Billing and Coding Tidbits for Not Leaving $$ on the Table

Transcription

1 Billing and Coding Tidbits for Not Leaving $$ on the Table Presented by Sarah Reed BSE, CPC, CPC-I Senior Managing Consultant Medical Revenue Solutions, LLC AAPC 2016

2 Presentation Objectives Review some of the more uncommon coding situations. Create skills and an environment by which a coder or staff member can feel comfortable requesting additional information or clarification. Create an understanding for the coder to know that researching and providing information to the practice is positive and necessary. Create an interest in the coder to continue educating themselves with ancillary and additional information necessary to perform their job in a professional manor. 2

3 Slides and Information Please be aware that not all slides will be covered in detail in the presentation. Some of them are for information only. However if you have a question on anything we are not covering in detail please be sure you ask about it. 3

4 Presentation Style Ms Reed prefers an interactive presentation and will try to address questions as they occur, unless we become short of time. Thank you in advance for your consideration of the others in the audience by not talking among yourselves. Also please put all cell phones and pagers on stun at this time so you will not disturb others in the room. 4

5 Taking a look at what seems obvious This presentation will take a look at areas of coding and packaging of charges that seem to be obvious but can really be looked at in several different ways 5

6 Time Out One of first clinical audits was undertaken by Florence Nightingale during the Crimean War of On arrival at the medical barracks hospital in Scutari in 1854, Nightingale was appalled by the unsanitary conditions and high mortality rates among injured or ill soldiers. She and her team of 38 nurses applied strict sanitary routines and standards of hygiene to the hospital and equipment; in addition, Nightingale had a talent for mathematics and statistics, and she and her staff kept meticulous records of the mortality rates among the hospital patients. Following these changes the mortality rates fell from 40% to 2%, and the results were instrumental in overcoming the resistance of the British doctors and officers to Nightingale's procedures. Her methodical approach, as well as the emphasis on uniformity and comparability of the results of health care, is recognized as one of the earliest programs of outcomes management. 6

7 A Coder Always Needs the Facts Strictly the Facts Who What When Why How 7

8 What every Code Must Have Medical Necessity for the service provided Documentation of all the services provided Remember Not all visits must have a chief complaint 8

9 Surgical Global Package Types of Surgical Package include: Medicare CPT Work comp 9

10 Global Issues What do you mean my H&P is not paid? Know your global days What is included in your payer global package What is typical post op care? Tracking outcomes and post op care in your practice Scheduled vs. Non-scheduled procedures Unrelated visits in the post-op period 10

11 Global Issues Global services and CCI rules New patient and procedure (what is significant) Established patient, procedure (what is significant) Pre and Post-op services Document Document Document! 11

12 CPT Surgical Package Local infiltration, digital block or topical anesthesia Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical) Immediate postoperative care, including dictation of operative notes, talking with the patient s family and other physicians. 12

13 CPT Surgical Package continued Writing orders Evaluating the patient in the post operative anesthesia recovery area Typical post-operative follow-up care??? How many payers do you know that use this package??? 13

14 CMS Global Surgical Package MLN/MLNProducts/downloads/GloballSurgery-ICN pdf This document is also attached at the end of the presentation. 14

15 Other Surgical Global Packages ACOG AAOS ACS surgical guide Payer specific global packages 15

16 Surgical Modifiers CPT nomenclature uses modifiers as an integral and important part of its structure. Modifiers are a clear way for information to be provided. WPS has excellent education on modifiers of all kinds on their website. 16

17 Let s talk modifiers

18 Who saw my patient or More than one visit in a day Hospital services including; in, out, observation and emergency Split or shared services Multi-specialty groups Recognized sub-specialist (taxonomy) Admits and follow up on the same day Critical Care Separate identifiable medical problems, the patient condition changed Adding up multiple visits Who gets credit for the visits and the work 18

19 Preventive vs. Sick Is it possible? Is it paid? Why do it? Documentation requirements Physical or Preventive services Significant separate service not minor or routine Multiple co-pays and carve outs Patient complaints 19

20 As Time Goes By Counseling and Coordinating Care Documentation Start and Stop Medical necessity Physician time, mid-level time Prolonged codes Critical Care Prolonged Care 20

21 The Often overlooked codes. Care Plan Oversight Transitional Care Management Welcome to Medicare Visit Annual Medicare Wellness Visit Chronic Care Management 21

22 Ancillary Services Documentation Lesions Injections Checks and Balances Who is in charge of charging for that???? 22

23 Did you really order that service? Verbal orders Standing orders Order sets What does a signature mean??? 23

24 Advanced Beneficiary Notice What is an ABN Why do we use an ABN Form completion Lab and Office ABN What is the difference in Non covered and Not allowed? Modifiers Lost Revenue 24

25 Can I still bill a Consult Code? Who still accepts consult codes Government payers What codes do I bill now Emergency Department Visit Codes How do I explain all this to my providers so they know what to bill? 25

26 Mid Level Providers What is considered a mid level? Credentialing mid levels Office, hospital, SNF, nursing home, where else Incident to or not Split/Shared 26

27 Palliative Care End of life counseling Palliative vs. Geriatric Location of services Use of mid levels Time based Treating signs and symptoms 27

28 Hospice Care Services included Treating signs and symptoms Employed providers Documentation 28

29 Evaluation and Management E/M is not black and white Double dipping all other systems negative Family History, non contributory Substance Use not Abuse BMI 29

30 Medical Decision Making What is the MEAT in the documentation? Was the sign, symptom, condition, or problem.. Monitored Evaluated Assessed/Addressed Treated 30

31 MDM Payer Perspective Please remember that each payer may have a different perspective or definition of Medical Decision Making. It is the way the payer views the care and definitions that can make a difference is how high the level of care is when audited. Your provider must be able to defend his/her documentation to the payer if they do not agree. 31

32 Discharge Summaries Location of services Time based What is included in the discharge summary? What happens if the patient does not get to go home? Split/shared service 32

33 A lot Depends on your contract Fee Schedule Payer website and what you should know Updates to your contract Auto renewals Termination of a contract How much does the payer need you? Negotiation and how s that going for you! 33

34 What is left???? Audits Paper vs. Electronic superbills Physicians coding themselves 34

35 QUESTIONS Sarah Reed BSE, CPC, CPC-I Senior Medical Consultant Office