prolonged service code may be billed. To use: Locate the appropriate code, then scan across to see whether your total time for the service fits the prolonged service thresholds. Note: Add an additional 0 minutes to the threshold times in the far right column to get the threshold time for 9956 and two units of Code Typical time for code (min.) Threshold time to bill 9956 (min.) Threshold time to bill 9956 and 9957 (min.)

65 Prolonged Services 99415: Prolonged clinical staff service (the service beyond the typical service time) during an E/M service in the office or outpatient setting (POS 11 only), direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient E/M service) To bill clinical staff Prolonged codes, time starts at >45 minutes 99416: Prolonged clinical staff service (the service beyond the typical service time) during an E/M service in the office or outpatient setting, direct patient contact with physician supervision; each additional 0 minutes (List separately in addition to code for prolonged service) Do bill with Do not bill or with NOTE: Document what you did and how long you did it. If you are billing additional procedures, document the time and note that they are excluded from the prolonged service so double-dipping is not questioned. OUTPATIENT ONLY. REGULATIONS PER CMS: The medical record must document by the practitioner to include the dated start and end times of the prolonged service. 65

66 Routine Physical Exam: Preventive Periodic comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, coded as new or established patient; infant to 65 years & older. When a practitioner sees an asymptomatic patient for a head-totoe routine physical, the correct procedure code to report is (periodic preventive medicine evaluation and management) or EPSDT. The extent and focus of the services will largely depend on the age of the patient. 66

67 Preventive Services An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported. The "comprehensive" nature of the Preventive Medicine Services codes reflects an age and gender appropriate history/exam and is not synonymous with the "comprehensive" examination required in Evaluation and Management codes Codes include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination. 67

68 Modifier 25 Be ALERT Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. The patient s condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and post-procedure care associated with the procedure or service performed The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. The service could be a minor procedure, diagnostic service, E/M visit with a preventive service or E/M with a Medicare Well Visit or Well-Woman service. It is STRONGLY recommended that 2 separate and distinct notes be included in the medical record to document the procedure and then the separate E/M service Only a practitioner or coder should assign a modifier 25 to a Claim Not a biller. 68

69 Preventive Visit and E/M Same Day "If the problem is significant enough that it would require the patient to come back for another issue if you didn't address it, that's a sign that it could warrant a problem-based E/M code". "In addition, check whether the problem-based visit has its own ICD-10 code. Also, these separate visits typically require some evaluation and treatment such as x-ray or lab tests, and may require a prescription". Example :The physician performs a preventive medicine visit on a 9-yearold girl (999). During the visit, he also reevaluates her ADHD and adjusts her medication. Therefore, you'll report 999 linked to well visit Dx for the preventive medicine visit, along with a problem-based E/M code such as linked to Dx for the ADHD. You'll most likely select the problem-based E/M code on the amount of time spent counseling the patient related to the ADHD problem. 69

70 Medicare Well Woman Medicare will reimburse for G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Pap Smear) if it has been 2 years for women at normal risk. Annually if the patient meets the criteria for highrisk or women of childbearing age with abnormal Pap test within past years. High risk factors for cervical and vaginal cancer are any one of the following: Early onset of sexual activity (under 16 years of age); Multiple sexual partners (five or more in a lifetime); History of sexually transmitted disease (including human immunodeficiency virus {HIV} ); Fewer than three negative Pap smears within the previous 7 years; Prenatal exposure to diethylstilbestrol Exposed daughters of women who took DES during pregnancy. High Risk: Z77.22, Z77.9, Z91.89, Z72.89, Z72.51, Z72.52, and Z72.5 Low Risk: Z01.411, Z01.419, Z12.4, Z12.72, Z12.79, and Z12.89 Source: Noridian Medicare Services/Medicare Preventive Services 70

71 Screening Breast & Pelvic Exam: G0101 Documentation MUST include at least 7 of the following 11 elements : 1. Inspection and palpation of breasts 2. Digital rectal exam including sphincter tone, presence of hemorrhoids, masses Pelvic exam (with or without specimen collection for smears and cultures) including:. External genitalia (e.g., general appearance, hair distribution, lesions) 4. Urethral meatus (e.g., size, location, lesions, prolapse) 5. Urethra (e.g., masses, tenderness, scarring) 6. Bladder (e.g., fullness, masses, tenderness) 7. Vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) 8. Cervix (e.g., general appearance, lesions, discharge) 9. Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support) 10. Adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity) 11. Anus and perineum 71

72 Screening for PAP Tests Medicare will reimburse for Q0091 (screening pap smear; obtaining, preparing and conveyance to lab) Every 2 years for women at normal risk. ICD-10 Coding High risk Z77.21, Z77.22, Z77.9, Z91.89, Z92.89, Z72.51, Z72.52, and Z72.5 Low risk Z01.411, Z01.419, Z12.4, Z12.72, Z12.79, and Z12.89 Annually if the patient is at high risk of developing cervical or vaginal cancer or women of childbearing age with abnormal Pap test within past years. Source: Medicare Preventive Services 72

73 If you are billing the patient for a preventive service and billing Medicare for the breast exam, pelvic exam, and obtaining the pap during the same encounter, CMS requires you to reduce the fees to the patient to offset what CMS is reimbursing you for what would have been considered preventive and paid for by CMS. Example, the charge for the preventive service is $00, Medicare reimburses the breast exam and pelvic exam $42.52 and obtaining the pap smear $48.7. The patient would be charged $

74 Non-Physician Practitioners (NPP s) or Physician Extenders Who is a NPP? Physician Assistant (PA) Nurse Practitioner (NP) 74

75 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) 75

76 INCIDENT TO Incident to services must be an integral part of the patient s treatment course Provided under the physician s direct personal supervision (Physician must be present in the office suite and be immediately available to provide assistance and direction throughout the time the services are being performed) Commonly furnished in a physician s office (not in a hospital setting) Auxiliary Personnel must be directly employed by the physician, physician group or entity that employs the physician or may be a leased employee 76

77 INCIDENT TO Established Patient Visits: Incident to Billing Requirements Commonly furnished in a physician s office that are incident to the professional services of a physician. Physician must personally perform an initial service for each new condition, make an initial diagnosis, and establish a treatment plan. Physician must personally perform subsequent services at a frequency that reflects his/her active participation in and management of the course of the treatment for each medical condition. Services must be performed under a physician s direct personal supervision: (Present in the office suite and immediately available to provide assistance and direction throughout the time the staff is performing the incident to services.) The incident-to practitioner may NOT see any new patients or any new issue not previously under a plan-of-care from a physician and bill as incident-to. 77

78 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 78

79 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. 79

80 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. 80

81 Scribes

82 Scribed Notes Record entries made by a "scribe" should be made upon the direction of the physician. A scribe should be merely that, a person who writes what the physician dictates and does. This individual should not act independently or obtain any information independently except to ROS and PFSH. They cannot obtain the HPI, any portion of the PE or MDM. The scribe must note "written by xxxx, acting as scribe for Dr. yyyy." Then, Dr. yyyy indicating that the note accurately reflects work and decisions made by him/her and then authenticate with signature. It is inappropriate for an employee of the physician to round at one time and make entries in the record, and then for the physician to see the patient at a later time and note "agree with above ". AAMC does not support someone dictating as a scribe by an NPP, as scribing is over the shoulder immediate documenter with no services personally performed by the scriber. In this case, the physician should be dictating their own visit. Scribes can do EMRs under their own password. 82

83 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] by [Name of scribe] [date and time of entry]. The following attestation should be entered by provider when closing the encounter: I was present during the time with [patient name] 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]. 8

84 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 84

85 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. 85

86 Unacceptable TP Documentation Assessed and Agree Reviewed and Agree Co-signed Note Patient seen and examined and I agree with the note As documented by resident, I agree with the history, exam and assessment/plan 86

87 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. 87

88 Minor (< 5 Minutes): For payment, a minor procedure billed by a TP requires that s/he is physically present during the entire procedure. Example: I was present for the entire procedure. Major (>5 Minutes) TP Guidelines for Procedures SINGLE Procedure / Surgery When the teaching surgeon is present or performs the procedure for a single non-overlapping case involving a resident, he/she or the resident can document the TP s physical presence and participation in the surgery. Example: I was present for the entire procedure (or key and critical portions & description of the key and critical portions of the procedure and immediately available). Endoscopy Procedures (excluding Endoscopic Surgery): TP must be present during the entire viewing for payment. The viewing begins with the insertion and ends with the removal. Viewing of the entire procedure through a monitor in another room does not meet the presence requirement. Example: I was present for the entire viewing. 88

89 Primary Care Exception(PCE) Rule In order to function under PCE, certain requirements must be met and approval must be granted. Qualifying residency programs may include family practice, general internal medicine, geriatric medicine, pediatrics and obstetrics/gynecology. Approved Programs are at JMH ACC West and Jefferson Reeves. In general, PCE allows the medical resident to see patients without the physical presence of a teaching physician for lower level E/M services (levels and below) and certain preventive services. The teaching physician (TP) has the primary medical responsibility for patients cared for by the medical residents under PCE and is responsible for reviewing the care provided by the medical resident during or immediately after each visit. If the TP personally sees and evaluates the patient, regular teaching rules apply and the TP can bill above level visits. 89

90 Primary Care Exception(PCE) Rule TP can work with 4 residents and of the 4 must have > 6months experience. The TP cannot be managing any other staff while providing PCE services (including NP s and PA s). For payment, a PCE service billed by a teaching physician requires that s/he personally document the extent of his/her participation in the review and direction of the services furnished to each patient. Case discussed with Dr. Resident at the time of the visit. Patient presents a diagnosis of..and treatment with..agree or (revise) with diagnosis of and plan of care.. Or: Patient case reviewed and discussed with resident at the time of visit. Given a history of Exam and assessment show..(state test findings of significance). I agree (revise) plan of care as. Phrases such as, Discussed and agree with resident s assessment and plan are NOT adequate, since this language does not show when the review occurred and what patient specific information was reviewed with resident. GE MODIFIER The GE Modifier must be used to bill Medicare for any service involving residents under the Teaching Physician Primary Care Exception Rule. 90

91 Orders Are Required For Any Diagnostic Procedure With a TC / 26 Modifier The CPT descriptions of documentation requirements for many ophthalmic diagnostic tests include the phrase,... with interpretation and report." Once the appropriate individual has performed the test, you must document your interpretation of the results somewhere in the medical records. This doesn't have to be anything elaborate. It may merely be a brief phrase indicating if a test is "normal," "stable from a previous test" or "mild superior arcuate defect." 91

92 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. 92

93 Top Compliance Issues For Documenting in EMR 9

94 Documentation in EMR PAYORS ARE WATCHING EMR DOCUMENTATION Once you sign your note, YOU ARE RESPONSIBLE FOR ITS CONTENT 94

95 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! 95

96 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 96

97 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!) 97

98 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 98