Office of Billing Compliance 2014 Professional Coding, Billing and Documentation Program

Transcription

1 Office of Billing Compliance 2014 Professional Coding, Billing and Documentation Program Dermatology Prepared by: Medical Compliance Services, Miller School of Medicine/University of Miami and Compliance Concepts, Inc. April

2 What is a Compliance Program? 7 Elements of an Effective Compliance Program A centralized process to promote honest, ethical behavior in the day-to-day operations of an organization, which will allow the organization to identify, correct, and prevent illegal conduct. It is a system of: FIND FIX PREVENT The University of Miami implemented the Billing Compliance Plan on November 12, The components of the Compliance Plan are: 1. Policies and Procedures 2. Having a Compliance Officer and Compliance Committees 3. Effective Training and Education 4. Effective Lines of Communication ( or ) 5. Disciplinary Guidelines 6. Auditing and Monitoring 7. Detect Non-Compliance Issues and Develop Corrective Action Plans 2 2

3 The Government In order to address fraud and abuse in the Healthcare Field, the government has on-going reviews and investigations nationally to detect any actual or perceived waste and abuse. The Government does believe that the majority of Healthcare providers deliver quality care and submit accurate claims. However, the amount of money in the healthcare system, makes it a prime target for fraud and abuse. Centers for Medicare and Medicaid Services (CMS) Estimates > $50 Billion In Payment Errors Annually in Healthcare OIG reported that in FY 2013 that $5.8 billion was recovered from auditing providers 3 3

4 Health Care Laws There are five important health care laws that have a significant impact on how we conduct business: False Claims Act Health Care Fraud Statute Anti-Kickback Statute Stark Law Sunshine Act Requires manufacturers of drugs, medical devices and biologicals that participate in U.S. federal health care programs to report certain payments and items of value >$10 given to physicians and teaching hospitals. 4

5 False Claims Act : United States Code Title What is a False Claim? A false claim is the knowing submission of a false or fraudulent claim for payment or approval or the use of a false record that is material to a false claim. OR Reckless disregard of the truth or an attempt to remain ignorant of billing requirements are also considered violations of the False Claims Act. 5

6 How do you create a False Claim? One method is to submit a claim form to the government This certification forms the basis for a false claim. 6

7 MEDICAL NECESSITY Quality & Cost: Emphasis on Pay-for- Performance 7

8 Quality & Cost: Emphasis on Pay-for- Performance PQRS & Meaningful Use Practitioner reimbursement will likely be tied to outcomes soon. Some experts say that the CMS penalties for not participating in the Physician Quality Reporting System (PQRS) signal that the pay-for-performance trend is not fading away and will likely will be adopted by private payers. I think we re slowly transitioning out of fee-for-service and into a system that rewards for quality while controlling cost, says Miranda Franco, government affairs representative for the Medical Group Management Association. The intent of CMS is to have physicians moving toward capturing quality data and improving metrics on [them]. 8

9 Medical Necessity Elective Procedures Alert When applicable for all prior procedures should be documented: List all failed: Therapies in the patients history or operative report Medication trials Prior surgeries, interventions or procedures Document worsening conditions as evidenced by abnormal test results or decline in functional abilities or why this elective procedure is the best option for the patient if other, lower cost options are available. Criteria which establishes medical necessity guidelines have been established for many procedures and diagnostic studies. DOCUMENT! DOCUMENT! 9 9

10 Medical Necessity for E/M Services Audits are being conducted for all payer types based on the medical necessity of procedures and E/M levels. Procedure are often linked to diagnosis codes and the E/M audits are generally expressed in two ways in conjunction with the needs of the patient: Frequency of services (how often the patients are being seen) and, Intensity of service (level of CPT code billed). 10

11 Elements of Medical Necessity CMS s determination of medical necessity is separate from its determination that the E/M service was rendered as billed. Complexity of documented co-morbidities that clearly influenced physician work. Physical scope encompassed by the problems (number of physical systems affected by the problems). 11

12 Referring Page: November 2012 E/M Coding: Volume of Documentation versus Medical Necessity Word processing software, the electronic medical record, and formatted note systems facilitate the "carry over" and repetitive "fill in" of stored information. Even if a "complete" note is generated, only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate level of an E/M service. Information that has no pertinence to the patient's situation at that specific time cannot be counted. An ISO 9001:2008 certified company 12

13 Office of the Inspector General (OIG) Audit Focus Annually OIG publishes it "targets" for the upcoming year. Included is: Cutting and Pasting Documentation in the EMR REMEMBER: More volume is not always better in the medical record, especially in the EMR with potential for cutting/pasting, copy forward, pre-defined templates and pre-defined E/M fields. Ensure the billed code is reflective of the service provided on the DOS. 13

14 Medical Record Documentation Standards Pre EMR: If it isn t documented, it hasn t been done. - Unknown Post EMR: If it was documented, was it done and was it medically necessary to do. - Reviewers 14

15 EMR Documentation Pitfalls On reviews, the following are targets to call into question EMR documentation is original and accurate: HPI and ROS don t agree HPI and PE don t agree CC is not addressed in the PE ROS and PFSH complete on every visit ROS all negative when patient coming for a CC Identical documentation across services (cloning) The lack of or Inappropriate Teaching Physician Attestations 15

16 Evaluation and Management E/M Documentation and Coding Inpatient, Outpatient and Consultations 16

17 New vs Established Patient for E/M Outpatient Office and Preventive Medicine What is the definition of "new patient" for billing E/M services? New patient" is a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., Procedure) from the same physician or another physician in the same group practice (same group NPI# and physician specialty) within the previous three years. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient. In 2012, the AMA CPT instructions for billing new patient visits include physicians in the same specialty and subspecialty. However, for Medicare E/M services the same specialty is determined by the physician's or practitioner's primary specialty enrollment in Medicare. 17

18 18 E/M Key Components History (HX)- Subjective information Examination (PE)- Objective information Medical Decision Making (MDM)- Linked to medical necessity The billable service is determined by the combination of these 3 key components with MDM often linked to medical necessity. For new patients all 3 components must be met or exceeded and established patient visits 2 of 3 are required to be met or exceeded. Often when downcoded for medical necessity it is determined that documented History and Exam exceeded what was necessary for the visit.

19 Elements of an E/M History The extent of information gathered for history is dependent upon clinical judgment and nature of the presenting problem. Documentation of the patient s history includes some or all of the following elements: Chief Complaint (CC) & History of Present Illness (HPI) WHY IS THE PATIENT BEING SEEN TODAY Review of Systems (ROS), Past Family, Social History (PFSH). 19

20 History of Present Illness (HPI) A KEY to Support Medical Necessity to in addition to MDM HPI is chronological description of the development of the patient s present illness from the first sign and/or symptom or from the previous encounter to the present or the status of chronic conditions being treated at this visit. The HPI must be performed and documented by the billing provider for New Patients in order to be counted towards the New Patient level of service billed. Focus upon present illness! HPI drivers: Extent of PFSH, ROS and physical exam performed Medical necessity for amount work performed and documented & Medical necessity for E & M assignment 20

21 HPI Status of chronic conditions being managed at visit Just listing the chronic conditions is a medical history Their status must be addressed for HPI coding OR Documentation of the HPI applicable elements relative to the diagnosis or signs/symptoms being managed at visit Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms 21

22 Review of Systems (ROS) 1 ROS documented = Pertinent 2-9 ROS documented = Extended 10 + = Complete (or documentation of pertinent positive and negative ROS and a notation all others negative. This would indicate all 14 ROS were performed and would be complete.) Record positives and pertinent negatives. Never note the system(s) related to the presenting problem as "negative". When using "negative" notation, always identify which systems were queried and found to be negative. 22

23 Past, Family, and/or Social History Past history: the patient s past experience with illnesses, surgeries, & treatments Family history: a review of medical events in the patient s family, such as hereditary diseases, that may place a patient at risk Social history: age appropriate review of past and current activities Record Past/Family/Social History (PFSH) appropriately considering the clinical circumstance of the encounter. Extensive PFSH is unnecessary for lower-level services. Don't use the term "non-contributory" 23

24 EXAMINATION 4 TYPES OF EXAMS Problem focused (PF) Expanded problem focused (EPF) Detailed (D) Comprehensive (C) 24

25 Coding 1995: Physical Exam Definitions BODY AREAS (BA): Head, including face Neck Chest, including breast and axillae Abdomen CODING ORGAN SYSTEMS (OS): Constitutional/General Eyes Ears/Nose/Mouth/Throat Respiratory Cardiac GI Genitalia, groin, buttocks Back, including spine Each extremity GU Musculoskeletal Skin Neuro Psychiatric Hematologic/Lymphatic 25

26 Sub-Specialty Physical Exam Cardiovascular Musculoskeletal Ears, Nose, Mouth and Throat Neurological Eyes Skin Psychiatric Genitourinary (Female) (Male) Respiratory Hematologic/Lymphatic /Immunologic General Multi-system Exam

27 Constitutional Eyes Ears, Nose, Mouth and Throat Neck Cardiovascular Gastrointestinal (Abdomen) Lymphatic Extremities Skin Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) Inspection of conjunctivae and lids Inspection of lips, teeth and gums Examination of oropharynx (eg, oral mucosa, hard and soft palates, tongue, tonsils, posterior pharynx) Examination of thyroid (eg, enlargement, tenderness, mass) Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness) Examination of liver and spleen Examination of anus for condyloma and other lesions Palpation of lymph nodes in neck, axillae, groin and/or other location Inspection and palpation of digits and nails (eg, clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes) Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities Inspection and/or palpation of skin and subcutaneous tissue (eg, rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas: 1) head, including the face; 2) neck; 3) chest, including breasts and axillae; 4) abdomen; 5) genetalia, groin, buttocks; 6) back; 7) right upper extremity; 8) left upper extremity; 9) right lower extremity; 10) left lower extremity. NOTE: For the comprehensive level, the examination of all four anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of the head and neck and extremities constitutes two areas. Inspection of eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidroses or bromhidrosis Neurological/ Psychiatric Brief assessment of mental status including Orientation to time, place and person Mood and affect (eg, depression, anxiety, agitation)

28 95: general multi-system exam (8 or more organ systems) or complete single organ system (a complete single organ system is undefined by CMS). 97=Specialty: All elements with bullet in shaded areas and at least 1 in non-shaded area. GMS: At least 2 elements with bullet from each of 9 areas/systems and 1997 Exam Definitions Problem Focused (PF) 95: a limited exam of the affected body area or organ system. (1 BA/OS) 97=Specialty and GMS: 1-5 elements identified by bullet. Expanded Problem Focused (EPF) 95: a limited exam of affected BA/OS and other symptomatic/related OS. (2-7 BA/OS) 97=Specialty and GMS: At least 6 elements identified by bullet. Detailed (D) 95: extended exam of affected BA/OS and other symptomatic/related OS.(2-7 BA/OS) 97=Specialty: At least 12 elements identified by bullet (9 for eye and psyc) GNS= At least 2 bullets from each of 6 areas or at least 12 in 2 or more areas. Comprehensive (C)

29 Medical Decision Making DOCUMENT EVERYTHING THAT EFFECTS YOUR SERVICE!! Exchange of clinically reasonable and necessary information and the use of this information in the clinical management of the patient Step 1: Number of possible diagnosis and/or the number of management options. Step 2: Amount and/or complexity of data reviewed, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed. Step 3: The risk of significant complications, morbidity, and/or mortality with the patient s problem(s), diagnostic procedure(s), and/or possible management options. Note: The 2 most complex elements out of 3 will determine the overall level of MDM 29

30 30 MDM Step 1 Number of Diagnosis or Treatment Options Identify Each That Effects Patient Care For The DOS Problem(s) Status Self-limited or minor (stable, improved or worsening) Est. Problem (to examiner) stable, improved Number Points Results Max=2 1 Est. Problem (to examiner) worsening 2 New problem (to examiner); no additional workup planned Max=1 3 New prob. (To examiner); additional workup planned Total POINT: E- 2, NEW-1,2 2 POINTS: E-3, NEW-3 3 POINTS: E-4, NEW-4 4 POINTS: E-5. NEW-5

31 MDM Step 2 Amount and/or Complexity of Data Reviewed Total the points REVIEWED DATA Points Review and/or order of clinical lab tests 1 Review and/or order of tests in the radiology section of CPT 1 Review and/or order of tests in the medicine section of CPT 1 Discussion of test results with performing physician 1 Decision to obtain old records and/or obtain history from someone other than patient Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider Independent visualization of image, tracing or specimen itself (not simply review of report). Total POINT: E- 2, NEW-1,2 2 POINTS: E-3, NEW-3 3 POINTS: E-4, NEW-4 4 POINTS: E-5. NEW-5 31

32 MDM Step 3: Risk The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options. DG: Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented. Risk is assessed based on the risk to the patient between present visit and the NEXT time the patient will be seen by billing provider or risk for planned intervention 32

33 Presenting Problem Min One self-limited / minor problem Low 2 or more self-limited/minor problems 1 stable chronic illness (controlled HTN) Diagnostic Procedure(s) Ordered Labs requiring venipuncture CXR EKG/ECG UA MDM Step 3: Risk (barium enema) Acute uncomplicated illness / injury (simple sprain) Mod 1 > chronic illness, mod. Exacerbation, progression or side effects of treatment 2 or more chronic illnesses Undiagnosed new problem w/uncertain prognosis Acute illness w/systemic symptoms (colitis) Acute complicated injury High 1 > chronic illness, severe exacerbation, progression or side effects of treatment Acute or chronic illnesses that may pose threat to life or bodily function (acute MI) Abrupt change in neurologic status (TIA, seizure) Physiologic tests not under stress (PFT) Non-CV imaging studies Superficial needle biopsies Labs requiring arterial puncture Skin biopsies Physiologic tests under stress (stress test) Diagnostic endoscopies w/out risk factors Deep incisional biopsies CV imaging w/contrast, no risk factors (arteriogram, cardiac cath) Obtain fluid from body cavity (lumbar puncture) CV imaging w/contrast, w/risk factors Cardiac electrophysiological tests Diagnostic endoscopies w/risk factors Management Options Selected Rest Elastic bandages Gargles Superficial dressings OTC meds Minor surgery w/no identified risk factors PT, OT IV fluids w/out additives Prescription meds Minor surgery w/identified risk factors Elective major surgery w/out risk factors Therapeutic nuclear medicine IV fluids w/additives Closed treatment, FX / dislocation w/out manipulation Elective major surgery w/risk factors Emergency surgery Parenteral controlled substances Drug therapy monitoring for toxicity DNR 33

34 Draw a line down any column with 2 or 3 circles to identify the type of decision making in that column. Otherwise, draw a line down the column with the 2 nd circle from the left. After completing this table, which classifies complexity, circle the type of decision making within the appropriate grid. Final Result for Complexity A Number diagnoses or treatment options < 1 Minimal 2 Limited 3 Multiple > 4 Extensive B Highest Risk Minimal Low Moderate High C Amount and complexity of data < 1 Minimal or low 2 Limited 3 Multiple > 4 Extensive Type of decision making STRAIGHT- FORWARD LOW COMPLEX. MODERATE COMPLEX. HIGH COMPLEX. 34

35 USING DIFFERENT LEVELS OF CARE * PATIENT ADMITTED * (PT. IS UNSTABLE) * (PT. HAS DEVELOPED MINOR COMPL.) * (PT. IS STABLE, RECOVERING, IMPROVING) or * PATIENT DISCHARGED

36 Using Time to Code Time shall be considered for coding an E/M level when greater than 50% of total Teaching Physician visit time is Counseling /Coordinating Care Total time must be Face-to-face for OP and floor time / face-to-face for IP 47 36

37 What Is Counseling /Coordinating Care (CCC)? A Discussion of: Diagnostic results, impressions, and/or recommended studies Prognosis Risks and benefits of management Instructions for treatment and/or follow-up Importance of compliance Required Documentation: Total time of the encounter John Doe MR# D.O.S. 9/15/014 Patient counseled regarding health risk, contraceptives, exercise, and usage of medication. Counseling Time: 20min. Total Encounter Time: 30 min. The amount of time dedicated to counseling / coordination of care The nature of counseling/coordination of care 48

38 National 12 CMS Data For Speciality E/M 70% 60% 59% 50% 40% 30% 20% 10% 0% 29% 10% 1% 0% Dermatology National Dist. 38

39 Top Billed Codes Billed in 2013 Top 5 CPT (Excl. E&M) CYTD % Tot Top 5 E&M CYTD % Tot Patch or application test(s) % % Level IV - Surgical pathology % % 96910Photochemotherapy % % Destruction second through 14 lesions, each (List separately in addition to code for first lesion) % % Biopsy of skin % % 88342Immunohistochemistry, 8% each separately identifiable antibody per block, % All Other Special stain % E&M 39

40 Working With NP's and PA's (NPP's) The NP or PA MUST BE AN EMPLOYEE OF THE PRACTICE AND CANNOT BE A HOSPITAL EMPLOYEE TO UTILIZE ANY OF THEIR DOCUMENTATION FOR PHYSICIAN BILLING AS SHARED Shared visit with an NPP may be billed under the physician's name only if: The physician provides a face-to-face portion of the visit and The physician personally documents in the patient's record the portion of the E/M encounter with the patient they provided. If the physician does not personally perform or personally and contemporaneously document their face-to-face portion of the E/M encounter with the patient, then the E/M encounter may only be billed under the PA/ARNP's name and provider number Procedures must be billed under the performing provider & not the supervisor. They cannot be shared 40

41 Mohs Micrographic Surgery ( ) Removal of complex or ill-defined skin cancer with histologic examination of 100% of the surgical margins. Single physician act in two integrated but separate and distinct capacities: surgeon and pathologist. If either of these responsibilities is delegated to another physician who reports the services separately, these codes should not be reported. The Mohs surgeon removes the tumor tissue and maps and divides the tumor specimen into pieces, and each piece is embedded into an individual tissue block for histopathologic examination. Thus a tissue block in Mohs surgery is defined as an individual tissue piece embedded in a mounting medium for sectioning. If repair is performed, use separate repair, flap, or graft codes. If a biopsy of a suspected skin cancer is performed on the same day as Mohs surgery because there was no prior pathology confirmation of a diagnosis, then report diagnostic skin biopsy (11100, 11101) and frozen section pathology (88331) with modifier 59 to distinguish from the subsequent definitive surgical procedure of Mohs surgery. 41

42 Lesion Destruction Ablation of benign, premalignant or malignant tissues by any method, with or without curettement, including local anesthesia, and not usually requiring closure. Any method includes electrosurgery, cryosurgery, laser and chemical treatment. Lesions include condylomata, papillomata, molluscum contagiosum, herpetic lesions, warts (ie, common, plantar, flat), milia, or other benign, premalignant (eg, actinic keratoses), or malignant lesions. (For destruction of lesion(s) in specific anatomic sites, see 40820, , 46924, , 54065, 56501, 56515, 57061, 57065, 67850, 68135) (For laser treatment for inflammatory skin disease, see ) (For paring or cutting of benign hyperkeratotic lesions (eg, corns or calluses), see ) (For sharp removal or electrosurgical destruction of skin tags and fibrocutaneous tags, see 11200, 11201) (For cryotherapy of acne, use 17340) (For initiation or follow-up care of topical chemotherapy (eg, 5-FU or similar agents), see appropriate office visits) (For shaving of epidermal or dermal lesions, see ) Destruction, Benign or Premalignant Lesions ( ) Destruction, Malignant Lesions, Any Method ( ) 42

43 Lesion Destruction Destruction, Benign or Premalignant Lesions ( ) Destruction, Malignant Lesions, Any Method ( ) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion second through 14 lesions, each (List separately in addition to code for first lesion) ADD-on CODE or more lesions Chemical cauterization of granulation tissue (proud flesh, sinus or fistula) Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less ; lesion diameter 0.6 to 1.0 cm ; lesion diameter 1.1 to 2.0 cm ; lesion diameter 2.1 to 3.0 cm ; lesion diameter 3.1 to 4.0 cm ; lesion diameter over 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; 43 lesion diameter over 4.0 cm

44 Lesion Destruction Cosmetic surgery and any complications of cosmetic surgery are not eligible for coverage. This includes any operative procedure or any portion of an operative procedure intended solely to improve physical appearance. Exceptions are those procedures that restore bodily function or correct deformity resulting from disease, trauma or complications of previous non-cosmetic surgery. Seborrheic keratoses, sebaceous (epidermoid) cysts, nevi, papillomas and viral warts (excluding condyloma acuminatum) must be symptomatic or present with objective signs/symptoms as listed below, otherwise, they are considered to have been removed for cosmetic purposes and, therefore, not medically necessary. 44

45 Lesion Destruction In addition wart destruction and/or removal will be covered when any of the following clinical circumstances are present: Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesional virus shedding Warts showing evidence of spread from one body area to another, particularly in the immunosuppressed patients. DOCUMENTATION REQUIREMENTS Medical records maintained by the physician must clearly and unequivocally document the medical necessity for lesion removal(s). Documentation must contain a written description of each surgically treated lesion in terms of location, and physical characteristics. A record of statement of a non-specific diagnosis such as "skin lesion" with or without documentation of signs and symptoms will not be sufficient justification for lesion removal when used solely to reference a patient's complaint or a physician's physical findings. 45

46 Lesion Destruction A record of statement of a non-specific diagnosis such as "skin lesion" with or without documentation of signs and symptoms will not be sufficient justification for lesion removal when used solely to reference a patient's complaint or a physician's physical findings. Similarly, use of ICD-9-CM code "Inflamed seborrheic keratosis" - will be insufficient to justify lesion removal without medical record documentation of the patient's symptoms and physical findings. When size change is present, documentation of size change is necessary. The documentation that establishes the medical necessity of each service must be maintained with the patient's record. The type of removal is at the discretion of the treating physician and the appropriateness of the technique used will not be a factor in deciding if a lesion merits removal. 46

47 Lesion Destruction A benign lesion excision, (CPT ), must have medical record documentation as to why an excisional removal, other than for cosmetic purposes, was the surgical procedure of choice. The decision to submit a specimen for pathologic interpretation will be independent of the decision to remove or not remove the lesion. It is assumed, however, that a tissue diagnosis will be part of the medical record when an ultimately benign lesion is removed based on physician uncertainty as to the final clinical diagnosis. Scar removal or revision (surgery or intralesional steroid injection) is considered medically necessary for the following indications when adequate documentation is provided: Interference with normal bodily function; OR Causing pain; OR For restoration to correct a functional impairment or facial scarring caused by accidental injury, covered surgery or other therapeutic processes. 47

48 CPT Surgical Package: Includes 0 and 10 day "surgeries" such as Mohs (0 day) or excisions /skin tags (10 days) The term surgical or global package constitutes one fee for the surgical procedure which includes the following services: Local anesthesia or metacarpal/metatarsal digital block After the decision for surgery, one related E/M service immediately prior to or on the same day Surgery Immediate postoperative care Writing orders Evaluating the patient, and Dictating the note, talking to the family and other physicians Typical postoperative follow-up care Please Note: Any complications that do not require a return to the operating room are included in Medicare s surgical package reimbursement. This includes E/M visits, clinic and bedside procedures 48

49 Guidelines for Teaching Physicians, Interns, Residents and Fellows For Billing Services, All Types of Services Involving a Teaching Physician (TP) Requires Attestations In EHR or Paper Charts 49

50 Evaluation and Management (E/M) E/M IP or OP: TP must personally document at least the following: That s/he performed the service or was physically present during the key or critical portions of the service when performed by the resident; AND The participation of the teaching physician in the management of the patient. Example: I saw and examined the patient and agree with the resident s note Time Based E/M Services: The TP must be present and document for the period of time for which the claim is made. Examples : Critical Care Hospital Discharge (>30 minutes) or E/M codes where more than 50% of the TP time spent counseling or coordinating care Medical Student documentation for billing only counts for ROS and PFSH 50 50

51 Unacceptable TP Documentation Assessed and Agree Reviewed and Agree Co-signed Note Patient seen and examined and I agree with the note As documented by resident, I agree with the history, exam and assessment/plan 51

52 Procedures Minor (< 5 Minutes & 0-10 Day Global): For payment, a minor procedure billed by a TP requires that s/he is physically present during the entire procedure. Example: "I was present for the entire procedure." i.e. joint injection Major (>5 Minutes) SINGLE Procedure / Surgery When the teaching surgeon is present or performs the procedure for a single non-overlapping case involving a resident, he/she or the resident can document the TP s physical presence and participation in the surgery. Example: I was present for the entire (or key and critical portions) of the procedure and immediately available. Endoscopy Procedures (excluding Endoscopic Surgery): TP must be present during the entire viewing for payment. The viewing begins with the insertion and ends with the removal. Viewing of the entire procedure through a monitor in another room does not meet the presence requirement. Example: "I was present for the entire viewing." 52 52

53 Diagnostic Procedures General Rule: The Teaching Physician may bill for the interpretation of diagnostic Radiology and other diagnostic tests if the interpretation is performed or reviewed by the Teaching Physician with modifier 26 in the hospital setting. Teaching Physician Documentation Requirements: Teaching Physician prepares and documents the interpretation report. OR Resident prepares and documents the interpretation report The Teaching Physician must document/dictate: I personally reviewed the film/recording/specimen/images and the resident s findings and agree with the final report. A countersignature by the Teaching Physician to the resident s interpretation is not sufficient documentation

54 Pathology Services In the teaching setting the attending pathologist qualifies for reimbursement if: The teaching physician's signature is the only signature on the report (Carrier will assume that the author/attending is indicating that he or she personally performed the interpretation). If a resident prepares and signs the report, the teaching physician must indicate that he or she has personally reviewed the specimen and the resident's interpretation and either agrees with it or edits the findings. I personally reviewed the specimen and agree with the final report. In cases where the documentation shows simply a countersignature of the resident's interpretation by the teaching physician no charges should be submitted by the attending physician 54 54

55 Modifier GC CMS Manual Part 3 - Claims Process - Transmittal 1723 Teaching Physician Services That Meet the Requirement for Presence During the Key Portion of the Service.-- In item 24d of Form CMS-1500, the GC modifier must be entered by the physician for Teaching Physician Services rendered in compliance with all the requirements outlined in of the Medicare Carriers Manual. Teaching Physician Services that are billed using this modifier are certifying that they have been present during the key portion of the service, and were immediately available during the other parts of the service. The claim should have the GC modifier even if a RNFA or a PA is working with the resident and teaching physician 55

56 Modifiers A billing code modifier allows you to indicate that a procedure or service has been altered by some specific circumstance but has not changed in its definition. Modifiers allow to: Increase reimbursement Facilitate correct coding Indicate specific circumstances Prevent denial of services Provide additional information Documentation in the operative report must support the use of any modifier Page 56

57 NCCI Manual: Modifier 25 If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is new to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. 57

58 NCCI Manual: Modifier 25 What this is saying is that the E/M required to address the patient's specific chief complaint(s) is included in the reimbursement for the billable minor procedure. This would include determining the chief complaint(s), taking or updating history, review of systems, examining the patient, past family/social history, diagnosing the problem, making the decision on how to treat the problem, informing the patient, obtaining consent, and providing postop instructions. In summary, none of the aforementioned tasks/processes can be billed for separately if they are related to a billable minor procedure. The exception, is when there is a "separately identifiable" E/M service performed during that visit that goes "above and beyond" the E/M necessary for the billable minor procedure. Additional Articles of Interest OIG Cracking Down on Modifier 25 Use E/M Update: DOJ Targets Improper Use of Modifier

59 NCCI Manual: Modifier 25 Q: What does separately identifiable mean in regards to adding modifier 25 to an E/M visit? A: A separately identifiable E/M visit is one that goes above and beyond the normal evaluation and management required to perform a procedure. For example, a patient has several large cysts on his neck and schedules an appointment with the dermatologist. The dermatologist examines the lesions, asks some relevant HPI and PFSH questions, performs a brief exam, and makes the decision to inject the lesions with Kenalog. The E/M performed in this situation is required to perform the procedure and is not separate and identifiable. In this example, reimbursement for the E/M service is included in the procedure and cannot be billed separately. 59

60 NCCI Manual: Modifier 25 Here is a SIMPLE way to look at it Take the chart note for the date of service in question, take a highlighter, and highlight all the documentation related to performing the procedure including the documentation required for evaluating, diagnosing, examining the patient, making the decision to perform the procedure in question, performing the procedure, and providing postoperative instructions and any prescriptions. Now, if the remaining documentation from that date of service can stand alone as a billable E/M visit (with all the appropriate elements required), then there is a high probability that this will stand as a separate and identifiable E/M visit. Note: The rules about separate and identifiable E/M visits apply to BOTH new patient and established patient E/M visits. 60

61 NCCI Manual: Modifier 25 Q: What if I perform multiple procedures because the patient has multiple problems/complaints? During that visit, I have to examine multiple areas of the body. Is that enough to justify billing a new or established office visit? A: Technically, no. Even, if you perform multiple procedures on the same visit and have to examine multiple areas of the body, than each procedure will have a certain inherent amount of E/M service included with each procedure, including the exam. Again, follow the test above. Take the chart note, and highlight all the documentation that has to do with each of the procedures, including any examination required to address the chief complaint(s). Look at what's remaining in the chart note. Is there enough documentation, and are there enough elements left to stand on their own as a complete E/M visit? If the answer is yes, then you should feel reasonably comfortable to justify billing a separate E/M service for that visit. 61

62 Modifier 59 Definition Distinct procedural service Designates instances when distinct and separate multiple services are provided to a patient on a single date of service. *TIP Strictly a billing modifier used to break the National Correct Coding Initiative (NCCI) edits. Identifies procedures/services that are not normally reported together, but are appropriate under the circumstances. Overrides the correct coding edit. Documentation must substantiate utilization. 62

63 Modifier 59 Designates instances when distinct and separate multiple services are provided to a patient on a single date of service that are bundled together.. The need to append modifier 59 may be prompted by: Different session or patient encounter. Different procedure or surgery. Surgery on different site or organ system. Separate incision/excision and/or lesions. *TIP Make sure your providers specifically document the location of the procedures, especially for lesions. Treatment to separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. *TIP Modifier -59 is only supposed to be used if a better modifier does not exist. 63

64 2014 CPT Code Changes Interprofessional consultations New codes to report interprofessional ( doctor-to-doctor ) telephone/internet consulting. Code is defined as an interprofessional telephone/internet assessment and management service provided by a consultative physician, including a verbal and written report to the patient s treating/requesting physician or other qualified health care professional, and involves 5 to 10 minutes of medical consultative discussion and review : 11 to 20 minutes of medical consultative discussion and review 99448: 21 to 30 minutes of medical consultative discussion and review 99449: 31 minutes or more of medical consultative discussion and review 64

65 2014 CPT Code Changes Interprofessional consultations The services will typically be provided in complex and/or urgent situations where a timely face-to-face service with the consultant may not be possible. The written or verbal request, its rationale, and the conclusion for telephone/internet advice by the treating/requesting physician or other qualified health care professional should be documented in the patient s medical record. Medicare allowable $

66 Increased specificity of the ICD-10 codes requires more detailed clinical documentation to code some diagnoses to the highest level of specificity. Coding and documentation go hand in hand ICD-10 based on complete and accurate documentation, even where it comes to right and left or episode of care. ICD-10 should impact documentation as physicians are required to support medical necessity using appropriate diagnosis code this is not an easy situation. Will not change the way a physician practices medicine 66

67 HIPAA Final Reminders for All Staff, Residents, Fellows or Students Health Insurance Portability and Accountability Act HIPAA Protect the privacy of a patient s personal health information Access information for business purposes only and only the records you need to complete your work. Notify Office of HIPAA Privacy and Security at if you become aware of a potential or actual inappropriate use or disclosure of PHI, including the sharing of user names or passwords. PHI is protected even after a patient s death!!! Never share your password with anyone and no one use someone else s password for any reason, ever even if instructed to do so. If asked to share a password, report immediately. 67

68 Any Questions 68

69 Available Resources at University of Miami, UHealth and the Miller School of Medicine If you have any questions or concern regarding coding, billing, documentation, and regulatory requirements issues, please contact: Gemma Romillo, Assistant Vice President of Clinical Billing Compliance and HIPAA Privacy; or Iliana De La Cruz, RMC, Director Office of Billing Compliance Phone: (305) Also available is The University s fraud and compliance hotline via the web at or toll-free at (24hours a day, seven days a week). Office of billing Compliance website: 69