Medical Coding Update 2016 Will you Survive a Medical Audit?

Transcription

1 Medical Coding Update 2016 Will you Survive a Medical Audit? Richard Soden, OD, FAAO, CPC I have nothing to disclosure! 1

2 GOALS To update you on important changes for 2016 To teach you advanced coding in the areas for modifiers, surgical codes, etc. To teach you new trends in Coding To explain current auditing principles and explain how you can avoid an audit 2

3 Insurance Concepts Receptionist: Why is the patient coming in: medical, vision, both Insurance coverage Record the chief compliant Perform the appropriate exam Establish the medical necessity: exams and tests Make the diagnosis Code based on the record - EACH RECORD SHOULD STAND BY ITSELF DO NOT ASSUME ANYTHING IS THE SAME FROM A PREVIOUS VISIT! HIPAA requires all providers and insurers to use CPT codes and definitions for describing services provided CPT copyright requires anyone who uses codes to comply with definitions for codes Choosing codes by matching content of record to CPT definition provides effective support in case of payer audits

4 Systemic Diseases Three scenarios: Ocular signs and symptoms of systemic diseases are present Perform examinations and procedures as long as they are medically necessary Document findings Ocular signs and symptoms of systemic disease are not present (will the systemic disease eventually affect the eye) While many systemic diseases pose a rick of ocular complications, many ophthalmic tests are not considered medically necessary or appropriate until the patient reports a symptom or physician discovers a clinical finding We generally do not get paid to document normal under most medical health plans. You can bill the patient for these services if they agree to pay. Have a patient sign an ABN Conditions such as diabetes Examinations should be covered Document medical necessity for procedures

5 Can I Bill and 92133/92134 on the same day? However, the policy does not have a list of these limited number of clinical conditions Modifier -59 is often overused than can raise scrutiny of carriers and the OIG. Modifier 59: Distinct Procedural Service: the clinician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. Be careful not to use these on all your patients until a definitive list of these clinical conditions is released.

6 Fundus Photography and OCT In the November edition of the authoritative publication CPT Assistant, the American Medical Association (AMA) has addressed how to report fundus photography using scanning laser technology. CPT Assistant indicates: If the scanner produces an image of the retina or optic nerve along with other data and imaging for quantitative analysis, it would be appropriate to report a single service from the appropriate scanning computerized ophthalmic diagnostic imaging code range ( ). If only an image is obtained, then code would be reported. The AMA further clarified that: if the only necessary service provided is generating a fundus photograph without the need to quantify the nerve fiber layer thickness and to analyze the data via a computer, then reporting code is appropriate, even if the photograph was taken with a scanning laser. [1]

7 Modifier 59 Modifier 59 is used to report procedure that are not typically reported together but are appropriate under certain circumstances. OCT for glaucoma and fundus photography for a retinal issue Modifier 59 is the most widely used modifier and is associated with abuse and overutilization. It s used frequently to bypass NCCI edits.

8 Modifier 59 CMS has created four new modifiers to selectively define subsets of modifier 59 used to designate distinct procedures services These modifiers will be implemented January 2015: XE: Separate Encounter XS: Separate Structure (organ/structure) XP: Separate Practitioner XU: Separate Non-Overlapping Service (services does not overlap usual components of the main service) Modifier 59 can still be used but if there is a more descriptive modifier (those above), these should be used More guidance will be forthcoming

9 Global Fee Schedules CMS announced that it will phase out global fee periods for surgical procedures. CMS believes Medicare is wasting cash by paying doctors for global periods that include visits doctors do not actually perform In 2017, all services will 10-day global periods will be assigned 0-day global periods Punctal plugs, trichiasis, etc. In 2018, all services with 90-day global periods will be assigned 0-days global periods Cataract co-management

10 What percentage of people have vision care plans(non-medical)? Large employee groups (firms with 100 or more employees) 35% of firms have benefits that include vision care Small employee groups (firms with 1-99 employees) 17% of firms have benefits that include vision care Public health insurance (Medicare, Medicaid, CHIP) Varies by state

11 Medicare Stats Since 2006, Medicare expenditures rose from $408 billion for 43.2 million beneficiaries to $582 billion for 52.3 million beneficiaries in 2013 Every 8 seconds, someone becomes Medicare eligible, so expenditures will continue to rise, even if spending rates slow down

12 Medicare Payment Accuracy Current: Billion Total Payments $36.0 Billion Improper Payments (10.1%) E & M Reviews June % of 1935 services were denied or reduced July % of 2385 services were denied or reduced

13 Audit Realities Auditors will focus on Considerations: what they expect to find Does the Chief Complaint for the visit support the coverage: Medical reason medical insurance Vision/Routine/Non-Medical vision insurance/private pay Does the reason for the visit support the extent of the history/examination provided- Medical Necessity Does the data match the diagnoses made? Was there medical necessity for additional tests/procedures that relate to the chief complaint and exam findings Was there an interpretation and report? Fees Are the fees charged consistent with other carriers and private pay patients

14 What Do I do If I Get Audited? Remember there are routine audits that are conducted routinely: Most are conducted via the mail Send in the information the carrier has requested All records should be signed Produce ALL of the records related to each patient If the audit is from a vision care company, you should include eyeglasses and contact lens information They may be looking for dates glasses and contacts were dispensed If you have a separate file for photographs, images, or interpretation and report, include these

15 What Do I do If I Get Audited? If an auditor shows up: Do not become defensive; be polite and cooperative Give the auditor all components of the record If you using an EHR, this includes pictures, images, etc. EHR records should be signed If you can not find a portion of the record, ask if you could mail it in within hours Keep a copy of everything you send or give to the auditor

16 After the Audit You will get a letter giving you the results Actions include: Percent of records that passes/failed Amount owed (remember the 20/80 rule) Other suggestions: You need to learn about documentation Possible sanctions Elimination from panel Recourse

17 Rules of the Road Medical Necessity All billed services, E & M or other, MUST be based on activities that are reasonable and necessary for the diagnosis and treatment of illness or injury per the Social Security Act Section 1862(a)(1)(A) To determine the appropriate level of service for a patient visit, the physician uses the presenting illness as a guiding factor and his or her clinical judgment about the patient s condition to determine the extent of key elements of services to be performed (Chapter 12, section )

18 Yogi Berra Quote If you don t know where you re going, you might not get there! 18

19 Eye doctor is accused of $240G scam Could this be You? ALBANY - State officials suspect an Anytown eye doctor pocketed nearly $240,000 in bogus Medicaid claims over the past five years, the Daily News has learned. Dr. X billed taxpayers for excessive numbers of routine eye exams and submitted claims for medical procedures that were either unjustified or not done, the state controller's office found. Dr. X also inflated the mileage he billed to Medicaid for trips to a Staten Island nursing home where he treated patients. "We can't allow unscrupulous providers to bilk taxpayers," said Controller Thomas DiNapoli. Dr. X frequently padded his claims by adding more complicated procedures when there was "little evidence that these patients had serious vision problems," the audit said. Dr. X also failed to produce medical records for 38 cases randomly sought by auditors, claiming they were missing. Of 31 other cases reviewed, only one had proper documentation. 19

20 Key Questions for You to Consider? Do your records support the codes you ve billed? Relates to both office visits and procedures Relates to patient symptoms reported in the case history and findings by the clinician If yes there is nothing to worry about If you bill based upon what sounds right or what reimburses higher, you may be in trouble.

21 Fundamentals of an Office Visit What will you do? Clinical guidelines Evidence based medicine What does the patient need? May not be what you want to do What s is in the patient s best interest?

22 Critical Coding Concepts to Consider Establishing Medical Necessity New vs. Established Chief complaint Medical vs. Refractive Contractual obligations for Vision Care Plans Supplemental Testing medical necessity

23 Establish medical necessity for each visit or procedure! Definition of Medical Necessity Services or supplies that are proper and needed for the diagnosis or the treatment of a patient s medical condition, are provided for the diagnosis, direct care and treatment of the patient s medical condition, meet the standard of good medical practice in the local area and aren t mainly for the convenience of the patient or the physician. The medical record must show that the service, procedure, or test ordered and performed was absolutely necessary in order to diagnose, treat, or monitor the treatment of the patient's condition

24 The Chief Complaint - The Medicare Carrier s Manual, Part 3 Section 2320 reads: The coverage of services rendered by a physician is dependent on the purpose of the examination rather than the ultimate diagnosis of the patient's condition When a beneficiary go to a physician with a complaint or symptom of an eye disease or injury, the services (except refractions) are covered regardless of the fact that only eyeglasses may have been prescribed When a beneficiary goes for an eye examination with no specific complaint, the expenses are not covered even though as a result of such examination the doctor discovered a pathologic condition!

25 The Chief Complaint - The Medicare Carrier s Manual, Part 3 Section 2320 reads: The coverage of services rendered by a physician is dependent on the purpose of the examination rather than the ultimate diagnosis of the patient's condition When a beneficiary go to a physician with a complaint or symptom of an eye disease or injury, the services (except refractions) are covered regardless of the fact that only eyeglasses may have been prescribed When a beneficiary goes for an eye examination with no specific complaint, the expenses are not covered even though as a result of such examination the doctor discovered a pathologic condition!

26 Additional Tests Routine Tests typically not covered by medical insurance Ordered tests Establish medical necessity Become familiar with code requirements Generally require an interpretation and report May require modifiers

27 Medical vs. Non-Medical (Wellness) It is relatively common to have a vision benefit plan in addition to your medical insurance Specified time: annual, every two years Periodic Vision Care Exam Medical plans Carriers may be the same or different You should not bill office visits to both medical plans and vision care codes on the same day! 27

28 Billing Pearls Chief Complaint Appropriate Chief Complaints for third party billing: Red eye, blurred vision, visual disturbance, diabetes, eye pain, floaters, etc. Inappropriate Chief Complaints for Third party billing: -Routine Eye Exam, need new glasses, broken glasses, I want contact lenses, I m doing well, I want a re-check, etc. 28

29 LCD s Local Carrier Determination contain information on what s Reasonable and Necessary Coding and documentation information will no longer be documented in LCD s but will be available in a set file LCD s can be challenged by ALJ s (Administrative Law Judges) for decisions, reversals, or changes while coding and documentation guidelines cannot be challenged by ALJ s These can be found on your local carrier s website or at: 29

30 Accessing Updates: Each practitioner can access CME and Medicare Part B carrier's website com or your own state s Medicare website With Listserv, you will automatically receive an notification when the new bulletins are available and when changes are made LCD s (formerly known as LMRP s) give you the diagnosis and procedures needed for claim approval LCD s now give you the utilization guidelines for CPT codes (undated as the individual policies are reviewed) 30

31 FEES A group or groups of optometrists should not be discussing fees this may be in violation of Anti-trust Don t discuss your fees with other providers this could lead to serious antitrust problems Medicare publishes allowables, they are public information and will be used here The allowables vary by region and are updated yearly so your allowables may not exactly match those used here Fee schedule 2015?????? Fees posted on you carrier s website 31

32 The Office of the Inspector General (OIG) The Office of the Inspector General (OIG) is the enforcement arm of the rules and regulations described in the Medicare manual It monitors the CMS which contracts with various insurance companies to process the claims filed for reimbursement Fees are paid based upon a fee schedule which is updated annually CMS reported an improper payment rate of 12.7 percent for Medicare fee for service (Parts A & B) in FY Billion Dollars This measure includes payments for unnecessary services, billing or coding errors, and payment for claims that did not meet documentation requirements! 32

33 OIG Work Plan Each year the Office of the Inspector General releases a report of its planned activities. This year will focus on: High Cumulative Part B payments unusually high payment made to an individual physician over a specified period of time E/M Services: Trends in coding claims overutilization Potentially inappropriate payments Use of EMR s documentation associated with potentially improper payments and records with identical documentation across services 33

34 OIG Work Plan Each year the Office of the Inspector General releases a report of its planned activities. This year will focus on: Place of Service Errors E&M Coding During Global Surgery Incident to Services services are provided as an integral (although incidental) part of a physician s services Modifier GY (services typically excluded statutorily) Correct use of Modifiers Are you in Compliance with your Assignment Rules Evaluation and Management Services Will be checking on potentially inappropriate payments for E/M services in 2010 Will be reviewing multiple E/M services for the same providers and beneficiaries to identify EHR documentation practices with potentially improper payments. We have noticed an increased frequency of medical records with identical documentation across services 34

35 OIG Ophthalmologists Questionable billing Billing and Payments. We will review Medicare claims data to identify inappropriate payments and/or questionable billing for ophthalmological services during We will also determine the geographic locations of providers exhibiting questionable billing for ophthalmological services in Context Medicare payments for Part B for physician services, which include ophthalmologists, are authorized by the Social Security Act, 1832(a)(1), and 42 CFR In 2010, Medicare allowed over $6.8 billion for services provided by ophthalmologists. (OEI; ; expected issue date: FY 2014; work in progress)

36 OIG Work Plan Ophthalmology If the OIG finds issues with the 2011 documentation, they will move forward into other documentation for providers with problematic records Use this as an opportunity to look at your overall documentation What are you doing well? Where are your risks? 36

37 OIG Questionable Codes Rank CPT Code Service Cataract IOL Comp Eye Exam, Estab Pt Intermediate Exam, Estab Pt Comp Eye Exam, New Pt Visual Field, Full Threshold YAG Capsulotomy Anesthesia for Proc on eye; Lens Surgery Fundus Photography Fluoroscein Angiography Scanning Laser (SCODI): Retina Retinal Surgery Scanning Laser (SCODI): Optic Nerve Ophthalmic Biometry with IOL Power Calc Blepharoplasty, Upper Eyelid Subsequent Extended Ophthalmoscopy E & M Codes Not Included

38 OIG Report Questionable Billing for Medicare Ophthalmology Services (includes optometry): In 2012, Medicare paid $6.7 billion to 44,960 providers for services that screened for, diagnosed, evaluated and treated wet AMD or Cataracts In 2012, approximately 4% of providers demonstrated questionable billing on at least one of the nine measures they studied. (Approximately 7% OMS and less than 2 % OD) CMS will continue to monitor billing of ophthalmological services including use of modifiers -24, -25, and -22 C MS will monitor place of service errors Fundus photography appeared to be a high number of fundus photography exams per beneficiary OIG will continue to monitor fraud and abuse issues

39 2016 Changes No new ICD-9 Codes Some changes to CPT 4 Reimbursement changes ICD-10 Implemented 39

40 2016 Changes Part B Deductible: Variable Numerous Auditing Programs Claims EHR EHR Updates to your 855 Recertification Fee schedule: Multiple fee schedules based upon quality measures PQRS, MU and EHR penalties Value Based Modifiers 40

41 New Edited CPT Codes for check Prolonged evaluation and management or psychotherapy service(s) each additional 30 minutes (List separately in addition to code for prolonged service) Used only when time is greater than 30 minutes over and above time spent for E&M

42 New CPT Codes for check Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service) Each additional 30 minutes (List separately in addition to code for prolonged service) Guidelines: - Use for minutes - Use and for minutes - Use multiples of for each additional 30 minutes above 105 minutes

43 New and Edited Codes for Implantation of intrastromal corneal ring segments Repair of retinal detachment, 1 or more sessions; cryotherapy or diathermy, including drainage of subretinal fluid, when performed photocoagulation, including drainage of subretinal fluid, when performed Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), including, when performed, implant,cryotherapy, photocoagulation, and drainage of subretinal fluid with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), cryotherapy, diathermy Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation 43

44 CPT III Code Changes for 2016 Deleted 0099T replaced with (Implantation of intrastromal corneal ring segments 0123T Fistulization of sclera for glaucoma, through ciliary body Modified 0308T Insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis New 0402T Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)

45 Signature Stamps CMS banned signature stamps on all physician orders and medical records 45

46 CPT Evaluation and Management Services for Inter-professional telephone/internet Consultations These codes describe a situation where a specialist consults with a patient s primary physician to offer opinion or advice, but does not meet face-to-face with the patient such as Telemedicine These time-based services are typically provided in complex and/or urgent situations where timely face-to-face service may not be feasible. These services include verbal and written report to the patient's treating/requesting physician or other qualified health care professional They include a review of the patient s medical, tests results These codes will probably not be recognized by Medicare and Medicaid (CMS does not recognize consultations) Typically 5 to 10 minutes of medical consultative discussion and review

47 CPT Consultation as described on previous slide with 11 to 20 minutes of consultative discussion and review Consultation as described on previous slide with 21 to 30 minutes of consultative discussion and review Consultation as described on previous slide with 31 minutes or more of consultative discussion and review

48 Category III Temporary Codes Emerging Technology Codes for digital interferonmetry of the tear film of the eye to detect lipid layer deficiency to aid in the diagnosis of dry eye syndrome If a Category III code is available, it must be reported instead of a Category I unlisted procedure 0330T Tear film imaging, unilateral or bilateral, with interpretation and report

49 Other Changes CPT external ocular photography instructs practitioners to use code 0330T to report tear film imaging CPT VEP testing central nervous system instructing practitioners to use 0333T to report screening of visual acuity using automated visual evoked devices CPT serial tonometry instructs practitioners to use 0329T to report the monitoring of IOP for 24 hours or longer

50 Additional New Codes CPT placement of amniotic membrane on the ocular surface, without sutures CPT placement of amniotic membrane on the ocular surface, single layer, suture CPT insertion of anterior chamber aqueous drainage devices, with extraocular reservoir, external approach

51 Additional New Codes CPT 0314T Quantitative pupillometry with interpretation and report, unilateral or bilateral Category III temporary code Recent studies demonstrate the relationship between pupil responses and early signs of Parkinson s, Alzheimer s, autism, cardiovascular and other systemic rheumatologies.

52 Category III Temporary Codes 0329T Monitoring of IOP for 24 hours or longer, unilateral or bilateral, with interpretation and report 0333T Visual evoked potential, screening of visual acuity

53 Multiple Procedure Payment Reduction (MPPR) on the Technical Component (TC) of Diagnostic Ophthalmology Procedures Section 3134 of the Affordable Care Act added Section 1848(c)(2)(K) that the Secretary of Health and Human Services shall identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service. As a further step in implementing this provision, Medicare is expanding the MPPR policy by applying MPPRs to the TC of diagnostic cardiovascular and ophthalmology procedures. The MPPRs on diagnostic cardiovascular and ophthalmology procedures apply when multiple services are furnished to the same patient on the same day. The MPPRs apply independently to cardiovascular and ophthalmology services. The MPPRs apply to TC-only services, and to the TC of global services.

54 Multiple Procedure Payment Reduction (MPPR) on the Technical Component (TC) of Diagnostic Ophthalmology Procedures For ophthalmology services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group NPI) to the same patient on the same day. Start date is expected to be January 1, 2013 The MPPRs do not apply to professional component (PC) services.

55 Example Code Code Total Current Payment Total 2013 Payment Payment Calculation PC $46.00 $23.00 $69.00 $69.00 No reduction TC $92.00 $53.00 $ $ $92 + (.80 x $53) Global $ $76.00 $ $ $69 + $92 + (.80 x $53) This results in a fee reduction of $ 10.60

56 Diagnostic Ophthalmology Services Subject to the Multiple Procedure Payment Reduction Ophth us b & quant a Ophth us quant a only Ophth us b w/non-quant a Echo exam of eye water bath Echo exam of eye thickness Echo exam of eye Echo exam of eye Corneal topography Special eye evaluation Visual field examination(s) Visual field examination(s) Visual field examination(s) Eye photography Cmptr ophth dx img ant segmt Cmptr ophth img optic nerve Cptr ophth dx img post segmt Ophthalmic biometry Remote retinal imaging mgmt Eye exam with photos Icg angiography Eye exam with photos Eye muscle evaluation Electro-oculography Electroretinography Color vision examination Dark adaptation eye exam Internal eye photography

57 Billing Pearls Bill all third party payers the same way you bill your private-pay patients as well as all of your managed care patients Bill all payers your usual and customary fees Be consistent with refraction If your office visit includes a refraction report it this way consistently 57

58 Billing Pearls Chief Complaint For major medical coverage, Medicare, and managed care companies, there must be a MEDICAL sign or symptom for the visit to be billable unless the patient has routine vision care. The reason for the visit can also be physician directed you told me to come back for an eye pressure check, to check me for diabetes, to assess my cataract, etc. 58

59 BILLING PEARL REMEMBER: NO CHIEF COMPLAINT = NO CODEABLE SERVICE IT S NOT WHAT YOU DID IT S WHAT YOU DOCUMENTED YOU DID! IF IT S NOT DOCUMENTED IT S NOT BILLABLE! 59

60 Billing Pearls Chief Complaint The Chief Complaint should be the FIRST diagnosis your billing form The case history should relate to the primary diagnosis listed and not want you find during the exam The case history continues throughout the entire exam In SUMMARY, the Chief Complaint determines if the visit is Medical or Non-Medical (routine vision, private pay, normal, etc). 60

61 CHIEF COMPLAINT The Chief Complaint drives the exam It relates directly to the HPI and drives the information considered & gathered for the HPI. Avoid Follow-up, Rule Out, Medication Refills, Evaluation of Medication, etc For Chronic Conditions: Evaluation & Management of Monitoring for control of and compliance to medical regimen 61

62 Medicare Coverage Policy The routine physical check-up exclusion applies to examinations performed without relationships to diagnosis or treatment and examinations for the purposes of prescribing, fitting, or changing eyeglasses or contact lenses for refractive errors. The exclusions do not apply to physicians services performed in conjunction with an eye disease.. 62

63 Why accurate coding is essential Payers are computerized to match procedure codes to diagnosis codes LMRPs - Diagnosis must support the reported services, procedures, or surgery submitted Audits avoided or at least office justified by accurate records As a provider you are responsible for your claims 63

64 ICDA Codes ICDA Codes Demonstrate: Medical Necessity Severity of Illness Justify Intensive Services/Procedures Support and JUSTIFY E & M and CPT Codes Reported and Billed DO NOT USE Abbreviations (JCAHO rule) 64

65 ICDA CODES ICD 10 Code as many diagnoses as possible Code to the highest specificity of diagnosis that is stated utilizing the most specific code possible Try to avoid: SUSPECTED; POSSIBLE; PROBABLE; RULE OUT; QUESTIONABLE Use: Elevated IOP Probably Related to Glaucoma Suspect 65

66 CPT Procedure Codes Identifies physician services and procedures Copyright held by the American Medical Association Updated yearly through CPT Editorial Process Changes effective January 1 AOA maintains representation in this process 66

67 Records Principles Examination data, tests, treatments, and outcomes of treatments recorded Assessment or clinical impression recorded Plan for further care recorded Reasons for ordering diagnostic or ancillary services should be clear or easily interpreted All records need to be signed 67

68 Records Principles Medical record should identify the provider of care (name of clinic and provider) The doctor is ultimately responsible for the content of the record and the services submitted for reimbursement age COPD Service unrelated to Hospice diagnosis 68

69 Error Categories Insufficient documentation Medically Unnecessary Incorrect Coding Others 69

70 Expensive Errors E/M services codes incorrectly Counseling time not documented Inadequate diagnosis codes Illegible notes Dates of service incorrect Diagnostic tests without interpretation and report Secondary surgical procedures not coded 70

71 Obama Administration Announces Ground-Breaking Public- Private Partnership to Prevent Health Care Fraud July 26, 2012 New partnership among federal government, state officials, several leading private health insurance organizations, and other health care anti-fraud groups to prevent health care fraud New partnership is designed to share information and best practices in order to improve detection and prevent payment of fraudulent health care billings One innovative objective of the partnership is to share information on specific schemes, utilized billing codes and geographical fraud hotspots so that action can be taken to prevent losses to gov t and health plans before they occur

72 Common Auditing Principles Insurance companies use internal and external audits to ensure they are paying for appropriate services All of your services should be medically necessary and documented properly It is estimated that incorrect billing costs the insurance industry billions of dollars annually Audits allow the carriers to recoup money If the auditor determines that your records do not support the exam codes and procedures you ve billed, there is a good chance you will be paying money back to the insurer! 72

73 Who is Auditing? Comprehensive Error Rate Testing (CERT) Improve accuracy of Medicare payments Method for CMS to look at paid claim error rate Random claims- Audit- Recoup dollars- Report to CMS Recovery Audit Contractors (RAC) To identify improper over/under payments 1. Automated Review 2. Complex Review 3. Semi-automatic Review Zone Program Integrity Contractors (ZPIC) Targeted to outliers typically reviewed Carrier Reviews Not common- typically outliers selected for review or Random selection Target potentially overused/misused codes- targeted Private Insurers 73

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76 Medicare Fraud: You do not want this to be you! Patient Recruiter Sentenced to 77 Months in Prison in Connection with 9 Million Medicare Fraud in Detroit (June 2011) Reasons: Patient recruitment and paying patients to sign paperwork claiming they had received injection therapy services they did not receive Billed Medicare more than 9 million dollars for services that were not performed Billing routine care as medically necessary 76

77 Interpretation and Report Doctors in many states are getting penalized by auditors for non-compliance. Such a note, which can be brief, should be made within the medical record for the day and summarize: CPT Procedures that require Interpretation and Report include: Scanning Laser 92132,92133,92134 Fundus Photography Visual Field 92081;92082;92083 Corneal Topography Sensorimotor Exam External Photography Extended Ophthalmoscopy 92225/92226 The following CPT Codes do not require Interpretation and Report Gonioscopy Pachymetry Foreign Body Removal 652XX Closure of Punctum (Plug)

78 Interpretation and Report Interpretation and Report Name of Test/Procedure: Reason for Test was ordered/performed: Findings: (List any comparative data from previous tests and indicate any change in the patient s condition Management Plan (Based upon this test): Additional documentation should address the following: Date of the test Reliability of the test Signature 78

79 Example: Name of Test: Visual Field (CPT 92083) Request 24-2 Reason for the Test: Glaucoma Suspect OU Findings: Early Nasal Step OD; Normal OS No Change from Previous Fields Reliabillity Management Plan: Monitor; Repeat Test 6 Months Diagnosis: Glaucoma Suspect 79

80 Audits Relating to Coding Issues: Can This Be You? Company felt an optometrist was billing inappropriately in two areas: Routine visits were coded as medical visits Extended ophthalmoscopy exceeded industry standards 20 records were reviewed: 6 were determined to be routine visits (30%) 10 records had some elements of medical chief complaints and examination findings; however, the assessments and plans were poorly documented 4 records were deemed appropriate Extended ophthalmoscopy was not billed appropriately in 50% of the cases and not documented appropriately in 75% of the cases 80

81 Key Questions for You to Consider? Do your records support the codes you ve billed? Relates to both office visits and procedures Relates to patient symptoms reported in the case history and findings by the clinician If yes there is nothing to worry about If you bill based upon what sounds right or what reimburses higher, you may be in trouble. 81

82 Examples To Consider When You Code a Specific Office Visit or Procedure When you bill 92004/14, do you perform a gross visual fields? When you submit a 92225/6, do you have a drawing that meets the carriers guidelines? If you code s, do you perform a dilated fundus examination (if a fundus evaluation was one of the component you chose for the examination)? For procedures, does you record include interpretation and report? 82

83 Types of Audits Pre-pay and Post-pay Audits Pre-pay submission of records prior to payment Post-pay random sampling carriers audit about 10% of claims results are to extrapolated to total claims for a specified period of time Focused Medical Reviews A carrier focuses on specific CPT codes and audits practitioners whose utilization patterns are inconsistent with the expected norms 83

84 The Bell Shaped Curve Carriers use the traditional bell shaped curve to see how you compare to your colleagues They can compare: all physician services individual classes of providers (i.e. OD to OD, OMD to OMD) similar providers (i.e. OD to OMD) Carriers can look at a specific procedure or a group of procedures 84

85 Bell Shaped Curves Normal Bell Shaped Curve: E&M Coding Usage 85

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88 Probable Under-Coding **some risk of error** Undercoding E & M Level: Excessive use of low complexity - probable under-coding 88

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90 Possible Over-Coding **higher risk of audit** Overcoding H i g h C o m p l e x i t y. High Risk of audit, but may be correct. Definitely need to look internally and make sure all encounters are well documented. E & M Level: E xc e s s i v e u s e o f h i g h c o m p l ex i t y - may be correct but insure not over-coding 90

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92 Utilization Rates for OD s and OMD s 2006 Carrier Summary Files (BESS) CODE Exam OMD s OD s Complex 2% 1% Comprehensive 15% 8% 99203; Detailed; 74% 77% Comprehensive 99202; EPF; 8% 14% Intermediate Problem Focused 1% 1% 92

93 Data Files New Patients 80 Utilization Utilization / /

94 Utilization Rates for OD s and OMD s 2006 Data Files CODE Exam OMD s OD s Complex 1% 1% 99214; Detailed 47% 51% Comprehensive 99213; EDF; 46% 37% Intermediate 99212; Problem Focused 6% 11% Minimal 1% 1% 94

95 Data Files Established Patients 60 Utilization Utilization 0 95

96 The take home is Need to insure the entire exam justifies the level of coding not just simply counting how many exam elements you documented Must be able to substantiate excessive use of higher level codes if audited Need to compare your utilization graphs with normative data Do what the patients needs Keep well documented records Code based upon the documentation in your records Use IC9; CPT-4 96

97 Medicare Utilization Rates Frequency Based Upon Percentage of 100 Exam Visits Test MD OD Ext Oph Fundus Photo Gonioscopy Scanning Laser Pachymetry VF

98 Medicare Audits CERT Process Comprehensive Error Rate Testing (CERT) In August 2000, CMS began a new program to improve the processing and medical decision-making involved with payment of Medicare claims. CERT has been implemented by CMS through an independent company that now serves as the basis for calculating a national error rate for Medicare claims. Goals: Reduce National Medicare Fee for Service Paid Claims Error Rate Reduced unnecessary denials 98

99 CERT CERT is designed to determine if providers are submitting claims accurately and if Medicare carriers are processing claims accurately Randomly selects a sample of claims from all Medicare contractors Read the request letter very carefully and respond with ALL documentation, including doctor s original orders for treatment, care plans, records for all services billed for the dates of service in question Do not ignore a CERT! Response time = 70 days (fax preferred method of response) 99

100 CERT Process Reviews claims along with medical records to see if the documentation supports all services billed Determines if the claim or service is processed correctly and is in compliance with all applicable requirements: LCD s / NCD s / Medicare Coverage Regulations / Federal Guidelines 100

101 CERT Reported results revealed significant errors with E & M codes: Missing progress notes Missing orders Missing or illegible signatures Incorrect coding Overpayments from claim errors must be recovered decision can be appealed! There are 5 levels of appeal Can appeal up to 120 days from date of claim adjustment 101

102 CERT Results (NJ) Analysis of the code: Almost all of the errors were due to either illegible documentation and failure of the provider to sign and date the record The simple omission of a signature will cause denial of payment for a service if the record is audited You must sign off on all encounters and your signatures must be legible CMS banned signature stamps on all physician orders and medical records 102

103 The Recovery Audit Program The Medicare Fee-for-Service (FFS) program consists of a number of payment systems, with a network of contractors that process more than 1 billion claims each year, submitted by more than 1 million providers, such as hospitals, physicians, etc. There are multiple circumstances that can result in improper payments, including payment for items or services that do not meet Medicare s coverage and medical necessity criteria, payment for items that are incorrectly coded, and payment for services where the supporting documentation submitted did not support the ordered service. Every fiscal year each Medicare Administrative Contractor (MAC) is required to complete an Error Rate Reduction Plan (ERRP) which includes agency-level strategies to clarify CMS policies and implement new initiatives to reduce improper payments. The Recovery Audit program is another valuable tool to assist CMS in the identification and recovery of improper payments 103

104 Recovery Audit Program To implement the National Recovery Audit program, CMS divided the country into four regional areas. 104

105 Improper payments in the Medicare FFS Program Improper payments on claims fall into three categories: Payment for items or services that do not meet Medicare s coverage and medical necessity criteria Payment for items that are incorrectly coded Payment for services where the supporting documentation submitted does not justify the ordered service 105

106 106

107 Medical Review Program Medicare program at the local level (Medicare Administrative Contractor (MAC)) Goals of the program: To reduce Payment Error Rate (CERT) To identify noncompliance coding To take action How do they identify issues: Data Analysis Review Selection Provider and/or Service 107

108 How Probes are Conducted Provider and Service Specific Number of Claims Documentation Requests Basis for Review Decisions Appeal Rights 108

109 Areas of focus by local carriers Evaluation and Management Services Specific Procedures Diagnostic Services Rehabilitation Services Psychiatric Services 109

110 What Triggers an Audit? Your services fall outside the bell shaped curve A disgruntled employee reports you Disgruntled family members report you Unhappy patients EOB s easily inform patient how to report possible fraudulent billing (provide toll-free numbers) Number of exams billed in a given day is thirty s on the same day reasonable? 110

111 What Can Trigger an Optometric Audit Billing exams to both Eye Glass Plans and Medical Plans on the same day Billing medical claims and routine claims ON or NEAR the same date of service Billing for medical care at a rate higher than other practitioners in your area Billing for medical procedure at a higher rate than you have traditionally billed 111

112 Can I Bill Medical and Vision Claims on the Same Day? Supplemental tests must be justified by clinical findings and/or patient complaints noted in the chart, but they can be billed the same day as a routine (92004/92014) exam if the medical indication is found during the course of the annual exam. An example might be a patient who reports a sudden onset on a floater on the same day as his/her routine examination. Can you bill both??? 112

113 Can I Bill Medical and Vision Claims on the Same Day Options: You CAN choose to perform the annual (920x4) exam (by billing the vision care carrier) and bill the floater eye as extended ophthalmoscopy office to the medical plan OR You can treat the entire visit as a medical exam ( ) with a diagnosis of floaters and schedule the routine visit on another day OR Only bill the routine vision care plan. If this was not an urgent visit (i.e. possible glaucoma suspect), you could also Bill the routine exam today (vision care) and have the patient return for a medical visit on another day (medical exam) 113

114 Audit Results Undercharge 10-35% Overcharge 10-25% Incorrect code 10-30% Incorrect date 1-10% Non-compliance 19% Lacks medical necessity 36% 114

115 Proper Documentation Clear and timely documentation promotes: Quality care Supports medical necessity Increases coding accuracy Reduces liability risk Improves compliance with Medicare and other payer s billing requirements 115

116 Documentation Errors Date on medical record does not match date of service on claim submission Patient and family health history was not recorded along with health risk factors when required Progress or response to treatment, along with changes in treatment or revision of diagnosis, was not recorded 116

117 Evidence Based Medicine Do you follow CPT/ICD-9/CMS/carrier guidelines: National Carrier Determination Local Carrier Determination Do you practice as others in the community do? 117

118 Evidence Based Medicine It is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. (Sackett 2002) 118

119 Evidence Based Medicine Insurance carriers can use it to insure they are paying for services and testing that is proven to be necessary and useful 119

120 120

121 Correct Coding Initiative CCI Edits Tabular list of codes: Codes you can never bill on the same day (i.e. they are mutually exclusive) Examples: and Procedure codes that cannot be billed together: Examples: and Procedures that may be able to be billed together with medical justification (Modifier 59) Examples: and OCT Non-compliance with these edits may trigger an audit! 121

122 Special Ophthalmological Services Scanning Laser GDX/HRT/OCT Utilization rapidly increasing Diagnosis justified in chart (LCD) Requires interpretation and report The following codes would generally not be necessary with SCODI: 92250; 92225; 92226; (B-Scan) Medicare has recently bundled Scanning Laser and Fundus Photography as part of the Correct Coding Initiative Use Modifier 59 (distinct procedural service) 122

123 Fraud and Abuse Fraud - outright cheating of the system Billing deceased individuals Billing OCT without appropriate instrumentation Reporting services not rendered Recruiting patients and driving them your office for services 123

124 Fraud and Abuse Abuse - inappropriate use of patient s health care policy (often with no knowledge on the practitioner's part) Up-coding or down-coding / unbundling Resubmitting claims excessively Always billing the same code Not routinely collecting co-insurance and co-pays (waiving fees) Inappropriate procedure or tests Incomplete medical records 124

125 Abuse Health Care Abuse Billing insurance companies more than private fees Billing non-covered services as covered (i.e. routine eye care as medical care) 125

126 Fraud and Abuse Abuse Collecting more than 20% with regard to coinsurance Not refunding overpayments Over utilization of a particular office visit (i.e. always billing level 3) Inappropriate use of modifiers Routinely bring patients back Abusive acts can become Fraudulent Acts!! 126

127 Fraud & Abuse $2,000 fee per line on CMS form Jail Time Possible discontinuation in other health care plans 127

128 Requirements of Comprehensive Ophthalmological Service 92004/92014 Payers may develop their own interpretations of these definition The elements that are required by the CPT definition are: 1. General evaluation of the complete visual system 2. History 3. General medical observation 4. External examination 5. Ophthalmoscopic examination (with or without cycloplegia or mydriasis 6. Gross visual fields 7. Basic sensorimotor examination 8. Initiation of diagnostic and treatment program 9. Greater than 8 examination elements (carrier specific) 128

129 Medical Coding and Billing Establish medical necessity. You must always establish the medical necessity for any test or procedure in the medical record The ICD-9 rules clearly state that the only time that one can use the patient's symptoms as a diagnosis is in the absence of a definitive physical finding Just because a patient has blurry vision doesn't mean that you can automatically order CPT procedures such as visual fields, scanning laser ophthalmoscopy, etc. 129

130 What determines Medical Necessity? Services furnished for dx or tx of an illness or injury or to improve functioning of a malformed body part Services furnished at the most appropriate level that can be provided safely and effectively to the patient A service that is reasonable and medically necessary does not exceed the patient s need The extent of an eye exam is defined by the number and type of service components performed during the exam Extent is based upon the clinical judgment of the doctor, the patient s history, and the nature of the presenting problem 130

131 Medical Necessity Coverage is dependent on the purpose of the examination rather than the ultimate diagnosis of the patient's condition When a beneficiary presents with a complaint or symptom of an eye disease or injury, the services are usually covered despite the fact that only eyeglasses may have been prescribed When a beneficiary goes for an eye examination with no specific complaint, the expenses are not covered even if the exam discovered a pathologic condition! 131

132 Fees Charge the same fee for the same procedure always! You must charge all parties the same fee for the same procedure If you're willing to bill a medical carrier for hundreds of dollars in ancillary tests/procedures, you must also be willing to bill a patient who has no insurance the same amount A patient having good health insurance coverage is not there to have unnecessary testing or excessive procedures performed 132

133 Preparing for An Audit: Audit Your Own Charts Records need to be: Legible Signed and dated Complete Must be able to support the level of service you billed Internal auditing your own charts 20 per month - compare to the bell shaped curve Look for and document changes over time 133

134 Results of an Audit Empire Medicare recently announced the results of the medical review of the E & M code. The highlights are as follows: 21% met the criteria for % met the criteria for % met the criteria for % met the criteria for % were denied due to documentation supporting that service was actually for a routine exam or screening 5.8 % were denied due to illegible documentation.9% were denied because no documentation was submitted or there was no response from the provider 134

135 The Importance of an Appropriate Case History: Chief Complaint For major medical coverage, Medicare, and managed care companies, there must be a MEDICAL sign or symptom for the visit to be billable The reason for the visit can also be physician directed: 6 month am IOP check 3 month progress check on dry eye syndrome 1 week follow-up of a conjunctivitis 135

136 The Importance of An Appropriate Case History The chief complaint drives the encounter! The chief complaint is what drives the encounter and establishes who the responsible party is for billing and payment If a patient has glaucoma and comes in for a contact lens check before ordering a new supply of contact lenses, you should not bill that visit to the medical carrier The chief complaint determines if the claim can be submitted to a third party medical carrier or to a vision care carrier or is self pay 136

137 Chief Complaint The CC states why the patient is in the office The CC can be physician directed Brief description of the reason for that day's visit, including symptoms, problems, abnormalities, chronic disease(s) or other explanation Stated in the patient's own words 137

138 Which exam codes do I use? Most services can be reported using either or codes appear to be more commonly used by OD s and OMD s than Does this put you at risk for an audit? As with all services, these codes should be used when they match the definitions found in CPT Many offices are unfamiliar with the CPT definitions and requirements for proper coding Must not use any codes unless familiar with the CPT definitions/requirements 138

139 92000 vs Requirements for codes are more general than those for the codes require history and a chief complaint series requires considerable more documentation, particularly in certain levels of history of present illness, review of systems and past/family/social history 139

140 92000 Codes Can be used to report both Medical eye care visits Routine eye care Many insurance carrier are considering the codes to be E&M codes for purposes of medical review and audit Refraction is a separate service (92015) and is not included in any other code, unless required by contract with payer (NYS Medicaid) 140

141 Requirements of Intermediate Ophthalmological Service 92002/92012 Payers may develop their own interpretations of these definitions BUT the following elements are included in the CPT definition: 1. A new or existing condition 2. Complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis 3. History 4. General medical observation 5. External ocular/adnexal examination 6. Other diagnostic procedures as indicated 7. Initiation or continuation of a diagnostic and treatment program 8. 1 To 7 (or 8) examination elements (Carrier Specific) 141

142 Requirements of Intermediate Ophthalmological Service 92002/92012 Does this mean that if one (or more) of these elements is missing, the visit cannot be coded as an intermediate ophthalmological service? You bet it does! 142

143 What is General Medical Evaluation? Poorly defined Probably includes: Comments on how the patient is doing Are there changes in visual functioning Is the person groomed appropriately Can he/she walk independently Does he/she appear well nourished 143

144 Requirements of Comprehensive Ophthalmological Service 92004/92014 Payers may develop their own interpretations of these definition The elements that are required by the CPT definition are: 1. General evaluation of the complete visual system 2. History 3. General medical observation 4. External examination 5. Ophthalmoscopic examination (with or without cycloplegia or mydriasis 6. Gross visual fields 7. Basic sensorimotor examination 8. Initiation of diagnostic and treatment program 9. Greater than 8 examination elements (carrier specific) 144

145 Requirements Elements for a Comprehensive Ophthalmological Service Does this mean that if one (or more) of these elements is missing, the visit cannot be coded as comprehensive ophthalmological service? You bet it does! 145

146 92000 Codes All four levels of examination require initiation or continuation of diagnostic and treatment programs 146

147 Dilation and 920XX and 992XX Dilation is NOT Mandatory with any of the 920XX Codes Dilation is Mandatory with the 992XX Codes if the two retinal elements are used to count towards the level of physical examination, UNLESS Contraindicated

148 Examination Codes Code Documentation Accepted by Medical Plans Role in Medical Plan 92xxx Lower than 99xxx Varied Varied 99xxx Higher than 92xxx Yes Always S Code Varies No Never

149 Initiation or Continuation of Diagnostic and Treatment Services Includes the following: NY Local Policy: The prescription of medications Lenses & other therapy And arranging for special ophthalmological, diagnostic or treatment services, consultation, laboratory and radiological studies as may be indicated CPT -4 Prescription of medication, and arranging for special ophthalmological diagnostic or treatment services, consultations, laboratory services and radiological services 149

150 Initiation or Continuation of Diagnostic and Treatment Programs A diagnostic program involves ordering or performing any diagnostic test that is not part of your standard eye exam such as: Visual fields, refractions, lab tests, etc Initiating or continuing a treatment plan involves providing therapy such as prescriptions, or arranging treatment or surgery It may involve educating patients on risk reduction and maintenance, such as diabetic management, or coordinating care with another provider 150

151 Initiation or Continuation of Diagnostic and Treatment Services Definition confusing and varies by each state Some carriers require treatment in order to use codes Monitoring a condition may be considered treatment for codes as it may be appropriate treatment Most frequent target of reviewers/auditors of eye care records Every office must have a clear definition and understanding of what s included in each component of the CPT definition, especially the initiation or continuation) of diagnostic and treatment program you should define it for your office! 151

152 Sample Diagnostic and Treatment Program Return to Office For recheck For additional tests Prescribing medications (OTC s and prescribed) Contact lens and spectacle prescriptions Referring out for second opinions Etc., etc., etc., 152

153 Initiating a Diagnostic and Treatment Plan Communication with patient Complete the medical record Set-up a follow-up date For recheck For additional tests Prescribing medications (OTC s and prescribed) Contact lens and spectacle prescriptions Referring out for second opinions Etc., etc.., etc..,

154 Diagnostic and Treatment Services The diagnostic or treatment program does not have to be a reimbursable service prescribing eyeglasses should count Ordering of special diagnostic tests (visual fields or OCT) is considered initiating diagnostic services Orders such as Return PRN or Return in One Year for CEE would not be initiation of diagnostic or treatment services 154

155 Contact Lens Coding and Billing Medically necessary contact lenses are frequently billed through a patient s medical carrier This should be a separate service from the or the codes. If appropriate, these should be reported based upon the level of service that was performed and documented

156 Contact Lens Wearers Elective Contact Lenses: Private Pay Vision Insurance Medical Insurance (if they administer routine care) Medically Necessary or Therapeutic Contact Lenses: Private Pay Vision Insurance Medical Insurance

157 Medically Necessary Contacts: Aphakia Aphakia: Bill Fitting Fees and Material Fees Fitting Codes: CPT (one eye) CPT (both eyes) Material Codes: V2513 Gas permeable, extended wear, per eye V2530 Hybrid contact lenses, per eye V2531 Gas permeable, scleral lens, per eye

158 Medically Necessary Contacts: Therapeutic Lens Fits Fitting of contact lenses for treatment of ocular surface disease Unilateral code (Indicate right eye or left eye) Bill material code (CPT or V2523 if appropriate) Fitting of contact lenses for management of keratoconus, initial fitting only Bilateral code Bill material code (99070 or V2530, V2531, or V2599) Other Fits CPT Contact Lens Fitting (Bilateral) Not every carrier recognizes these codes Bill office visits in addition (the level performed/documented)

159 Medically Necessary Contacts: Therapeutic Lens Fits Question: A long time keratoconic patient is returning for an exam and needs new contact lenses. How do we code this? Exam: or (depending upon the level of service performed and documented) Contact Lens Fee: Can vary fees (complex vs. follow-up) Appropriate V Code for Materials CPT is for the initial fitting only You can bill both Exam Codes + Contact Codes as long as they are both medically necessary and you have the proper documentation to support them

160 CPT Supplies and materials (except spectacles) provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided) (For supply of spectacles, use the appropriate supply codes V Codes)

161 Example of Unilateral Code Date of Service Place of Service CPT Diagnosis Charge Days or Units RT/LT Total 145

162 Example of Bilateral Date of Service Place of Service CPT Diagnosis Charge Days or Units RT/LT Total 145

163 Confusion about when codes allowed Some speakers recently have lectured that, without a new problem, you cannot use the code I am not aware of any audits to back this up CPT Definitions of 92002/92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient

164 Confusion about when codes allowed Here s the Problem Evaluation of new/existing condition complicated by a new diagnostic/management problem not necessarily related to primary diagnosis

165 Some Considerations CPT is ONLY official definition for codes CPT code wording is the ONLY official definition for codes CPT code introductions are NOT official definitions- only to further explain code use Official Code Wording established patients Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program Introduction to Code Wording established patients Evaluation of new/existing condition complicated by new diagnostic/management problem not necessarily related to primary diagnosis 165

166 The take home is Know the definitions of CPT! Avoid cloning of records! Several Medicare carriers announced they would recoup payment for claims if an audit revealed cloned documentation Cloned documentation will be considered misrepresentation of medical necessity for coverage of services due to the lack of specific individual information for each patient If you sign the (cloned) note (without reading it) you are saying: That s what I saw, that what I told the patient to do, that s what you attesting to!

167 99000 Codes Visit codes are chosen based upon the details of the definitions in CPT and the Documentation Guidelines for three key components: Case History Physical Examination Medical Decision Making 167

168 Grading the Office Visit New Patient Level Code History Exam Medical Decision Problem Focused Problem Focused Expanded PF Expanded PF Straight Forward Straight Forward Time (Minutes) Detailed Detailed Low Comprehensive Comp Moderate Comprehensive Comp High New Patient visit is graded to the lowest of the three components: History, Exam, Medical Decision Making All 3 are required 168

169 Example of Code History Exam Medical Decision Problem Focused Problem Focused Expanded PF Expanded PF Straight Forward Straight Forward Time (Minutes) Detailed Detailed Low Comprehensive Comp Moderate Comprehensive Comp High

170 Documentation Guidelines Detailed history Extended history of present illness (4-8 elements) Extended review of systems (at least 2 systems reviewed) Problem pertinent past/family/social history (1 area) Detailed physical examination At least nine examination elements recorded Low complexity medical decision making Limited diagnoses/management options Low risk 170

171 Grading the Visit with If the visit had the following elements: 1. General evaluation of the complete visual system 2. History 3. General medical observation 4. External examination 5. Ophthalmoscopic examination (with or without cycloplegia or mydriasis 6. Gross visual fields 7. Basic sensorimotor examination 8. Initiation of diagnostic and treatment program If meets above criteria, then could be coded rather than

172 THE CONCEPT of TIME Time can be utilized to increase the level of E&M coding when you spend more than 50% of the office time coordinating and counseling you patient. It is critical that you document the time you started the exam as well as the you completed the exam Time needs to be documented Time is face-to-face

173 Coding Claims Based on Time When counseling and/or coordination of care dominates (more than 50%) of the encounter, time may be considered the key or controlling factor for a particular level of service In this case, the provider may be an appropriate level of service based on the TOTAL ENCOUNTER TIME You should record counseling topics and/or how time was spent coordinating the patient s care

174 The Concept of Time Record encounter start and stop time Record refraction time Record Counseling/Coordinating Time E & M Time = Total Encounter Time refraction time other procedure time

175 Example Example 1 Face-to-Face Time 25 minutes (CPT -4) Total Counseling Time 15 minutes Level of Care (Typical Time 25 minutes) (Time is key factor as opposed to History,Exam & MDM) Example 2 Face-to-Face Time 60 minutes Total Counseling Time 30 minutes Level of Care Base on history, exam, and MDM (50% not exceeded)

176 Selecting a Code Use the time listed in CPT (this is the typical time a physicians spends with the patient and or the family) If the time spent engaged in counseling and/or coordination of care is more than 50% of the typical time listed, then a code can be chosen and billed

177 99000 vs About 75% of visits can be billed as a code or a code How to decide? Higher reimbursement for one or other Record more clearly supports one or other Patient s insurer requires using one set or other Your in-office protocol requires for nonmedical services and for medical 177

178 WHEN DO I USE and THE E & M CODES? Perhaps one needs to consider when not to use the codes? Evaluation of new or existing condition, complicated with a new diagnostic or management problem, not necessarily relating to the primary diagnosis: Are these acceptable: Glaucoma with dry eye - Yes IOP check for known glaucoma patient - No Annual diabetic exam No? Annual diabetic exam with onset of ocular pain - Yes Cataract with blurred vision - Yes You establish a new treatment plan - Yes 178

179 92000 s vs. E&M When reporting services related to an optometric or ophthalmologic office visit, it is important to closely review the CPT definitions and ensure that all criteria are met for the code used. In this regard, the January 2007 issue of the AMA's CPT Assistant provides clarification regarding the difference between ophthalmology codes and the evaluation and management (EM) code series. According to the AMA, from a CPT coding perspective, the general ophthalmologic service codes share several definitions with the E/M codes, such as "new" and "established" patient and maybe used to report services rendered in the ophthalmology or optometry office. 179

180 Other Considerations Difficult cases (patients whose diseases are not well controlled) justify higher levels of service Simple re-evaluation of well controlled patients suggests the use of lower levels of service 180

181 Therefore and Perhaps For complex or very difficult cases, you should consider using higher level E/M Codes. Lower-level E/M codes may be best utilized for follow-up visits and examinations for uncomplicated problems or stable patients. Eye codes are more easily understood than the E/M codes with simpler definitions and only 2 levels to choose from 181

182 Specialty Codes Surgical Codes (66000) Radiological Codes(76000 Codes) Medical Procedure Codes (90000) 182

183 Surgery - Eye and Ocular Adnexae Surgical codes are stand alone and typically cannot be submitted for payment on the same day as and series codes for the same diagnosis If the patient is seen for one reason and a surgical service is then provided at the same visit, the separate service modifier 25 must be used The same general rules of proper documentation should be followed for surgical codes 183

184 The Surgical Package The Global Surgical Fee : includes all necessary services performed the day before (for major surgery), the day of (for minor surgeries), during, and after a surgical procedure. Payment for a given surgical procedure includes applicable preoperative, intraoperative, treatment for complications, and postoperative care (follow-up visits) and pain management related to the surgical procedure 184

185 What s Not Included in the Surgical Package? Initial consultation or evaluation Services unrelated to the surgical condition Diagnostic test or procedures Care unrelated to the surgery Other distinct surgical procedures 185

186 Post-op period Major Procedures: 1 day pre-op 90 days post-op i.e. cataract surgery Minor Procedures: procedures with an (*) in CPT manual Same day (zero days) or 10 days starred (includes services the day of the minor surgical procedure) i.e. Punctal occlusion 186

187 Surgery Post-op care Be certain that the patient is given the option of having the post-op care in the surgeon s office or in your office. Coordinate your standard of post-op care with those of the surgeon Release signed by the patient and the ophthalmologist, with transfer date 187

188 Surgery Post-op care The value of the service is in the # of days of care provided not the # of visits The results must be communicated with the surgeon s office Range of dates that the postoperative care was provided. If the OD cares for the patient for 80 days, list as follows: Surgery 10/1/10 and transfer occurs 9 days later 10/1/ Item 19 on CMS form 1500 : 10/10/10 to 12/30/10 Check your carrier s individual guidelines for billing and coding these procedures 188

189 Modifiers Modifier 24 Visit for unrelated problem during global post-op period Cataract patient presents with allergic conjunctivitis ALT patient presents with conjuctival heme Modifier 79 Unrelated Procedure 189

190 Take home You need to be familiar with global fee periods associated with surgical codes 190

191 Surgery - Eye and Ocular Adnexae Punctal dilation and occlusion Per-punctum procedure Follow the rules of your carrier s LCD Use correct modifiers E1 Upper Left E2 Lower Left E3 Upper Right E4 Lower Right 191

192 68761 Closure Lacrimal Punctum with plug Medicare allowable (includes materials) Use modifier 50 if bill on same line of CMS form 1500 Medicare pays 50% for each subsequent closure Permanent vs. temporary 192

193 Multiple Surgery Reduction Rule Primary/highest-valued procedure 100% of fee schedule Second through fifth highest valued procedure 50% of fee schedule Procedures beyond the fifth, priced on a byreport basis 193

194 Diagnostic Tests / Procedures The boom in diagnostic instrumentation has give OD s incredible tools to better manage our patients. However, this requires proper use, billing and coding of these new technologies Sales reps may tell you how much money you can make from new technology; however, they will not protect you from an audit. Avoid these: Our monthly payment is $xxx and you will only need to do YY procedures to meet your monthly obligation. 194

195 Special Ophthalmological Procedures Procedures that can be billed in addition to your examination codes (99000 or s) Exception is this in bundled with special procedure codes Check your carrier for utilization guidelines and limitations Examples: gonioscopy, scanning laser, visual fields, fundus photography Either unilateral or bilateral extended ophthalmoscopy unilateral visual fields bilateral 195

196 New CPT Codes for Scanning Eliminated Laser Scanning computerized ophthalmic diagnostic imaging; posterior segment, with interpretation and report, unilateral or bilateral, optic nerve Scanning computerized ophthalmic diagnostic imaging; posterior segment, with interpretation and report, unilateral or bilateral, retina Scanning computerized ophthalmic diagnostic imaging; anterior segment, with interpretation and report, unilateral or bilateral 196

197 Special Ophthalmological Services & Extended Ophthalmoscopy Unilateral use Rt or Lt modifier Diagnosis justified in chart (LCD) Requires drawings (LCD) Requires interpretation and report Medicare allowable / Utilization Guidelines: For up to six(6) times a year Other Conditions usually no more than two (2) per eye, per year. For patients being treated with intravitreal injections of medications for wet AMD (362.52) up to 12 times per year Some tumors 4 times per year 197

198 Extended Ophthalmoscopy Revisited CPT is not intended to be a one-time-only code unless a local policy lists it that way Use for the initial extended Ophthalmoscopy of new symptoms of a non-chronic problem such as flashes and floaters Examples A) New spider web six months later B) One month follow-up PVD C) DFE for diabetic one year after initial visit CLINICAL PEARL: CPT 92225/92226 refer to initial and subsequent and not new or established 198

199 Interpretation and Report When required (for certain CPT medical and surgical procedures), you need to include the interpretation and report on a separate document from the exam record. Doctors in many states are getting penalized by auditors for non-compliance Such a note, which can be brief, should be made within the medical record for the day and summarize: What was done Why it was done What was found (comparative data/change in condition) What will be done about it (clinical management: change or stop medications, recommending further diagnostic testing, etc.) 199

200 Interpretation and Report Scanning Laser, Extended Ophthalmoscopy, Fundus Photography, Visual Field Address the reason for ordering the test with rationale Date of the test Reliability of the test (cloudy due to a cataract) Description of Findings (hemorrhage) Comparative data when available State diagnosis and resultant treatment Signature 200

201 Place of Service All Medicare Fee-for-Service claims MUST now note the specific location at which services are provided Affects Fee Reimbursement Reduced fees for Nursing Nurse, Hospitals, Assisted Living, etc (Codes with asterisks) 11 Office Visits 31 & 32 Skilled Nursing Homes 33 Assisted Living Main Office vs. Satellite Office (Geographical Fees) 201

202 Diagnostic and Treatment Services The diagnostic or treatment program does not have to be a reimbursable service prescribing eyeglasses should count. Ordering of special diagnostic tests (visual fields or OCT) is considered initiating diagnostic services. Orders such as Return PRN or Return in One Year would not be initiation of diagnostic or treatment services. Continuation of the same medications would probably not also. 202

203 New CPT Codes for Scanning Eliminated Laser Scanning computerized ophthalmic diagnostic imaging; posterior segment, with interpretation and report, unilateral or bilateral, optic nerve Scanning computerized ophthalmic diagnostic imaging; posterior segment, with interpretation and report, unilateral or bilateral, retina Scanning computerized ophthalmic diagnostic imaging; anterior segment, with interpretation and report, unilateral or bilateral 203

204 NCCI Edits & may be allowed on same visit if both are medically necessary & are not allowed on the same visit or & (remote imaging for retinal disease) are not allowed on the same visit & may be allowed on same visit if both are medically necessary or & may be allowed on same visit if both are medically necessary 204

205 Extended Ophthalmoscopy & Fundus Photo Fundus photography involves the use of a retinal camera to photography the regions of the vitreous, retina, choroid and optic nerve Fundus photography may be indicated to document abnormalities of disease processes affecting the eye or to follow the progress of such disease. Photographs and an interpretation and report of the test may be necessary to document a disease and to plan treatment for a disease process. 205

206 Extended Ophthalmoscopy & Fundus Photo Extended ophthalmoscopy is the detailed examination of the retina with drawing. It may use scleral depression. It is performed when a more detailed examination (including that of the periphery) is needed following routine ophthalmoscopy. It is usually performed with the pupil dilated and ALWAYS includes a true drawing of the retina (macular, fundus, and periphery) with interpretation and report. The examination must be used for medical decision making. 206

207 Extended Ophthalmoscopy & Fundus Photo Extended ophthalmoscopy is indicated when the level of examination requires a complete view of the posterior segment of the eye and documentation is greater than that required for general ophthalmoscopy. Covered diagnoses: Symptoms suggestive of retinal defects (flashes and/or floaters) Experienced sudden visual loss or transient visual loss Disorders of the vitreous (PVD). Spots before the eye (floaters) and flashing lights (photopsia) can be signs/symptoms of these disorders. Systemic disorders which may be associated with retinal pathology High risk medication for retinopathy or optic neuropathy 207

208 Extended Ophthalmoscopy & Fundus Photo Interesting Diagnosis Codes for both extended ophthalmoscopy and fundus photography: Long-Term (Current) use of other medications (V58.69) and high risk medications (V67.51) 208

209 Extended Ophthalmoscopy Additional Approved Diagnosis Diabetes without complications Visual Field Defects Unspecified; Scotomas; Homonymous and Heteronymous Defects ( ) Unspecified Visual Disturbance Child emotional/psychological abuse WHAT DO YOU DRAW? 209

210 Extended Ophthalmoscopy Revisited CPT is not intended to be a one-time-only code unless a local policy lists it that way Use for the initial extended Ophthalmoscopy of new symptoms of a non-chronic problem such as flashes and floaters Examples A) New spider web six months later B) One month follow-up PVD C) DFE for diabetic one year after initial visit CLINICAL PEARL: CPT 92225/92226 refer to initial and subsequent and not new or established 210

211 Extended Ophthalmoscopy Comment from a provider: Payment for extended ophthalmoscopy should be allowed in some circumstances, such as a trauma victim who requires a comprehensive extended ophthalmoscopy detailed retinal exam to make sure that the peripheral retinal is intact but no pathology is detected 211

212 Extended Ophthalmoscopy Response from the Medical Director: The extended ophthalmology service as described in CPT includes a retinal drawing as part of the service. The code should not be billed unless s drawing has been made. In order to bill this service, it would be necessary to create a properly labeled drawing, albeit of a normal fundus. Alternatively, it would be appropriate to document in the medical chart that the fundus was normal, forego creating the drawing, and &not bill this as a separate service 212

213 Special Ophthalmological Services Fundus Photography Bilateral Diagnosis justified in chart (LMRP) An interpretation and report of this test is also required in addition to the photographs themselves. Not routine photos Medicare allowable Medicare has recently bundled Scanning Laser and Fundus Photography as part of the Correct Coding Initiative Use Modifier 59 (distinct procedural service) 213

214 Screening Tests Screening is part of a wellness program to check for disease that may otherwise go undetected Screening is not prompted by a patient complaint, symptom, or problem (not medically necessary) For those payers who do not cover screening, the results of any screening are immaterial with respect to reimbursement. For most third party payers, screening is a non-covered service regardless of what is found. Use V80.2 (special screening for neurological, eye and ear diseases, other eye conditions) If screening reveals pathology, additional testing can be ordered and these follow-up services will be covered (on a different date??). This requires complete chart documentation and supportive data. Other coding options: GY Item excluded or not medically necessary S9986 Not medically necessary services -patient is aware the service is not medically necessary screening test 214

215 Order and Interpretation Many special procedure request this information What does it mean? A) an order is just the request for a test i.e. VF today, or Gonioscopy 6 months B) Interpretation write your test results on a separate page in the patient s medical chart consider the following: was the test reliable, what were the test results, what were the implications of the test, did the test help you make a diagnosis, what s the impact of the test results on the patient s treatment or prognosis? 215

216 Interpretations When required (for certain CPT medical and surgical procedures), you need to include the interpretation and report on a separate document from the exam record. Doctors in many states are getting penalized by auditors for non-compliance Such a note, which can be brief, should be made within the medical record for the day and summarize: What was done (clinical findings) Why it was done What was found (comparative data/change in condition) What will be done about it (clinical management: change or stop medications, recommending further diagnostic testing, etc.) 216

217 Surgery - Eye and Ocular Adnexae Surgical codes are stand alone and cannot be submitted for payment on the same day as and series codes for the same diagnosis If the patient is seen for one reason and a surgical service is then provided at the same visit the separate service modifier must be used -25 The same general rules of documentation should be followed 217

218 65205 Superficial FB removal External eye, conjunctiva superficial Starred procedure No post-op component Medicare Allowable $

219 65210 Conjunctival FB removal External eye conjunctiva, embedded Subconjunctival, scleral, non-perforating Starred procedure No post-op component Medicare allowable $

220 65220 FB Removal without Slit Lamp Starred procedure No post-op component Medicare allowable

221 65222 FB Removal with Slit Lamp Starred procedure No post-op component May use modifier for unusual procure -22 or multiple procedures -51 Medicare allowable Use the same code for one or multiple FB 221

222 67820 Epilation with forceps Starred procedure 10 days post-op component Medicare allowable Some carriers pay per eye, per eyelid, and even per lash Medicare usually pays per eye If per eye, use Modifier Rt, Lt, or 50 If per lid, use E1, E2, E3 or E4 222

223 67825 Epilation other than forceps Starred procedure 10 days post-op component Medicare allowable

224 Surgery Codes and Office Visits? Can You Bill a Surgical Code and Office Visit on the Same Day? Yes if the office visit is totally unrelated to the surgery? If patient complains of a FB sensation and you epilate an eyelash and determine that s causing the FB sensation, then you cannot bill both. However, if the patient complains of a new floater, they you can bill both and use Modifier 25 for the Office Visit (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) 224

225 CORRECT USE OF MOFIDER 25 Patient report ocular pain on the same day you plan on inserting a punctal plug for dry eye: Code /51/E1/E2/E3/E4 DX: (Tear Insuffiency) Code Appropriate E&M with modifier 25 DX (Pain in and around eyes) Modifier 51 (Multiple procedure same eye); Modifier 50 (Bilateral procedure) 225

226 Correct Use of Modifier 25 June 1, 2006 Revisions Only append modifier 25 to the E/M service Only used on the same day as another procedure or service Different diagnosed are not required for reporting the E/M service and the procedure done on the same day (I do not believe this) You should document the medical necessity of performing both services on the same day (even though you do not have to send this in) 226

227 Modifier 25 and 79 Modifier 79 Unrelated procedure or service by the same physician during the postoperative period when a physician has to return a patient to the OR for procedures during the postoperative period of another surgical procedure. An example would be when a surgeon performs cataract surgery on the second eye during the postop period of the first eye. 227

228 Emergency Codes There are codes for After-Hours and Emergency Care although they might not always be reimbursed by Medicare and private carriers. They are billed in addition to the office visit and procedure codes CPT services after posted hours CPT services between 10PM and 8 AM CPT services on Sundays and Holidays CPT Office services provided on an emergency basis (patient cannot be on your schedule) Can you this in the middle of the day if it s a TRUE emergency! 228

229 Emergency Code According to the August 2006 edition of the AMA s CPT Assistant, CPT is used to report office services provided on an emergency basis that disrupt other schedule office services. It is reported for those office patients whose condition, in the clinical judgment of the physician, of the physician warrants the physician s interrupting his/her care of another patient to deal with an emergency. This code is not to be reported when the physician s usual practice is to have time slots available in the schedule and patient s are fit into the schedule. At times, we see CPT incorrectly used to identify a visit for an ill patient who was fit into the appointment schedule, rather than one with an emergency identified by the physician s clinical judgment which interrupted the physician s care of another patient. 229

230 New CPT for 2005/2006 Phone calls are not reimbursable However, some insurance carriers (not Medicare) are allowing for correspondence regarding from the patient to the doctor for advice, clarification, etc. 230

231 E & M Non-Face to Face Physician Services Most E & M services are: FACE-to-FACE Two exceptions: Telephone Services On-line Medical Evaluation 231

232 Telephone Services Physician Services - Code Initiated by established patients, parent or guardian only Not reportable: If patient visit was within past 24 hours If patient refers to E&M services with last 7 days (considered part of E&M service) Billable 1 time in a 7 day period Three levels of the code delineated by time: 5-10 minutes (99441) minutes (99442) minutes (99443) If telephone service ends with a decision to see the patient within 24 hours or next available urgent problem, the code is not reported. Is it reimbursable by Medicare or Private Sector? 232

233 On-Line Medical Evaluation - CPT Code Response to an on-line patient inquiry Physician personally responsible, must permanently store notes Reported once in a 7 day period (can be billed by multiple physicians) If on-line request refers to E&M services or procedures within previous 7 days considered covered by E&M or global period Service includes sum of communications: related calls, prescriptions provisions, lab orders, etc) CPT It is reimbursable by Medicare or Private Sector? 233

234 Can You Charge Patients for No-Shows You can charge Medicare patients for not showing up but you must follows this rule: Your practice s no-show policy, including the amount you charge patients for missed appointments MUST apply equally to all patients, no matter their insurance payor. Medicare and carriers will not pay it s the patient s responsibility The amount you charge for a missed opportunity should reflect the missed business opportunity not the amount you would have received had the appointment occured 234

235 Modifiers A way of telling an Insurance Carrier that you are doing something different Inappropriate use of modifiers can trigger audits See handout for commonly used modifiers 235

236 Modifiers Unusual Procedure (-22) Unrelated Service (-24) Separate Service (-25) Professional Component (-26) Bilateral Procedure (-50) Multiple Procedures (-51) Reduced Services (-52) Pre-op/Post-op Management (-56, -55) Unrelated Procedure (-79) 236

237 Modifiers GA Waiver of Liability Statement on File GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit. GZ Item or service expected to be denied as not Reasonable and Necessary GX Item not covered by Medicare 237

238 MODIFIERS GA modifier Indicates that the patient has signed an ABN for services and material that may be denied by Medicare. Retain this in patient s record and the patient is not responsible for payment is he/she did not sign the ABN and Medicare denies the claim. Example: Exceed Number of Approved Scans or Pachymetry GZ modifier must be used when the physician wants to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they HAVE NOT had an ABN (Advanced Beneficiary Notice) on file 238

239 MOST COMMONLY CONFUSED MODIFIERS 25 Significant, separate E&M service, same physician, same day as procedure or other service 59 Distinct procedures, same day, same physician 79 Unrelated procedure or service, same physician during post-op period 24 Unrelated E&M service, same physician, during post- op Period 26 Professional component for special ophthalmologic service TC Technical component for special ophthalmologic service GW Service unrelated to terminal condition (Hospice Care) 239

240 MODIFIER 25 Separate E&M service, same physician, same day as procedure Use with E&M code only Use when an office evaluation is necessary to determine the patient problem Once diagnosed, the procedure is performed the same day Example: Pain in or around the eye Redness or discharge of the eye Removal of foreign body, corneal, with slit lamp 240

241 MODIFIER 59 Distinct procedural service When a procedure or service that is designated as a separate procedure is carried out independently or considered to be unrelated or distinct from other procedures/services provided at that time, it may be reported by itself, or in addition to other procedures/services by appending modifier 59 to the specific separate procedure code to indicate that the procedure is not considered to be a component of another procedure, but is a distinct, independent procedure. 241

242 Modifier 59 Before appending modifier 59 (Distinct procedural service), the claim must meet the minimum following conditions: The two service/procedures are provided for the same patient by the same provider The two services/procedures ordinarily are not encountered on the same day Neither of the services/procedures is an E/M service In the CCI edits, a 1 modifier indicator must be present No other modifier betters describes the circumstances Example: Dx: Glaucoma Scanning Laser Imaging Fundus photography 242

243 MODIFIER 79 Unrelated procedure during post op period by same physician Example: RT Cataract post op DOS: January 20, LT Cataract post op DOS: February 20,

244 MODIFIER 24 Unrelated E&M service during post op Period, same physician Episcleritis OS Patient currently in cataract post op period for the right eye 244

245 MODIFIER 26 & MODIFIER TC Modifier 26 Professional component of a special ophthalmologic service Modifier TC The technical component of a special ophthalmologic service Example: The professional component of the service TC The technical component of the service 245

246 MODIFIER GW GW Services unrelated to terminal condition (Hospice Care) Patient under hospice care Seen for condition unrelated to terminal condition Example: GW DX: Glaucoma Patient under Hospice care for end stage COPD Service unrelated to Hospice diagnosis 246

247 Place of Service Codes Basically tells a carrier where you rendered the care: Your Office; the Patient s Home; In a Nursing Home Affect Physician Reimbursement Inappropriate use of the Service Code can trigger AUDITS! 247

248 Coding: Place of Service Place of Service codes 11 - Office Visits 13 Assisted Living Facility 31 Skilled Nursing Facility 32 Nursing Facility 248

249 Medicare Determinations National Coverage Determinations (NCD) Defines specific services, procedures, or technologies covered on a national basis a) Reasonable and necessary coverage b) Advance Beneficiary Notice (ABN) to inform patients c) NCD takes precedence over any local determination National Correct Coding Edits (NCCI edits) Identifies coding pairs that cannot or should not be billed together- update quarterly 249

250 Medicare Determinations Local Coverage Determinations (LCD) a) outline coverage criteria b) define medical necessity c) provide references for policy d) list codes to describe what is covered or not a) CPT b) ICD-10 e) further defines NCD f) used when no NCD available g) developed at Carrier discretion 250

251 What's An ABN? An Advance Beneficiary Notice (ABN) is a standardized form (CMS-R-131-G) that notifies a beneficiary in writing before a procedure why Medicare in unlikely to cover it. The provider must describe the procedure in simple language and explain why it will not be covered by Medicare Bill procedures with GA modifier New ABN form as of March

252 Advance Beneficiary Notice of Noncoverage (ABN) NOTE: If Medicare doesn t pay for D. below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. below. D. E. Reason Medicare May Not Pay: F. Estimated Cost WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the D. listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this. G. OPTIONS: Check only one box. We cannot choose a box for you. OPTION 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the D. listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don t want the D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. H. Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on 252

253 Foundation of Health Care Reform Health Care Quality and Value Most payers, including CMS, are looking at Evidenced Based Medicine (EMB), as a way to only pay for medically necessary care Patients and providers must find middle ground between expectations and best practices Quality measures facilitate findings a middle ground between quality care and valuable care

254 Challenges The United States has the planet s highest per capita health care expenditures In 2010, 2.6 trillion was spent on health care (an amount equal to the entire economy of France) By 2019, an estimated 19 cents of every dollar will be spent on health care Many new regulations will come into play ICD-10, 5010, Obamacare)

255 Challenges Many industry stakeholders and lawmakers are looking to payers and providers for ways to reduce costs, while ensuring efficacy and quality Nearly 32 million Americans do not have insurance Most of these patients do not seek care until they are really sick leading to increased costs (ER)

256 The wrap up Every record will contain basic data (name, birth date, encounter date, allergies, meds, etc) Every record will have a chief complaint a reason for the visit Records will be organized and legible Documentation matches the billed services CPT: Record must match the description in CPT or LCD or Carrier s Rules ICD: Record must support the code chosen Medical decision making MUST match service level 256

257 The wrap up Enter information into records in timely manner Enter information into record at time of service Clearly identify amendment, correction or delayed entry Clearly identify date/author of amendment, correction, or delayed entry Addendums or alterations are properly documented and records are completed within 8-24 hours Addendums dated and signed Insure proper use of modifiers and place of service codes Make sure you document an interpretation and report for procedures as required 257

258 The wrap up Insure proper use of modifiers and place of service codes Make sure you document an interpretation and report for procedures as required Be well versed on all requirements for the codes you bill (NCD/LCD/individual carrier policies) If you don t know it don t bill for it! 258

259 Coding and Billing Pitfalls Avoiding test interpretation and chart documentation Repeating tests too often Failing to records an order for a test in chart notes Selecting an inappropriate ICDA or CPT code 259

260 Cloned Documentation When documentation is worded exactly like or very similar to previously recorded entries, this is considered cloned documentation The cloning of documentation may be considered misrepresentation of medical necessity requirement and recoupment of money Applies to paper records or EMR It is not expected that every patient had the same problem, symptom, and required the same treatment

261 Avoid cloning of records! Cloned Charts Several Medicare carriers announced they would recoup payment for claims if an audit revealed cloned documentation Cloned documentation will be considered misrepresentation of medical necessity for coverage of services due to the lack of specific individual information for each patient If you sign the (cloned) note (without reading it) you are saying: That s what I saw, that what I told the patient to do, that s what you attesting to!

262 Cloned Documentation Cloned documentation does not meet medical necessity due to the lack of specific, individual information for each patient

263 Increase Since EHR 263

264 Hopefully NOT Like This?

265 The bottom line 265

266 TEN COMMANDMENTS FOR EYE CODING 1. Every record will contain basic data (name. birth date, encounter date, allergies, meds, etc.) 2. The record will be organized 3. Documentation matches the billed services 4. Medical decision making MUST match service level 5. Examination must be legible

267 TEN COMMANDEMENTS FOR EYE CODING 6. All case history questions, all care provided, all diagnoses and management options recorded must be based on the needs of the patient that day 7. All CPT codes are chosen by comparing the contents of the medical record with the CPT definitions for the related codes. 8. Do Not Clone Medical Records Avoid boilerplates & copying records 9. Do not abuse modifiers especially Clearly document time based encounters

268 BILLING PEARL REMEMBER: NO MEDICAL CHIEF COMPLAINT - NOT A CODEABLE SERVICE TO A MEDICAL CARRIER IT S NOT WHAT YOU DID IT S WHAT YOU DOCUMENTED YOU DID! IF IT S NOT DOCUMENTED IT S NOT BILLABLE!

269 The take home is You need to be familiar with the exact guidelines as written in the pertinent NCD and/or LCD Cannot code an exam based solely on your opinion of case complexity or your impression of how much you should get reimbursed for your efforts

270 Yogi Berra Quote THE FUTURE AIN T WHAT IT USED TO BE 270

271 Questions???? 271

272 THANK YOU! Good Luck! What is going to happen next year? Will the system be even more broken? 272