Evaluation and Management Services

Transcription

1 Evaluation and Management Services Print 1. If a physician sees a patient in the morning and again in the afternoon for a new or worsened condition, do we report modifier 25 for the second visit? 2. When is it appropriate to append modifier 51 to a service? 3. How does Novitas Solutions review Evaluation and Management Services (E/M) billed with the 25 modifier? 4. Under the Examination Section of the 1995 Score sheet, can we combine the body areas and organ systems? 5. If we are using the 1997 evaluation and management guidelines for the examination component, do we have to use the 1995 guidelines for the history and medical decision making components? 6. What is meant by "Status of chronic conditions"? 7. When scoring medical records, how is medical necessity considered? 8. If the physician states same/unchanged from last visit, will he receive credit for reviewing the last visit information? 9. For the Review of Systems, can the physician reference a sheet that he has in the patient's chart where the physician checked off items? 10. What is the 4 x 4 method for determining if an examination is scored as an expanded problem focused or detailed? 11. Our office requests that our patients complete a form by checking yes or no regarding their medications, medical history, family history, and social history information. Can we include this information as documentation of the Past, Family, Social History (PFSH) and Review of Systems (ROS)? 12. We are seeing denials for our physician s new patient visits. The denial message is saying that this patient was seen by our group in the last three years. Why is this occurring? What can we do about it? 13. Can I use the patients past history in the review of systems (ROS) or history of present illness (HPI) elements of the E/M score sheet? 14. Where can I find the evaluation and management (E/M) specialty score sheets on the Internet? 15. When scoring the review of systems (ROS), can you use the systems addressed in the history of present illness (HPI) elements or is that "double dipping"? 16. Do body areas of the examination section of the 1995 score sheet work exactly as the organ systems? 17. How do we get credit for a test under the Amount and/or Complexity of Data Reviewed section of the evaluation and management (E/M) score sheet? 18. What constitutes additional workup in the Amount and Complexity of Data grid for Medical Decision Making? 19. My patient visits are dominated primarily by counseling and coordination of care. How do I bill for this type of patient visit? 20. If I personally review a film, e.g. x ray, electrocardiogram (EKG) in my office, will I receive 2 points on the evaluation and management (E/M) score sheet? 1/10

2 21. Can the Review of Systems (ROS) and/or Past, Family, Social History (PFSH) sections of the History component of an Evaluation and Management (E/M) be recorded by ancillary staff? 22. Under limited circumstances, could the term noncontributory be used as appropriate documentation to support the review of systems (ROS) and family history sections of the history component of an evaluation and management service (E/M)? 23. How can we differentiate modifying factors versus associated signs and symptoms? 24. The March 2013 CPT Assistant Professional Edition, (page 8), states that providers may bill an office/outpatient Evaluation and Management (E&M) visit ( ) for meeting with a patient s family, to discuss the patient s care, without the patient present. Is this appropriate billing under the Medicare program? 25. Can two physicians in the same group practice, who see the same patient on the same day, each bill for an Evaluation and Management (E/M) service and receive payment? 26. How does Novitas Solutions credit military history when scoring the past, family, and social history (PFSH) in evaluation and management (E/M) services? 27. If we decide to admit from the office, should we bill the office visit and the lowest initial admission code? 28. When the specialist submits their claim, is the name of the admitting/treating physician reported in Block 17? 29. Can we bill another initial inpatient hospital service if the patient is readmitted and the same physician is requested again for consultation? 30. Can you confirm when I d use the AI modifier? 31. Will my claims deny if the admitting physician does not append the AI modifier? 32. Is there a higher reimbursement for the AI modifier? 33. Has Medicare taken steps to ensure that consultants coming to the emergency department and billing codes will not result in rejections for duplicate claims since the emergency department physician will be billing using the same Current Procedure Terminology (CPT) codes? 34. Medicare used to pay for one initial hospital visit per stay. Has this changed? 35. Should the admitting physician utilize the AI modifier only on the initial hospital/nursing facility visit or must it be used for all visits including subsequent hospital and/or ER services billed by the admitting physician? 36. Would an initial inpatient hospital service by a consultant be denied or rejected if a claim is not received from the admitting physician appended with the AI modifier? 37. If the physician who submits a claim for an initial hospital or nursing home visit with an AI modifier uses the same diagnosis as the consultant physician, will either claim be denied or rejected? 38. Am I permitted to bill an initial hospital visit (for a consultation) even though I have an established relationship with the patient? 39. When a physician performs an Evaluation and Management (E/M) service and the patient is not able to provide history, if the physician documents patient in a coma ; patient not able to respond ; patient unresponsive, can they count a comprehensive history? 2/10

3 Since January 1, 2010, consultation codes ( and ) are no longer recognized for Medicare Part B payment. Physicians shall code patient evaluation and management (E/M) visits with E/M codes that represent WHERE the visit occurs and that identify the COMPLEXITY of the visit performed. Please refer to the Centers for Medicare and Medicaid Services (CMS) Medicare Learning Network (MLN) Matters Article MM6740 * for details. 1. If a physician sees a patient in the morning and again in the afternoon for a new or worsened condition, do we report modifier 25 for the second visit? No, modifier 25 is used to identify a significantly, separately identifiable evaluation and management (E/M) service performed by a physician on the same date as a procedure or other service. Novitas Solutions would not expect to see two E/M services reported on the same date on a routine basis. A second E/M service would be billed for rare circumstances only. If a second E/M service is required on the same date of service, the documentation should clearly provide evidence that the second E/M service occurred, the reason for the additional E/M service, and documentation of the medical necessity of the second E/M service. If a second E/M service is reported on the same date, the service could initially be denied. The denial can be appealed using the Part B Appeals Reference Guide. 2. When is it appropriate to append modifier 51 to a service? When multiple procedures, other than evaluation and management services, are performed on the same day or at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier 51 to the additional procedure or service code(s). This modifier should not be appended to designated "add on" codes or codes identified in the Current Procedural Terminology (CPT) manual as modifier 51 exempt. 3. How does Novitas Solutions review Evaluation and Management Services (E/M) billed with the 25 modifier? Modifier 25 is defined as a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. In the review of E/M services billed with the 25 modifier, Novitas Solutions will first identify within the medical records the documentation specific to the procedure or service performed on that date of service. Next, we will consider the additional documentation separate from the documentation specific to the procedure or service to determine: If there is a significant, separately identifiable E/M service that was rendered and documented, and If the required components of the E/M service are supported as "reasonable and necessary" per Social Security Act, Section 1862(a) (1) (A), and What level of care is supported by the documentation? 4. Under the Examination Section of the 1995 Score sheet, can we combine the body areas and organ systems? No. The examination section of the 1995 score sheet is divided into body areas and organ systems. The Current Procedural Terminology (CPT) manual recognizes 7 body areas and 12 organ systems. Depending on the documentation in the patient's medical record, you can use either the body areas or the organ systems. There is a dotted line between the 3/10

4 body areas and organ systems indicating you must choose one or the other. If you combined the body areas and organ systems, you would be giving credit twice, which would be incorrect when determining the final score for the examination section of the score sheet. An example could be the documentation in the patient's medical record stated abdomen soft, credit can only be given in the body areas under abdomen or in the organ systems under Gastro Intestinal (GI), which ever area benefited the physician the most. 5. If we are using the 1997 evaluation and management guidelines for the examination component, do we have to use the 1995 guidelines for the history and medical decision making components? The 1997 guidelines provided the specialty examination guidelines only. Therefore, the history and medical decision making components from the 1995 guidelines are used for all evaluation and management services. This said, under the history component, the Status of chronic conditions was added after the 1995 guidelines were instituted. This element of the history component is also available for all services. 6. What is meant by "Status of chronic conditions"? In 1997, the Evaluation and Management (E/M) Guidelines were enhanced under the History of Present Illness (HPI) section of the 1995 score sheet to include the patient's chronic conditions the practitioner is following or in which an exacerbation may have occurred resulting in the chief complaint and the reason for the patient encounter. The documentation in the patient's medical record must clearly state a status of the chronic condition in order to meet the requirement under the History HPI Status of 1, 2, or 3 Chronic Conditions on the 1995 score sheet. An example could be hypertension stable on Atenolol. 7. When scoring medical records, how is medical necessity considered? All services under Medicare must be reasonable and necessary as defined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section states, no payment may be made for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of a malformed body member. Therefore, medical necessity is the first consideration in reviewing all services. 8. If the physician states same/unchanged from last visit, will he receive credit for reviewing the last visit information? Credit may be taken only if the physician includes the documentation from the previous visit. Otherwise, the reviewer would not know what was same or unchanged from the previous visit. 9. For the Review of Systems, can the physician reference a sheet that he has in the patient's chart where the physician checked off items? Yes. However, if medical records are requested, the sheet must be submitted with all of the other documentation for that date of service. Otherwise, no credit can be given for the information on the check off sheet. 10. What is the 4 x 4 method for determining if an examination is scored as an expanded problem focused or detailed? Under the 1995, guidelines both the expanded problem focused examination and the detailed examination provide for the 4/10

5 examination of up to 7 systems or 7 body areas. This has led to variability in reviews utilizing the 95 guidelines, and requiring an interpretation for proper and consistent implementation of the evaluation and management (E/M) guidelines. By providing a tool we call 4X4 (4 elements examined in 4 body areas or 4 organ systems satisfies a detailed examination; however, less than such can be a detailed exam based on the reviewers clinical judgment) our reviewers and physicians have a clinically derived tool to assist in implementing the E/M guidelines and decreasing one area of ambiguity. This tool is consistent with the way medicine is practiced, as confirmed in Documentation Coding & Billing by Laxmaiah Manchikanti, M.D, and A Guide to Physical Examination by Barbara Bates, M.D. And, it is a tool to reduce reviewer variability. Novitas Solutions nurse reviewers follow the guidelines for auditing E/M services that are provided by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA). This includes consideration of both the 1995 and 1997 guidelines, with the utilization of the guidelines that are most beneficial to the physician. We also instruct our nurse reviewers to use their clinical knowledge while reviewing the medical record documentation to determine the correct and appropriate level of care. Clinical inference overrides the 4 x 4 tool. It provides for an individual consideration, and makes the review of all services (including E/M examinations) fairer to the physician. Clinical inference is in keeping with the CMS current instructions for reviewing all medical records. Again, our reviewers utilize either the 95 or the 97 guidelines when reviewing E/M services, and utilize the guidelines that benefit the provider. With all of this said, our reviewers utilize one of the following when making a determination on whether an examination is expanded problem focused or detailed. The method chosen must be the one that is most beneficial to the physician E&M examination guidelines, 1995 E&M examination guidelines utilizing the 4 x 4 tool, or 1995 E&M examination guidelines utilizing clinical inference 11. Our office requests that our patients complete a form by checking yes or no regarding their medications, medical history, family history, and social history information. Can we include this information as documentation of the Past, Family, Social History (PFSH) and Review of Systems (ROS)? Yes, this information may be used if the physician notes that he has reviewed the form. It is also appropriate for the physician to note in the medical records any additional information obtained during the face to face encounter. 12. We are seeing denials for our physician s new patient visits. The denial message is saying that this patient was seen by our group in the last three years. Why is this occurring? What can we do about it? In a multi specialty group, if the patient was seen by a non physician practitioner (NPP), this may cause your new patient visit to deny for a physician. If you can provide documentation that shows that the non physician practitioner and the physician are trained in different specialties, request a redetermination of the claim with the documentation. A new patient is defined as a patient who has not received any professional services, i.e., evaluation and management (E/M) service or other face to face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. Currently, under the CMS enrollment process, NPPs are not afforded the opportunity to designate a sub specialty. A NPP can only designate their primary licensure, e.g. Nurse Practitioner, Physician Assistant, Certified Nurse Midwife, etc. Reference: 5/10

6 Centers for Medicare and Medicaid Services (CMS) Publication 100 4, Chapter 12, Section A * 13. Can I use the patients past history in the review of systems (ROS) or history of present illness (HPI) elements of the E/M score sheet? No. The ROS and HPI elements pertain to the chief complaint and the reason for the patients visit that day, not past history information. 14. Where can I find the evaluation and management (E/M) specialty score sheets on the Internet? The E/M specialty score sheets are found on the Novitas Solution's website. 15. When scoring the review of systems (ROS), can you use the systems addressed in the history of present illness (HPI) elements or is that "double dipping"? ROS inquiries are questions concerning the system(s) directly related to the problem(s) identified in the HPI. Therefore, it is not considered "double dipping" to use the system(s) addressed in the HPI for ROS credit. 16. Do body areas of the examination section of the 1995 score sheet work exactly as the organ systems? You may count up to 7 body areas or 7 organ systems for an expanded problem focused or detailed examination and you may count 8 body areas or 8 organ systems for a comprehensive examination. However, you may not add body areas and organ systems together to determine the level of the examination. 17. How do we get credit for a test under the Amount and/or Complexity of Data Reviewed section of the evaluation and management (E/M) score sheet? Credit is given in this section when the test (clinical lab test, test in the radiology section of the CPT, or test in the medicine section of the CPT) is documented as reviewed and/or ordered, and the service is medically indicated. 18. What constitutes additional workup in the Amount and Complexity of Data grid for Medical Decision Making? The number of possible diagnosis and/or the number of management options that must be considered is based on the number of types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions that are made by the physician. For each encounter, an assessment clinical impression or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation. Additional workup is defined as anything that is being done beyond that encounter at that time. For example, if a physician sees a patient in his office and needs to send that patient on for further testing, that would be additional workup. The physician needs to obtain more information for his medical decision making. 19. My patient visits are dominated primarily by counseling and coordination of care. How do I bill for this type of patient visit? When counseling and/or coordination of care dominate more than 50% of the time a physician spends with a patient during 6/10

7 an evaluation and management (E/M) service then time may be considered as the controlling factor to qualify the E/M service for a particular level of care. If the physician elects to report the level of care based on counseling and/or coordination of care, then a number of factors must be documented in the patient's medical record. The following must be documented in the patient's medical record in order to report an E/M service based on time: The total length of time of the E/M visit; Evidence that more than half of the total length of time of the E/M visit was spent in counseling and coordinating of care; and The content of the counseling and coordination of care provided during the E/M visit. 20. If I personally review a film, e.g. x ray, electrocardiogram (EKG) in my office, will I receive 2 points on the evaluation and management (E/M) score sheet? Yes, two points may be given for independent visualization of an image, tracing or specimen on the E/M score sheet in the Amount and/or Complexity of Data Reviewed section under the Medical Decision Making key component. The medical record documentation must clearly indicate that the physician/qualified non physician practitioner (NPP) personally (independently) visualized and performed the interpretation of the image; tracing or specimen and that he/she did not simply read/review a report from another physician/qualified NPP. 21. Can the Review of Systems (ROS) and/or Past, Family, Social History (PFSH) sections of the History component of an Evaluation and Management (E/M) be recorded by ancillary staff? Yes, according to the 1995 E/M Documentation Guidelines, the ROS and/or PFSH section of the history component of an E/M may be recorded by ancillary staff. There must be a notation supplementing or confirming the information that was recorded by the ancillary staff member by the physician. 22. Under limited circumstances, could the term noncontributory be used as appropriate documentation to support the review of systems (ROS) and family history sections of the history component of an evaluation and management service (E/M)? It is understood that there may be circumstances where the term "noncontributory" may be appropriate documentation when referring to the ROS and/or family history sections of the history component of an E/M service. Under the E&M documentation guidelines, it is noted that, "those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented." The use of the term "noncontributory" may be permissible documentation when referring to the remaining negative review of systems. The term "noncontributory" may also be appropriate documentation when referring to a patient's family history during an E/M visit, if the family history is not pertinent to the presenting problem. 23. How can we differentiate modifying factors versus associated signs and symptoms? A modifying factor is something that is being done to help or alleviate the problem. Associated signs and symptoms are signs and symptoms that are associated or could be related to the presenting problem. 24. The March 2013 CPT Assistant Professional Edition, (page 8), states that providers may bill an 7/10

8 office/outpatient Evaluation and Management (E&M) visit ( ) for meeting with a patient s family, to discuss the patient s care, without the patient present. Is this appropriate billing under the Medicare program? No, billing office/outpatient E&M services ( ), in the absence of the patient, is not billable under the Medicare program. Please refer to Internet Only Manual Publication , Chapter 15 30(A) * and Claims Processing Manual, Publication , Chapter 12, * 25. Can two physicians in the same group practice, who see the same patient on the same day, each bill for an Evaluation and Management (E/M) service and receive payment? Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one E/M (face to face) service is provided on the same day, to the same patient by the same physician or more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group. If more than one physician in the same group practice with the same specialty bills for an E/M on the same day for the same patient, it may result in a denial of one of the E/M services. In this instance, an appeal of the denied E/M service will be necessary to provide supporting documentation of an unrelated service or a physician sub specialty not reflected in the Medicare provider record. Reference: Centers for Medicare and Medicaid Services Claims Processing Manual, Publication , Chapter 12, section * 26. How does Novitas Solutions credit military history when scoring the past, family, and social history (PFSH) in evaluation and management (E/M) services? Novitas Solutions will give credit under social history when there is a reference to the patient s military history. Social history also includes marital status and/or living arrangements, current employment, occupational history, use of drugs/alcohol/tobacco, level of education, and other relevant social factors. You can find information on E/M services in the Medicare Learning Network Evaluation and Management Services Guide * and the 1995 Documentation Guidelines for Evaluation and Management Services *. 27. If we decide to admit from the office, should we bill the office visit and the lowest initial admission code? The basic requirements for the initial hospital admission codes have not changed so a face to face visit at the hospital is still required. If admitting the patient after an office visit, the initial hospital code would include all work performed by the physician in all sites office and hospital. 28. When the specialist submits their claim, is the name of the admitting/treating physician reported in Block 17? Since you are not billing consultations anymore, there is no requirement for this information. However, reporting it is not incorrect. 8/10

9 29. Can we bill another initial inpatient hospital service if the patient is readmitted and the same physician is requested again for consultation? If the patient is in a new stay (discharge and readmitted) and you are consulted again, you bill the evaluation and management (E/M) code that best describes what you did and documented. That could be an initial hospital visit, or a subsequent hospital visit code. 30. Can you confirm when I d use the AI modifier? The AI modifier (Principal Physician of Record) is appended by the principal physician of record to the evaluation and management (E/M) code. Medicare defines the principal physician of record as the physician who oversees the patient s admission and care. 31. Will my claims deny if the admitting physician does not append the AI modifier? No. 32. Is there a higher reimbursement for the AI modifier? No. 33. Has Medicare taken steps to ensure that consultants coming to the emergency department and billing codes will not result in rejections for duplicate claims since the emergency department physician will be billing using the same Current Procedure Terminology (CPT) codes? Payment will be considered for physician of different specialties. Reference: CMS Pub , Chapter 12, Section * 34. Medicare used to pay for one initial hospital visit per stay. Has this changed? Yes. Novitas Solutions will consider payment for more than one initial hospital visit by different specialties. Reference: CMS Pub , Chapter 12, Section G * 35. Should the admitting physician utilize the AI modifier only on the initial hospital/nursing facility visit or must it be used for all visits including subsequent hospital and/or ER services billed by the admitting physician? The AI modifier is to be utilized by the Principal Physician of Record on the initial hospital or nursing home visit codes. The Principal Physician of Record would be the physician who admitted the patient to the facility and who oversees the patient s care from all other physicians who may be furnishing specialty care. This physician would bill Medicare for an initial hospital or nursing facility service provided to the patient upon admission to the facility. However, claims that include the AI modifier on codes other than the initial hospital or nursing home visit codes will not be rejected and returned to the physician or provider. 9/10

10 Reference: CMS Pub , Chapter 12, Section G* 36. Would an initial inpatient hospital service by a consultant be denied or rejected if a claim is not received from the admitting physician appended with the AI modifier? No. 37. If the physician who submits a claim for an initial hospital or nursing home visit with an AI modifier uses the same diagnosis as the consultant physician, will either claim be denied or rejected? No. However, the service(s) must be reasonable and necessary in keeping with the Social Security Act, Section 1862(a) (1)(A), to be eligible for coverage and payment under Medicare. 38. Am I permitted to bill an initial hospital visit (for a consultation) even though I have an established relationship with the patient? Yes. The concept of a new or established patient does not apply to initial hospital visits since these codes are used for hospital inpatients. Practitioners can use these codes for the first visit to an inpatient even if they have an established relationship with the patient. 39. When a physician performs an Evaluation and Management (E/M) service and the patient is not able to provide history, if the physician documents patient in a coma ; patient not able to respond ; patient unresponsive, can they count a comprehensive history? When a physician performs an encounter and is not able to obtain parts of the history component for that encounter, the documentation should clearly reflect the components that were not obtained (HPI, ROS and/or PFSH), why the components were not obtained (patient unresponsive, sedate on a vent, etc.), and the attempts to obtain information from other sources; such as a family member, spouse, nurse, etc. When the Clinical Reviewers are reviewing documentation, it is reviewed in its entirety. If the documentation clearly supports that the patient is not able to provide the information necessary (history components) and attempts were made to obtain the history from other sources, a comprehensive history level may be credited. Information related to history component requirements are available in the 1995 Documentation Guidelines for Evaluation and Management Services and 1997 Documentation Guidelines for Evaluation and Management Services. *An asterisk denotes a web site that is external to Novitas Solutions. These links will open in new browser windows. 10/10