Michelle Ann Richards BSHA, CPC, CPCO, CPMA, CPPM Subject Matter Expert on: Compliance Programs Human Resources Practice Management Revenue Cycle Management Billing & Coding Documentation Pitfalls Policies & Procedures Front Desk Coding Rules 1
Policies & Procedures Office Policies Not Clearly Established Patient payments and co-pays Verifying insurance information Self pay patients ( i.e. cash patients ) What to charge? When to collect? Billing policies and contractual issues Verifying insurance information How to handle physicals 4 Policies & Procedures Once policies are developed, they must be communicated to the staff Talk to staff about collecting from patients Give them some scripting for talking to patients who cannot pay If the staff don t feel comfortable, or not on board, policies won t be effective Finally, the policies need to be made clear to the patient, reminders can be added to call when verifying the patient s upcoming appointment or mentioned to patients at check-in 5 Front Desk This is Your Front Line Person Answers questions from patients Collects co-pays Collects payments from self pay Enters patient demographic information Verifies insurance information 6 2
Coding Rules Basic Coding Knowledge Local Carrier Coverage Decisions National Coverage Issues Correct Coding Initiative Modifiers Add-on-codes Diagnosis Coding Provides medical necessity Describes severity Inaccuracies lead to denials 7 Coding Rules NPPs Incident to rules (Medicare Guidelines) MD must establish plan of care NPP may not see new patients NPP may not see established patients with new problems Basic CPT Modifier usage 24, -25, -58, -76, -77 Established versus new patients Knowledge of E/M level of service requirements 8 Questions to Ponder How do we achieve bulletproof E/M documentation? Would another provider be able to step in? Would documentation be specific and legible? Would another provider understand the rationale for treatment? In the worst case scenario, if a provider is in a court of law, would they be able to defend their documentation? 9 3
Evaluation & Management Read the Guidelines OIG Medicare CPT Guidelines 10 Office of Inspector General https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf The above link will take you to the OIG document titled Coding Trends of Medicare Evaluation & Management Services. 11 Centers for Medicare & Medicaid Services http://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNEdWebGuide/EMDOC.html The above link will take you to the CMS Medicare Learning Network link, which has PDF files for the 1995 & 1997 E&M Documentation Guidelines. 12 4
Medicare Documentation Guidelines For E/M services, the nature and amount of physician work and documentation varies by: Type of service Place of service, and Patient s status 13 Medicare Documentation Guidelines The medical record should be complete and legible The documentation of each patient encounter should include: Reason for the encounter and relevant history and examination Findings and prior diagnostic test results (order) Assessment, clinical impression or diagnosis Plan for care Date and legible identity of the observer If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred 14 Medicare Documentation Guidelines Cont d Past and present diagnoses should be accessible to the treating and/or consulting physician Appropriate health risk factors should be identified The patient s progress, response to and changes in treatment, and revision of diagnosis should be documented. The CPT and ICD-10-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others 15 5
CPT Guidelines http://static.aapc.com/3f227f64-019f-488a-b5a2-e864a522ee71/897a15ce-8474-498a-ac32-7f2cdc7e34a0/4edbc7b6-cae1-43d7-9c48-e6296616d7cf.pdf The above link will take you to the AAPC Evaluation & Training Module. 16 CPT Guidelines The guidelines for the E&M section supply the necessary definitions for determining the level of service based on the work provided. There are four types of each of the three key components in selecting the level of service. Each type is defined within the guidelines to assist the user in determining the extent of : History, Examination, and Medical Decision Making 17 Evaluation & Management Services Categories within this section are based on: Type of service Place of service Status of patient Code Selection can be based on: Level of service Time based Type of service 18 6
Evaluation & Management Services Physician Office Visits New vs. Established patient visits New Patient ( 99201-99205 ) Established Patient ( 99211 99215 ) 19 Evaluation & Management Services Physician Office Visits Three-Year Rule A patient who has not received professional services from the physician or another physician of the same specialty who belongs to the same group practice, (using the same tax ID number) within the past three years 20 Evaluation & Management Services Getting Credit for All Services Performed Document what was done Describe all events Tell why! This is all you will have when appealing a denial or when someone is selecting a code 21 7
E & M Level of Service 99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising theses services. 22 Vital Factor for Billing 99211 Incident To Must be an established patient There must be an established plan of care There must be an E/M service provided by an employee of the physician Service must be provided in the office There must be direct physician supervision 23 Inappropriate Use of 99211 Giving the patient an injection (ex:b12) Drawing blood, venipuncture (ex: INR) Writing a prescription renewal Making telephone calls 24 8
Effective Denial Management Know Your Denials Understand why these claims were denied in the first place Keep your denial management process organized Complete claim denials within a week Track your progress and success Identify most common denials and trends Outsource your denial management process 25 Medical Record Documentation Tips & Guidelines 26 Documentation Requirements Validates that services were provided Ensures continuity of care Verifies that services provided are reported with accuracy Both coding and documentation must be in sync on any day of service Legal document Supports medical necessity 27 9
Documentation Requirements The Physician s signature and credentials must be on each entry as a condition of payment The patient s name and the date of service must be on each page of the patient chart The medical record must be complete and legible Only standard medical abbreviations should be used The medical record must support all diagnoses coded for the date of service and must be able to stand alone for audit on those reported diagnosis codes 28 Documentation Requirements The listing of DX codes is not enough; there must be evaluation (PLAN) The medical record must thoroughly document all conditions evaluated. Evaluative documentation would include statements such as: Stable on meds Condition worsening; medication adjusted Tests ordered; documentation reviewed Condition improving 29 Services Performed by Ancillary Staff When ancillary staff members perform a service and write documentation, the record must be signed by the provider billing for the service. B-12 injection- whoever was covering for the incident-to service or providing supervision would need to sign the documentation. 30 10
Problem Prevention Know what is expected when the appointment is made Be sure to repeat to patient the reason for the visit 31 Evaluation & Management Preventive Medicine?????? Well Visit Yearly Physical Well Women Medicare Non Medicare School/Sports PPE AWV 32 Preventive Medicine Services New Patient: 99381-99387 Established Patient 99391-99397 33 11
Preventive Medicine Services The Comprehensive nature of the Preventive Medicine Service codes 99381-99397 reflects an age and gender appropriate history/exam and is NOT equal with the comprehensive examination Required in Evaluation and management codes 99201-99215. 34 Preventive Medical Services Specific preventive medicine services for varying age and sex patients will vary but the basic components for CPT s preventive medicine service codes ( 99381-99397) are consistent: A comprehensive history and physical examination Precautionary guidance, risk factor reduction intervention or counseling Appropriate Immunizations/Labs Management of insignificant problems 35 Preventive Medical Services Preventive Medicine Services performed when a new problem or a chronic problem is addressed; Use the -25 modifier on the problem visit CPT code Two notes outlining the separate work performed 36 12
Evaluation & Management Services Just Getting to Know You Visit... New patients that present with no complaints and want to get to know you. For any new patient level of service, all three work requirements must be met: HX, Exam, MDM If there is no chief complaint or HPI then it will be difficult to have a visit code at all. 37 E/M Preventive Services School or Sports Physical Call it what it is Do not waiver Be clear to patient Patient can choose a full CPE (complete physical exam) 38 E/M Preventive Services Well Woman??? What is that??? Medicare Non- Medicare Is it a CPE with a PAP? 39 13
Conclusion It s important to know OIG definition of Health Care Fraud intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, or the entity or to some other party. Changes brought about by health care reform, including new language under the HIPAA, now argue that fraud occurs when an individual knows or should have known about improper practices. Therefore responsibility shifts to those submitting claims. 40 Question & Answer Time Thank you for your time & attention today! CPPM-I Michelle Ann Richards BSHA, CPC, CPCO, CPMA, Director of Engagement, Compliance Services Healthicity michelle.richards@aapc.com 440-387-3114 41 14