Clinic Specific Coding and Reporting Changes for 2017

January 2017 Jean C. Russell, MS, RHIT jrussell@epochhealth.com 518-369-4986 Richard Cooley, BS, CCS, rcooley@epochhealth.com 518-430-1144 Matthew H. Lawney, MSPT, MBA, CHC mlawney@epochhealth.com 845-642-6462

2 Agenda Clinic-specific Coding and Reporting Changes for 2017 Split billing for Provider-based Departments and Clinics Medicare Physician Fee Schedule Types of Splitting Case Studies Questions/Discussion 2

3 Clinic Specific Coding and Reporting Changes for 2017

4 Patient Care Management

5 Ongoing Move to Support Primary Care and Patient-Centered Care Management 2013: New codes for Transitional Care Management 99495 and 99496 2015: Enhanced the codes for Chronic Care Management 99487, 99489 and 99490 2017: New HCPCS codes for additional patient care management G0501-G0507

6 Complex and Chronic Care Management The initial CCM visit would be an E/M (G0463) or AWV (G0438/G0439) or IPPE (G0402) or a Transitional Care Management Code (99495/99496) CMS has released additional information recently with reduced payment rules: https://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/Downloads/ChronicCareManagementServicesChanges2017.pdf

7 Complex and Chronic Care Management

8 Transitional Care Management and Advanced Care Planning

9 New 2017 Patient Care Management Codes

10 New 2017 Patient Care Management Codes For more information on the reporting of these codes see Section II (F) of the MPFS - 80350 Federal Register / Vol. 81, No. 220 / Tuesday, November 15, 2016 / Rules and Regulations

11 Health Risk Assessments

12 Health Risk Assessments Moved from an unpaid E/M code to the Medical section of CPT with a Medicare payable APC SI S. Report technically only in a PBD 99160 may be used with the CRAFFT tool to screen adolescents for alcohol or drug use 96161 may be used for depression screening such as maternal depression for an infant patient

13 Prolonged Service Codes

14 Prolonged Services There are a number of prolonged services codes, some for IP and others for OP and two for clinical staff 99358 and 99359 were not payable under the MPFS until 2017 They are for prolonged time w/o face-to-face care in addition to the standard time for an E/M service and cannot be reported in conjunction w/ chronic care or transitional care management services See Medicare Claims Processing Manual (Pub. 100-04, Chapter 12, Section 30.6.15.2)

15 Medicare Preventative Services

16 US AAA Screening CPT has established a new 2017 code 76706 Therefore CMS no longer needs the US AAA screening screening G code:

17 Smoking Cessation Counseling There were four codes for smoking cessation counseling in early 2016 The asymptomatic G codes were deleted as of 10/1/2016 The new rates represent a significant reduction if asymptomatic > 10 minutes was being performed

18 Hepatitis B Screening New HCPCS code, G0499, Hepatitis b screening in non-pregnant, high risk individual includes hepatitis b surface antigen (hbsag) followed by a neutralizing confirmatory test for initially reactive results, and antibodies to hbsag (anti-hbs) and hepatitis b core antigen (anti-hbc) Effective 9/28/2016, APC SI A See Chapter 1, Medicare NCD Manual, Section 210.10 for more information

19 Telemedicine

20 Telemedicine Services Professional Reporting CPT 2017 changes The star symbol in CPT indicates codes which may be used for reporting telemedicine services Appendix P lists CPT codes that may be used for Synchronous Telemedicine Services Modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System New POS (place of service) 2 for Telehealth and Distant Site Payments Paid by Medicare on the MPFS at the facility rate

21 Telehealth Consult for Critical Care Two new G codes for critical care consultations via telehealth

22 Telemedicine Services Technical Reporting Modifier GT, Via interactive audio and video telecommunication systems, and GQ, Via asynchronous telecommunications system, is still required when billing Medicare for Telehealth services Q3014, Telehealth originating site facility fee, is reported for the originating site facility fee

23 Possible Implications of Some Changes on Hospital Technical ED E/M Guidelines

24 Closed Tx Vetebral Fx 22305, Closed treatment of vertebral process fracture(s), has been deleted for 2017 Reported for treatment with a immobilization device (e.g., cervical collar) Consider for inclusion in ED E/M level (like the closed rib fx strapping which was removed previously) If appropriate, be sure to bill the cervical collar L code (on the DME POS fee schedule as a PO, prosthetic/orthotic)

25 Split Billing and Provider-Based Departments and Clinics

26 Split Billing Professional Bill Technical Bill

27 Medicare Regulations Medicare expects hospitals to Bill professional charges on a CMS-1500 and Technical charges on a CMS-1450 (UB-04) When the services are performed as an outpatient in a provider-based clinic by a clinician (physician, NP or PA) that is employed by the hospital Source: Medicare Claims Processing Manual, Chapter 3, Section 10, Chapter 25 and Chapter 26 27

28 NY Medicaid regulations For NY Medicaid, physician (but not NPP) services are carved out of the APG payment for all services provided in hospital outpatient settings Billed separately using the Medicaid Physician Fee Schedule for DOH HIPAA 837P or CMS-1500 Source: NY Medicaid APG Provider Manual, http://www.health.state.ny.us/health_care/medicaid/rates/apg/docs/apg_provider_manual.pdf 28

29 Technical bill UB-04 Hospital outpatient technical services Bricks and Mortar Medicare reimburses under OPPS outpatient prospective payment system APC for most services either 100% for excepted PBDs or 50% for non-excepted PBDs Lab fee schedule Other services, e.g., PT/OT/ST, mammography on Medicare Physician Fee Schedule 29

30 Technical bill UB-04 Hospital outpatient technical services Medicaid reimburses under APGs Ambulatory Patient Groups - for most services, with some exceptions Lab fee schedule APG fee schedule Final procedure based payments Ordered ambulatory services Carve outs 30

31 Technical bill UB-04/CMS 1450 Reports Date of Service Revenue code CPT /HCPCS code Modifiers (including PO and PN modifiers) Units Charges 31

32 Technical bill UB-04/CMS 1450 Revenue code assignment is not specifically established by Medicare Revenue code 510 clinic general classification Appropriate for most clinic visits Assignment should reflect the facility cost center where the procedure was performed 32

33 Professional bill CMS-1500 Professional Services Performed by the Physician/Dentist/NPP/Other Reimbursed on the Medicare or Medicaid Physician Fee Schedule Reports: Date of Service Place of Service (including POS 11, 22 and 19) CPT /HCPCS Modifiers Diagnoses 33

34 Medicare physician fee schedule (MPFS) - Where to get it - How to interpret it

35 Medicare Physician Fee Schedule Source: https://www.cms.gov/medicare/medicare-fee-for-service- Payment/PhysicianFeeSched/PFS-Carrier-Specific-Files.html 35

36 MPFS Carrier Specific Files Document in the zip file contains information about the file contents and field definitions - PF17PA.PDF 36

37 MPFS Fee schedule amounts Non Facility Fee Schedule Amount (e.g., POS 11) Facility Fee Schedule Amount (e.g., POS 19/22) Less the Site of Service Differential The difference ($71.11-$50.12) or $21.10 is the technical component of a private office visit 37

38 Determining Split billing 1. Place of Service POS 2. Modifier 26 / TC 3. Different codes Defined by PC/TC indicator Split billed code Technical only Professional only 38

39 1 - Place of Service (POS) Unique to the CMS-1500/837P Common POS: 11 Office (NOT a hospital-based clinic, e.g., private physician s office) 19 Hospital off-campus outpatient departments 21 Hospital inpatient 22 Hospital on-campus outpatient departments 23 Emergency room - hospital Impacts reimbursement for the service reported Source: Medicare Claims Processing Manual, Chapter 26, Completing the CMS-1500, Section 10.5: https://www.cms.gov/manuals/downloads/clm104c26.pdf 39

40 1- Place of service Subject of audit by Medicare OIG and Medicaid OMIGs and increasingly by the Recovery Audit Contractors and other Auditors It is extremely important that you correctly code the place of service on Part B claims. Using non-facility place-of-service codes for services that are actually performed in hospital outpatient departments or Ambulatory Surgical Centers (ASCs) often results in overpayments. You must insure you have adequate controls in your (or your billing agent s) billing routines to identify potential place-ofservice coding errors. Source: MedLearn Matters MLN Matters Number: SE1104, 3/9/2011 40

41 1- Place of service Impact on Reimbursement: 99213 billed with POS 11 MPFS reimburses $71.22 Covers the Professional and Technical cost for the physicianowned practice 99213 billed with POS 19 or 22 MPFS reimburses $50.12 Covers only the Professional cost POS differential $21.10 Assumes the Technical cost is covered with a Technical claim (e.g., UB-04) 41

42 1- Place of service Impact on Reimbursement: If billing for a PBD visit to a global payer (i.e., a payer that does not split bill) be sure to consider the appropriate Place of Service In order to receive full compensation (i.e., the nonfacility fee) from the PFS, POS 11 must be billed 42

43 2 - MPFS 26/TC Modifier Modifier (e.g., 76942, US guided bx): Modifier 26 Professional component = $32.26 Modifier TC Technical component = $26.78 No Modifier Global = $59.04 Two fees - Modifier Dependent 43

44 2 - MPFS 26/TC Modifier Billing for 76942 US guided bx: Radiologist professional bill for services performed in hospital outpatient (modifier 26) = $32.26 Hospital technical bill (CMS-1450/UB) = $0 44

45 3 - MPFS Different Codes Example, EKG: 93010, interpretation and report Professional component 93005, tracing only Technical component 93000, complete Global POS and 26/TC modifiers have no impact on reimbursement Three codes Professional Fees depend on the code reported 45

46 3 - MPFS different codes Professional component 93010 - Reported on 1500 for professional services, e.g., Reading an EKG done in Inpatient hospital or Outpatient hospital Technical component 93005 Reported on 1500 or 1450 (UB) for technical services performed in a setting other than the interpreting physician s office, e.g., EKG tracing done in a primary care physician office Global 93000 - Reported on 1500 for professional and technical services performed in a non-hospital setting, or Billed on a 1500 for a global payer, e.g., 46 EKG Tracing and Reading done in a private cardiology physician office

47 MPFS PC/TC Indicator 0 Physician Service Codes 1 Diagnostic Tests for Radiology Services 2 Professional Component Only Codes 3 Technical Component Only Codes 4 Global Test Only Codes 5 Incident to Codes 6 Laboratory Physician Interpretation Codes 7 Physical Therapy Services 8 Physician Interpretation Codes 9 Not Applicable 47

48 MPFS PC/TC Indicator 48

49 Physician Service Codes (PC/TC Indicator of 0 ) Codes that describe physician services Concept of PC/TC does not apply Cannot be split into professional and technical components on professional bill (1500) Modifiers 26 and TC cannot be used with these codes 49

50 Physician Service Codes (0) Examples include visits, consultations, and surgical procedures Most common PC/TC indicator When split billed, typically the same code is reported on the 1500 and UB for hospitalbased outpatient and inpatient departments Technically the hospital is reimbursed under APCs/APGs for outpatients And MS-DRGs for inpatients 50

51 Physician Service Codes (0) PC/TC 0 codes are usually split billed Verify split billing by checking the following: Is there a site of service differential in the PFS payment? Does the service have a payable OPPS/APC status indicator, even a packaged or conditionally packaged code? Does the service represent something that has a cognitive and technical component? If yes, then the service is very likely to be split billed

52 Physician Service Codes (0) E.g., 90791/90792 Psych Eval w/ and w/o Med Services Performed in a hospital-based psychiatric clinic by a hospital-employed physician Technical services (90792 on 1450 / UB) - $125.96 Professional serv. (90792 on 1500 POS 19/22) - $141.04 52

53 Diagnostic tests for radiology services (1) Codes that describe diagnostic tests for radiology services Have professional and technical components Always associated with 26 / TC modifiers Same code is reported on the 1500 and UB for hospital-based outpatient and inpatient departments Modifier is the differentiation 53

54 Diagnostic tests for radiology services (1) E.g., 76000 - Fluoroscopy Performed in a hospital by an employed physician Technical services (76000 on 1450 / UB) - $225.81 Professional services (76000-26 on 1500 POS 19/22) - $8.63 54

55 Professional component only codes (2) Stand-alone codes Describe physician work for selected diagnostic tests There is another code for the technical components (e.g., 93010 EKG Interpretation) Often have a description including the words supervision or interpretation and report 55

56 Professional component only codes (2) E.g., 93010 EKG interpretation (professional component) And 93016 and 93018 Stress test supervision and interpretation professional components 56

57 Technical component only codes (3) Stand alone codes Describe technical component of selected diagnostic tests Either there are associated (but different) codes that describes the professional component, Or Diagnostic tests only that do not have a related professional component Not reported with 26 and TC 57

58 Technical component only codes (3) E.g., 93005 EKG tracing 93017 Stress test tracing Technical service is billed on a 1450/UB-04 58

59 Global tests only codes (4) Stand-alone codes Diagnostic tests for which there are associated professional and technical-only codes Not reported with 26 and TC 59

60 Global tests only codes (4) E.g., 93000 EKG or 93015 Stress test Complete (Professional and Technical) service including supervision (stress test), tracing and interpretation 60

61 Incident to codes (5) Codes that describe services covered incident to a physician s service Auxiliary personnel employed by the physician and working under his/her direct personal supervision Does not pertain to services when provided in a hospital-based inpatient or outpatient department such as the ER or observation 61

62 Incident to codes (5) Reported on the technical claim when associated with a hospital based outpatient department or clinic 62

63 Physical Therapy Service (7) Codes that describe therapy services Billed technically (UB/CMS-1450) when performed in a hospital department no professional component 63

64 Physical therapy service (7) Physical therapy performed on a hospital outpatient is billed technically only on a UB and paid on the physician fee schedule 64

65 CMS Addendum B and APC Status Indicators

66 APC Status Indicators Addendum D1 lists the OPPS status indicators A Not payable under OPPS, usually payable on a separate fee schedule B Not payable under OPPS, often these are professional only codes C Inpatient only procedure E Not payable by Medicare (but could be reportable to another payer technically, like Medicaid for a vaccine) F Corneal tissue acquisition, not payable under OPPS, payable based on a cost calculation

67 APC Status Indicators G Pass-thru drug/biological Payable under OPPS H Pass-thru device Payable on cost J1 C-APC Payable under OPPS J2 C-APC Payable under OPPS K Drug/biological Payable under OPPS L Vaccine Payable on cost, not under OPPS M Not billable to the MAC, not payable under OPPS

68 APC Status Indicators N Packaged Payable under OPPS P Partial hospitalization Payable under OPPS Q1 STV-packaged code Payable under OPPS Q2 T-packaged codes Payable under OPPS Q3 Composite APC Payable under OPPS Q4 Conditionally packaged lab Payable under OPPS or the CLFS (if paid) R Blood and blood products Payable under OPPS

69 APC Status Indicators S Significant Procedure Payable under OPPS T Significant Procedure w/ multiple procedure reduction Payable under OPPS U Brachytherapy sources Payable under OPPS V Medical visit Payable under OPPS Y Non-implantable DME Not payable under OPPS

70 An Additional Verification of Whether a Service is Split Billed or Not Review the APC Status Indicator on CMS OPPS Addendum B If Q1,Q2, Q3, J1 or J2 refer to Addendum A Often indicates how the service will be paid Examples: V = Medical procedure (E/M) T = Surgical procedure S = Significant procedure Each of these is an OP Billable Technical Service 70

71 Another Guide for Splitting Other APC Status Indicators are not paid under OPPS Status B are indicative that the service is a professional-only service Code not recognized under OPPS on a technical bill Examples: 59051 Fetal monitoring/interpretation 77261 Radiation therapy planning 71

72 APC Status Indicator B Each of these services represents a cognitive activity 72

73 Try it out

74 Examples / Case Studies (Assumes hospital-based clinics/departments unless otherwise noted)

75 Nurse Visit Scenario Sally has high blood pressure which her physician wants to have closely monitored. He asks her to return to the (hospital based) primary care clinic for weekly blood pressure readings by the nurse. Technical E/M based on hospital technical guidelines No professional component Professional Bill (POS 19/22) NONE Technical Bill G0463 (Medicare) 75

76 Physician Visit (Hospital Employed) Scenario After several visits with the nurse, Sally s blood pressure reading increases. The physician schedules a visit with her to discuss treatment options. Sally is registered and has her vitals taken by the nurse before seeing the physician. The physician examines her and then orders a stress test and a new blood pressure medication. Professional Bill (POS 19/22) 99214 Technical Bill G0463 (Medicare) 76

77 Annual Physical Visit (Hospital Employed) Scenario Thomas has his annual physical with his physician. While there the nurse takes his vitals and does an EKG. The EKG will be read by a private cardiologist. A phlebotomist draws blood for follow-up lab tests. The nurse also administers a Dtap shot. The physician examines Thomas and indicates that he should increase his physical activity and decrease his alcohol intake. 77

78 Annual Physical Visit (Hospital Employed) Components Nurse none (Medicare) Physician-G0439 Vaccination - 90471 Venipuncture - 36415 Tdap drug - 90715 EKG (technical) - 93005 Code for Medicare subsequent annual preventative visit not split billed PC/TC indicator of 5 incident to only technical only Not on the MPFS technical only PC/TC indicator of 3 technical component only billed technically Professional Bill (POS 19/22) G0439 (Medicare) Technical Bill 93005 90471 90715 36415 78

79 Stress Test Scenario Calvin visits the local hospital cardiology center for a stress test. The cardiologist works for the hospital. 93015 stress test; complete 93016 physician supervision 93017 tracing only 93018 inter and report only Global Professional Technical Professional Professional Bill (POS 19/22) 93016 93018 Technical Bill 93017 79

80 Emergency Department Jessica presents to the ED with severe ankle pain and chest palpitations following a fall down stairs. The nurse triage s her, takes her vitals and history. The ED physician completes a full examination and orders an EKG and x-ray (read by the radiologist), as well as morphine for pain. The nurse places an IV and administers the morphine by IVP. The EKG is normal, the x-ray reveals a displaced fracture of the ankle requiring closed reduction. After the reduction, her ankle is casted and she is given crutches and discharged. Professional Bill (POS 23) 99283 25 27786 93010 Technical Bill 99283 25 27786 73600 96374 59 93005 59 80

81 Summary

82 To Summarize Medicare outpatient services are split billed when performed in a hospital-based outpatient setting The split allows payment for the professional component and the technical component Frequently the same codes are billed on both claims, with some exceptions 82

83 To Summarize Reimbursement and correct reporting of these services is dependent on the splitting methodology: 1. Place of Service differential 2. Modifier 26 / TC 3. Different codes 4. PC/TC indicator A. Split B. Technical only C. Professional only 83

84 To Summarize Determining how to bill can be tricky Keep in mind the basic premise surrounding the billing for services performed in a hospital-based department Professional Covering the cost associated with the physician, NPP or other clinician Technical Covering the cost of the technical services, e.g., the x-ray machine, nursing services, sterile supplies 84

86 Jean Russell Contact Us Phone: 518-369-4986 Email: JRussell@EpochHealth.Com Richard Cooley Phone: 518-430-1144 Email: RCooley@EpochHealth.Com Matt Lawney Phone: 845-642-6462 Email: mlawney@epochhealth.com

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