6/5/2014 ABOUT ME ORGANIZATIONS

Transcription

1 ABOUT ME Worked 5 years for CPA (client accounting & payroll for about 30 companies) Worked 21 years for private practice Did Medical Billing on the side Started my own business Skinner Medical Billing & Consulting, LLC Started Practice Management with Texas Osteopathic Medical Association ORGANIZATIONS American Academy of Professional Coders Professional Assn of Healthcare Office Management Texas Osteopathic Medical Association 1

2 OFFICES Vice President of Abilene Chapter of AAPC Member of the Practice Management Committee with Texas Osteopathic Medical Association Member of the Early Ballot Board in Eastland Co. SPECIALITIES Family Practice Dermatology Urgent Care OMM Internal Medicine Pediatrics Chiropractic CERTIFICATIONS CPC Certified Professional Coder CFPC Certified Family Practice Coder CMM Certified Medical Manager 2

3 WHAT DOES SYMPOSIUM MEAN? - A social gathering at which there is free interchange of ideas - A collection of opinions on a subject - A party with music, wine and conversation REMIND 101 To (254) CODING UPDATE FOR Removal of cerumen impaction requiring instrumentation, unilateral ** How do you bill? 59? 50? 51? LT? RT? 3

4 EFFECTIVE JUNE 1, 2014 Blue Cross Blue Shield will require NDC codes for injectables TYPICAL FACE-TO-FACE TIME Level 1 New Patient 10 minutes Level 2 New Patient 20 minutes Level 3 New Patient 30 minutes Level 4 New Patient 45 minutes Level 5 New Patient 60 minutes Level 1 Est. Patient 5 minutes Level 2 Est. Patient 10 minutes Level 3 Est. Patient 15 minutes Level 4 Est. Patient 25 minutes Level 5 Est. Patient 40 minutes PROLONGED OFFICE VISITS (ADD ON CODES) Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service ; first hour (List separately in addition to code for office visit) each additional 30 minutes after the first hour TOTAL DURATION PROLONGED CODE(S) LESS THAN 30 MINUTES NOT REPORTED SEPARATELY MINUTES X MINUTES X 1 AND X OR MORE X 1 AND X 2 OR MORE EACH ADDL 30 MINS. 4

5 PROLONGED SERVICES IN-PATIENT CARE Face-to-Face Contact Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient E & M Service) each additional 30 minutes TIME BILLING Total time determines the level of service Encounter must be dominated by counseling and coordination of care Measured differently for outpatient vs inpatient (observation is face-to-face time & inpatient is unit/floor time) TIME BILLING 5

6 OBSERVATION CODES Level 1 - ADMIT Level 2 - ADMIT Level 3 - ADMIT Discharge NEW SUBSEQUENT OBSERVATION CODES Level 1 Subsequent Observation care (Problem focused history, Problem focused exam, Straightforward Medical decision making) Level 2 Subsequent Observation care (Expanded problem focused history, expanded problem focused exam, Moderate complexity Medical decision making) Level 3 Subsequent Observation care (Detailed history, Detailed exam, High Complexity Medical decision making) OBSERVATION SERVICES Documentation must support medically reasonable and necessary care May span up to two midnights Consider observation when: Patient is stable and/or improving Treatment plan includes Monitor and/or observe **Medicare has no rule about designated observation beds any bed may be assigned 6

7 OBSERVATION SERVICES Must be patient specific (General standing orders are not acceptable) Orders should clearly define what service is being requested (ex: placed in observation ) Observation time must be documented BILLING May not require the presence of a physician Documentation must support a face-to-face encounter Requires direct physician supervision Modifier 25 is not appropriate Not paid with drug admin services, therapeutic or diagnostic injection codes (including flu & pneumonia) 7

8 QUESTION An appointment was made for an Established Patient. The family wanted to talk with the doctor about the patient without the patient being present. Can you bill an Established patient visit? ANSWER Yes Established patient E & M Office Visits of ALL levels states Time spent face-to-face with the patient and/or family. 8

9 QUESTION An appointment was made for a New Patient. The family wanted to meet with the doctor before they brought patient in. So the appointment was actually for meeting with the family. Can you bill a New patient visit? ANSWER Yes New patient E & M Office Visits of ALL levels states Time spent faceto-face with the patient and/or family. DIFFERENCES BETWEEN MODIFIERS 51 AND 59 Modifier 51 Multiple Procedures Performed on same day Modifier 59 Distinct procedural Service ** Both can be used when two or more procedures are performed on same day. And both reduce payment by 50%. 9

10 Conditionsthat apply : MODIFIER 51 CPT code cannot be an add-on code CPT code cannot be listed in Appendix E (modifier 51 exempt table) CPT must be a stand-alone procedure and not inclusive to other procedures res performed at the same time. MODIFIER 51 EXAMPLE A physician performs a joint injection to a major joint and a joint injection to an intermediate joint during the same session MODIFIER 59 Conditions that apply: When there is no other more specific modifier (51 multiple, 50 bilateral) that will explain the situation to the payer When code combination is correct but the payer has a reimbursement edit in place ** Modifier 59 is referred to as last resort modifier 10

11 MODIFIER 59 EXAMPLE Surgeon documents injections to the right hip joint and the right knee joint on the same day. Both procedures are defined by CPT code HAND-HELD NEBULIZER TREATMENTS Can you bill for more than one HHN treatment on the same day? Answer is: YES x x 1 with a 76 modifier (a repeat procedure by the same physician ) INJECTIONS NOTE: When giving injectable medications in the office, make sure your doctor is letting the billing department know how many Milligrams not how many CCs they are giving. 11

12 EXAMPLES J1100 Dexamethasone is billed out per 1 mg If you gave 8 mg, it would be billed as J1100 x 8 units J3301 Kenalog is billed out per 10 mg If you gave 40 mg, it would be billed as J3301 x 4 units J1885 Toradol is billed out per 15 mg If you have 30 mg, it would be billed as J1885 x 2 units J0696 Rocephin is billed out per 250 mg If you have 1 g, it would be billed as J0696 x 4 units COPAY CODES FOR MEDICAID CP001 Private HMO Copayment CP002 Private PP0 Copayment CP003 Medicare HMO Copayment CP004 Medicare PPO Copayment Reimbursement $ BRIDGES TO EXCELLENCE Incentives paid to providers for performance benchmarks 12

13 BRIDGES TO EXCELLENCE Physicians Nurse Practitioners Physician Assistants BRIDGES TO EXCELLENCE INS PLANS Aetna Anthem-Wellpoint BCBSLA BCBSNC BCBSNM BCBSOK BCBSTX CareFirst BCBS CDPHP CIGNA Fallon Community Health Plan HarvardPilgrim HealthPartners Horizon BCBS Kaiser Permanente of GA MVP Health Plan Rocky Mountain Health Plans Tufts Health Plan United Healthcare 13

14 96372 Injection Administration code G0436 Smoking Counseling G0372 Power Mobility Evaluation G0402 IPPE Exam (Welcome to Medicare Exam) G0438 AWV Annual Wellness Visit G AWV Subsequent Annual Wellness Visit G0447 Face-to-face obesity counseling G0179 Re-Cert Home Health Services G0180 Cert Home Health Services G0181 Care Plan Oversight Home Health CP001 Private HMO Copayment CP002 Private PP0 Copayment CP003 Medicare HMO Copayment CP004 Medicare PPO Copayment WHO CAN PROVIDE THE ANNUAL WELLNESS VISIT? - Doctor of Medicine or osteopathy - Physician Assistant - Nurse Practitioner - Clinical Nurse Specialist - Health Educator - Registered Dietitian - Medical Professional working under the direct supervision of a physician (RN, LVN, MA) FREQUENTLY ASKED QUESTION # 1 If a physician states same/unchanged from last visit, will he receive credit for reviewing the last visit information? 14

15 ANSWER: Credit may be taken ONLY if the physician includes the documentation from the previous visit. Otherwise, the reviewer would not know what was the same or unchanged from the previous visit. FREQUENTLY ASK QUESTION #2 Our office requests that our patients complete a form. Can we include this information as documentation of the Past Family Social History and Review of Systems? ANSWER: Yes, this information may be used if the physician notes that he has reviewed the form. It is also appropriate for the physician to note in medical records any additional information obtained during the face-toface encounter. 15

16 FREQUENTLY ASKED QUESTION # 3 Can a Non-Physician Practitioner provide a new patient visit? ANSWER: Yes, but must be within state scope of practice and billed under the their NPI. FREQUENTLY ASK QUESTION #4 Why are we seeing denials for our physician s new patient visits? The denial message is saying that this patient was seen by our group in the last three years. 16

17 ANSWER: In a Multi-specialty group, if the patient was seen by a Non-Physician Practitioner, this may cause your patient visit to be denied for a physician. If you can provide documentation that shows that the NPP and the physician are trained in different specialties, request a redetermination of the claim with the documentation. NEW PATIENT GUIDELINES Patient has not received care within the last 3 years by: Same physician Physicians with the SAME specialty in the SAME group practice Physicians with the same sub-specialty in the same group practice 17

18 Accounts Receivable Reports Monthly (Patient and Insurance Balances) Monthly Income Reports (Total Charges Billed and Total Income Collected) How often is your staff working the Insurance AR? (Monthly?) On Labs, X-rays, Injectable Medications, etc. - How much are you billing for them and how much are they costing you? How many patients are you seeing in a day? In a Month? What does your Income vs. Expense Report look like each month? Are you overstaffed or understaffed? What changes can you make to help your practice run efficiently? What changes can you make to help your practice be profitable? Are you charging for the Level of care that you are doing? Contact Information: Kelly Skinner, CMM, CPC, CFPC Skinner Medical Billing & Consulting, LLC 112 S. Seaman St. Suite 314 Eastland, Texas (254) Office (254) Cell skinnermedicalbilling@gmail.com 18