2016 Winter Refresher Course Coding and Billing with Confidence! Elizabeth Keltner, CPC, CHCA MCW Compliance Education Coordinator Disclosure The Speaker Has No Financial Relationships to Disclose 2 1
Overview Objectives o Coding and Billing with Confidence o Explain the connection between Regulations and your billing practice o Explain the process of choosing the appropriate level of service Agenda o Regulatory Updates o Evaluation and Management - Overview Level of Service Consultations Preventive Medicine E/M with Preventive Medicine E/M with Procedure o Interactive Coding Examples 3 Regulatory Updates 4 2
CMS Fraud Prevention Strategies CMS Report to Congress; Fraud Prevention System Second Implementation Year, June 2014 5 The Use of Predictive Analytics by CMS 6 3
Types of Government Audits RAC Recovery Audit Contractor (including Medicaid) ZPIC Zone Program Integrity Contractor MIC Medicaid Integrity Contractor MAC Medicare Administrative Carrier CERT Comprehensive Error Rate Testing HEAT - Health Care Fraud Prevention and Enforcement Action Team PERM Payment Error Rate Measurement PSC Program Safeguard Contractor (MIP) OIG Office of the Inspector General DOJ Department of Justice 7 RAC Summary Results for 2014 State Collected Overpayments Restored Underpayments Total Corrected Amount WI $6,840,846.13 $1,587,853.10 $8,428,699.23 Total $2,394,846,150.25 $173,096,903.76 $2,567,943,054.01 November 16, 2015 Effective November 13, 2015, all Recovery Auditors may continue active recovery auditing activities, including sending additional documentation requests (ADRs). 8 4
Most Common Reason for Improper Payments Payment is made for services that do not meet Medicare s coverage and medical necessity criteria, Payment is made for services that are incorrectly coded, or Payment is made for services where the documentation submitted does not support the ordered service 9 Top Five Topics Audited Evaluation and Management codes Procedure code utilization by frequency Procedure code utilization by RVU Modifier Utilization Time 10 5
Whistleblowers, Money and HIPAA HIPAA but not the way we normally think of it Created a new crime called Health Care Fraud Penalties of up to 10 years imprisonment Increased fines for a false claim from $2,000 to $10,000 Creates a beneficiary incentive program where a portion of recoveries may be paid to a relator as a result of a qui tam lawsuit or whistleblowers suit. 11 Recoveries by HHS/OIG - HIPAA Impact Millions HIPAA 86% are the result of a whistleblower action $3,212,400,000 Total Relator Share 12 6
What else is new? 13 ICD 10 CM ICD-10-CM up to 7 digits o both Alpha and Numeric o Extreme specificity Hurdles o System software conversion costs for both providers & payers o Education Will NOT replace CPT procedure codes for physicians. o Inpatient hospitals will have to switch to ICD-10-PCS to report procedures CMS officially in place October 1, 2015 There have been no payment issues to date! 14 7
New Codes 2016 Cerumen Removal o 69209 - Removal impacted cerumen using irrigation/lavage, unilateral o 69210 - Removal impacted cerumen requiring instrumentation, unilateral Prolonged Care Clinical Staff time o o 99415-99416 - Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; Discussed later in the presentation. Immunizations o 90697 DTaP, IPV, Hib, HepB. Hexavalent vaccine. o Be sure to watch the administration codes for 6 diseases if education is provided 15 E/M Documentation AN OVERVIEW 16 8
Where do the Guidelines Come From? 17 Factors for an E/M Service Type of service required by the patient Office visit, consult,etc. Location of the patient Office, inpatient, nursing home,etc. Is patient new or established A new patient is one who has not had any service in your division/specialty within 3 years 18 9
Key Components of E/M 19 E/M Level of Service The descriptions for the levels of E/M service recognize SEVEN components: o History o Exam o Medical Decision Making o Counseling o Coordination of Care o Nature of Presenting Problem/Patient Condition o Time 20 10
E/M Level of Service The first three components are considered KEY to determining the level of service. The remaining components can be considered contributory factors in determining the level of service. Contributory factors are used in the case where the visit consist predominately of counseling and/or coordination of care Nature of the presenting problem determines the appropriate level of service for the patient. 21 Review of Systems (most responsible for down coding) Documentation Guidelines: The patient s positive responses & pertinent negative for the system related to the problem must be documented. A Problem Pertinent ROS inquires about the system directly related to the problem identified in the HPI An Extended ROS requires documentation of 2 9 systems. A Complete ROS requires review of at least 10 systems. For the remaining systems, a notation indicating all other systems reviewed are negative is permissible. 22 11
Admission History & Physicals, Consultations Family History, Social History, ROS o Wisconsin Medicare Carrier does NOT allow NON-CONTRIBUTORY o Significant down coding due to NO documented family or social histories Everyone has family and social history to some extent o Parents dead or alive or adopted, etc. o Married, single, lives alone, etc. o Smoking or alcohol use 23 Examination Component There are currently two sets of examination guidelines that are accepted. 1995 1997 General and are structured around organ systems and body areas. More specific and allow for single organ systems 24 12
Physical Examination Important to Note negative or normal findings Remember to elaborate and summarize all abnormal/unexpected findings Document any negative findings related to the affected or symptomatic systems. 25 Assessment/Impression List the Diagnosis(es) that you are treating or are affecting your decision making for today s visit. Describe the problem as: o Improved, well controlled, resolving or resolved o Worsening, uncontrolled...acute, chronic Avoid Note Bloat 26 13
Elements of the Medical Decision Making Component The levels of medical decision making are comprised of the following elements: 1. Number of diagnoses and/or management options 2. Amount and/or complexity of data to be reviewed and/or ordered 3. Risk of complications, morbidity and/or mortality To qualify for a given type of decision making, two of the three elements must be either met or exceeded 27 Medical Decision Making Table of Risk Note For the Table of Risk: The highest level of risk in any one category determines the overall risk. Please refer to the Table of Risk which provides clinical examples for guidance 28 14
29 Office/Outpatient New Patient/Consultations Three of Three Key Components Select the Level of History Exam MDM Final Code is selected from the LEFT 30 15
Office/Outpatient New Patient/Consultations Three of Three Key Components Select the Level of History Exam MDM Final Code is selected from the LEFT 31 Office/Outpatient Established patient/ clinic Two of Three Key Components Select the Level of History Exam MDM Final Code is selected from the two highest key components from the RIGHT 32 16
Office/Outpatient Established patient/ clinic Two of Three Key Components Select the Level of History Exam MDM Final Code is selected from the two highest key components from the RIGHT 33 Time as the Key and Controlling Factor 34 17
Evaluation and Management Billing Based on Time Time may be considered the key or controlling factor to qualify for a particular level of E/M service Must dominate over 50% of the encounter with patient and/or family o Face to face time in office or out patient setting o Floor/unit time in hospital or nursing facility 35 Evaluation and Management Billing Based on Time The contributory factor of time may be used for numerous CPT E/M codes If time is used to determine the level of service, it must be that of the billing provider Summary content defining time spent must be documented Must be recorded in the official medical record 36 18
Evaluation and Management Billing Based on Time Documentation Example: I have spent 25 minutes of a 40 minute visit discussing Sara s rheumatoid disease. We discussed treatment options along with physical therapy recommendations and medications. Legible/Electronic Signature LOS = 99215 37 Let s code an example Take out your Audit tool 38 19
History Key Component History of Present Illness (HPI) o Location, Severity, Timing, Modifying Factors, Quality, Duration, Context, Associated Signs and Symptoms Review of Systems o 14 Organ System Past Medical, Family, and Social History Only need one to check the box. 39 History Key Component PFSH is different for Established (2/3) vs New/Consults/Admissions (3/3). 40 20
History Example Chief Complaint: Itchy red rash and shortness of breath History: the patient was in her usual state of good health until this evening when she went to a night club where she was to meet some of her friends after work. She ordered her usual bloody mary with extra celery when she suddenly broke out in a red, itchy, hivey, rash. She called the local ER and they told her to take Benadryl. She now feels short of breath and is having some wheezing. She states she does have a history of asthma in the past. It has been over thirty minutes since she took the Benadryl and she now is worse and presents for evaluation. She does have a history of mild allergic reaction to fruit and certain men s cologne. Allergies: Fruit and Certain cologne Medications: None PFSH: She works at the accounting firm of D&D, lives alone in her mobile home on fourth street. Her mother and father are deceased from a car accident in her teens. No brothers or sisters. She is thrice married and divorced. 41 Choose a History Level Using your iclicker, choose one of the following: 1. Problem Focused 2. Expanded Problem Focused 3. Detailed 4. Comprehensive 42 21
History Example Chief Complaint: Itchy red rash and shortness of breath Chief Complaint History: the patient was in her usual state of good health until this evening when she went to a night club where she was to meet some of her friends after work. She ordered her usual bloody mary with extra celery (Context) when she suddenly (Timing) broke out in a red, itchy, hivey, (Quality) rash. She called the local ER and they told her to take Benadryl (Modifying Factor). She now feels short of breath and is having some wheezing (Associated Signs and Symptoms). She states she does have a history of asthma in the past (ROS). It has been over thirty minutes (Duration) since she took the Benadryl and she now is worse and presents for evaluation. She does have a history of mild allergic reaction to fruit and certain men s cologne (ROS). Allergies: Fruit and Certain cologne (PMH) Medications: None (PMH) PFSH: She works at the accounting firm of D&D (Social), lives alone in her mobile home on fourth street (Social). Her mother and father are deceased from a car accident in her teens Family). No brothers or sisters. She is thrice married and divorced (Social). 43 History Key Component Rash, shortness of breath PFSH is different for Established (2/3) vs New/Consults/Admissions (3/3). 44 22
Office/Outpatient New Patient/Consultations Three of Three Key Components Select the Level of History Exam MDM Final Code is selected from the LEFT 45 Exam Key Component Problem Focused o 1 organ system or body area Expanded Problem Focused o Limited exam of affected body area or organ system o Industry standard: 2-4 organ systems or body areas Detailed o o Extended exam of affected body area and other symptomatic or related organ systems Industry Standard: 5-7 organ systems or body areas Comprehensive o 8+ organ systems or complete exam of single organ system 46 23
Exam Key Component 47 Exam Example General: Exam reveals a 36 year old very well developed female with shortness of breath and moderate distress. Vital Signs: B/P 158/100, Pulse, 145, Respiratory rate of 30. Temp of 98.8 HEENT: TM s are clear, Nares are clear. Oropharynx benign, no edema. Neck: Supple and nontender. Lungs: Moderate wheezing, no rub, no rhonci Chest: A blotchy, hivey, confluent rash over most of the chest, back and arms. Palms are erythematous and itchy. No blistering is noted. 48 24
Choose an Exam Level Using your iclicker, choose one of the following: 1. Problem Focused 2. Expanded Problem Focused 3. Detailed 4. Comprehensive 49 Exam Example General: Exam reveals a 36 year old very well developed female with shortness of breath and moderate distress. Vital Signs: B/P 158/100, Pulse, 145, Respiratory rate of 30. Temp of 98.8 Constitutional HEENT: TM s are clear, Nares are clear. Oropharynx benign, no edema. Head or ENT. Not both Neck: Supple and nontender. Neck or Musculoskeletal Lungs: Moderate wheezing, no rub, no rhonci Lungs Chest: A blotchy, hivey, confluent rash over most of the chest, back and arms. Palms are erythematous and itchy. No blistering is noted. Chest or Skin 50 25
Exam Key Component 51 Office/Outpatient New Patient/Consultations Three of Three Key Components Select the Level of History Exam MDM Final Code is selected from the LEFT 52 26
Medical Decision Making Straightforward Low Complexity Moderate Complexity High Complexity 53 Medical Decision Making 54 27
Medical Decision Making Example Assessment: Acute allergic dermatitis Plan: Patient was given 0.4 subcu 1:100,000 epinephrine stat and 60 mg of prednisone orally. She was observed until her shortness of breath and hives resolved approximately 5 hours later. At the time she was discharged, she was given instructions to continue taking Benadryl 50 mg every 4-6 hours as needed for itching. We also gave her a prescription for prednisone 30 mg three times a day for three days then twice a day for three days. She is to return to the ER if she has airway problems or worsening asthma symptoms. 55 Choose MDM Level Using your iclicker, choose one of the following: 1. Straightforward 2. Low Complexity 3. Moderate Complexity 4. High Complexity 56 28
Medical Decision Making Example Assessment: Acute allergic dermatitis New Problem (3) Plan: Patient was given 0.4 subcu 1:100,000 epinephrine stat and 60 mg of prednisone orally. She was observed until her shortness of breath and hives resolved approximately 5 hours later. At the time she was discharged, she was given instructions to continue taking Benadryl 50 mg every 4-6 hours as needed for itching. We also gave her a prescription for prednisone 30 mg three times a day for three days then twice a day for three days. She is to return to the ER if she has airway problems or worsening asthma symptoms. 57 Medical Decision Making 58 29
Office/Outpatient New Patient/Consultations Three of Three Key Components Select the Level of History Exam MDM Final Code is selected from the LEFT 59 Example Results 99203- New Patient Established Prolonged Observation if documented by ancillary staff o 99415 (First hour) o 99216 x 8 (each additional 30 minutes) Private Practice code for supply of subcutaneous injection. 60 30
Consultations 61 The 5 Consultation R s Request Reason Recommendations Return the Report 62 31
Documentation Tips Certain words and phrases implies that a transfer of care (New Patient) has occurred rather than a consultative service. o Thank you for referring Mrs. Smith for the evaluation of her.. o Thank you for allowing me to participate in Mrs. Smith s care Instead use the word consultation at every opportunity o o Thank you for requesting a pre-operative consultation on our patient, Mrs. Smith. Thank you for allowing me to consult on your patient preoperatively. My recommendations are.. 63 Pre operative H&P s.. Are They Billable???? 64 32
Pre operative H&P s.. Are They Billable???? Hospital facilities require an H&P on all surgical patients Can surgeons perform an H&P? 65 Nomenclature Disparities H&P = History and Physical Examination including an Assessment and Plan Is often completed when performing different types of encounters (The type of encounter determines the CPT E/M Code Assignment) Admissions Consultations New Patient visits Inpatient Interval assessments o Satisfies numerous clinical and administrative requirements Facility requirements 66 33
Medical Clearance Consultation Preoperative Evaluation o In the case of a pre-operative clearance, the surgeon is typically requesting the family physician s opinion or advice regarding the patient s fitness for surgery, especially if the patient has chronic or comorbid conditions that may be relevant (e.g., diabetes, hypertension). If the family physician documents the surgeon s request, the resulting advice and any services ordered or performed and then provides a written report to the surgeon, it is appropriate to code a consultation for this service. AAFP Use codes Z01.810-Z01.818 as the Primary Diagnosis and any comorbid conditions as secondary Note: An H&P for an established patient does not qualify for a consultation. 67 Preventive Medicine Services 68 34
Nomenclature Disparities Health Maintenance Visit Annual Exam Annual GYN Exam Complete Physical Adult Physical Comprehensive Exam Preventive Physical Well Child Check All reported with Preventive Medicine Codes 69 Preventive Medicine Services New Patients o (99381-99387) o Under one year (99381) o Age 1-4 (99382) o Age 5-11 (99383) o Age 12-17 (99384) o Age 18-39 (99385) o Age 40-64 (99386) o Age 65 and over (99387) Established Patients (99391-99397) o Under one year (99391) o Age 1-4 (99392) o Age 5-11 (99393) o Age 12-17 (99394) o Age 18-39 (99395) o Age 40-64 (99396) o Age 65 and over (99397) 70 35
Preventive Medicine Services Comprehensive History Is NOT problem oriented and does NOT involve a chief complaint or present illness. It does include Comprehensive System review Comprehensive or Interval Past, family and social history Comprehensive or Interval Assessment/history of pertinent risk factors 71 Preventive Medicine Services Comprehensive Examination The comprehensive examination o Multisystem o Based on the age/gender of the patient o Based on identified risk factors. It is NOT synonymous with the comprehensive examination required in the other problem oriented E/M service codes. 72 36
Preventive Medicine Services Ancillary Services Ancillary services are not included in preventive medicine service codes and should be reported separately. o Immunizations o Diagnostic Testing Laboratory Radiology 73 Medicare Preventive Medicine Services CPT Codes Medicare does NOT pay for the CPT Preventive Medicine Codes. o It is NOT a covered benefit o Does NOT require an ABN unless you need it for secondary coverage coordination Medicare DOES cover/pay for certain other Preventive Services 74 37
75 Welcome to Medicare Annual Wellness Visit Be sure to use the EPIC Templates for these services. 76 38
Medicare Part C vs Part B Part C o Medicare Advantage plans UHC, Humana, Blue Cross Additional coverages above Straight Medicare Part B o Basic Medicare Physician Coverage o Follows CMS Policies 77 Problem Oriented Services During Preventive Medicine Visit 78 39
Abnormality/Preexisting Problem During Preventive Medicine Visit Must be SIGNIFICANT enough to require additional work to perform and document the KEY components of a problem-oriented E/M service. If the problem/abnormality/preexisting condition does NOT require additional work, then it should not be reported separately. 79 Abnormality/Preexisting Problem During Preventive Medicine Visit In the event that a problem, abnormality or preexisting condition does require additional performance The appropriate level of service should be provided to the patient as required by the patient and documented separately. 80 40
Who Decides Significant Additional Work? Only the provider can decide if the problem or pre existing condition required a significant amount of additional work The provider must document the necessary E&M components to meet the appropriate level of service 81 Abnormality/Preexisting Problem During Preventive Medicine Visit Assign the appropriate ICD10 diagnosis code to both services o General Exam is linked or attached to the preventive medicine service Z00.00 -Encounter for general adult medical examination without abnormal findings Z00.01 -Encounter for general adult medical examination with abnormal findings o L03.115 Cellulitis of right lower limb, would be linked or attached to the problem oriented E/M service. 82 41
25 Modifier Review 83 25 = Significant, Separately Identifiable E&M For an E&M service to be paid separately on the same day as a procedure or other service, a significant, separately identifiable service would need to be performed & documented. o Must be medically necessary o Separately identifiable = Separately documented Must meet criteria for the level of E&M service to be billed: o History, Exam, Medical Decision Making, Time for Counseling Coordination of care. 84 42
25 = Significant, Separately Identifiable E&M Separate document or entry Preventive Medicine Services Diagnostic Service Procedural Service 85 E/M Services and Procedures 86 43
Procedures and Significant, Separately Identifiable E&M Caution: Every procedure/diagnostic study has inherent E&M components contained within it. Pre-service evaluation (brief pre-op history & exam) Intra-service work Post-service evaluation Do Not use the 25 modifier if a patient presents for a previously scheduled, planned procedure. 87 Procedures (Clinic/Bedside) (other than in the OR) Date of service Appropriate entry heading if using progress note; or Service identification o Who you are (resident, fellow, student or faculty) o Indicate who your attending is-very Important Reason (clinical indication/definitive diagnosis) Detailed description of procedure o Approach, technique, patient status, instructions, etc. Teaching physician documentation, if necessary must be entered by the teaching physician Legible or electronic signature, date and time 88 44
Other Services Review 89 Advance Care Planning 99497 and 99498 Must be Face to Face Counseling and discussion of advance directives May or may not include completion of legal forms 90 45
Advance Care Planning cont. Medicare will now covers this service $$ May be reported on the same day as E/M service 99497 First 30 minutes (T18 Nonfacility Payment $85.99) 99498 each additional 30 minutes. (T18 Nonfacility Payment $74.88) With the annual wellness visit no deductible or co insurance. Without the annual wellness visit deductible and co insurance apply. 91 Care plan oversight (CPO) Home Health Certification Medicare vs. Non-Medicare rules Time-based Create lists and logs o Have a log in each patient s chart that you provide CPO o Document and date each activity and length of time spent o Sign each activity Engage staff to work these logs at the end of the month Invoice according to payer 92 46
Care plan oversight (CPO) Home Health Certification CMS o Certification for Medicare covered HHS per certification period= G0180 o o o Re-certification for Medicare covered HHS per re-certification period= G0179 CPO HHS 30 minutes or more per 30 days = G0181 CPO Hospice 30 minutes or more per 30 days = G0182 AAFP website Family Practice Management..Great resource 93 Prolonged Services Prior to 2016, codes 99354 and 99355 were the only codes used to report prolonged services provided face to face with the patient. These services, however, implied that the physician or qualified healthcare provider was providing the service. The new codes allow for reporting face to face services not provided by the physician /QHP for things that only require face to face observation by clinical staff under the supervision of a provider or QHP. Development of the new codes allow for such reporting under specifically noted circumstances. 94 47
Prolonged clinical staff Services Reporting 99415 and 99416 o The typical face-to-face time of the primary service is used in defining when prolonged service time begins o Less than 45 minutes is not reported separately o When face-to-face time is noncontiguous, use only the face-to-face time provided to the patient by the clinical staff o Used once per date of service 95 Prolonged Clinical Staff Service Example Provider sees the patient and bills a 99214 based on key components. The patient is monitored for 2 hours by ancillary staff before being released to go home. 99214 Office or other outpatient visit for the evaluation and management. Typically 25 minutes are spent face-to-face with the patient. 99415 First hour, prolonged care 99416 x 2 (each additional 30 minutes) 96 48
Motivational Interviewing https://www.youtube.com/watch?v=wvnre0bh8q8 o Motivational Interviewing Diet counseling low carb good eating Counseling can be included in the time of a Problem Evaluation and Management Service Counseling can be included in the risk factor reduction counseling included in the preventive medicine service. Counseling can be billed using the Preventive Medicine Counseling Codes. (Not recommended) 97 Smoking Cessation 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes 98 49
Smoking Cessation Behavior Change Interventions, Individual o o 99406 Smoking and Tobacco Use cessation counseling visit; Intermediate, greater than 3 minutes up to 10 minutes 99407 - ; Intensive, greater than 10 minutes Code Typical Charge T18 (Non Facility) Payment 99406 (3 9 min) $82.00 $14.33 99407 (> 10 min) $163.00 $27.95 99 Preventive Medicine Counseling Codes 99401 - Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes 99402 - ; approximately 30 minutes 99403 - ; approximately 45 minutes 99404 - ; approximately 60 minutes Not payable by Medicare. 100 50
Patient Visit Video https://www.youtube.com/watch?v=mzoebjyvle0 o Medical Student Encounter Problem focused car accident 13 min 101 Thank You..Questions? 102 51
Medical College of Wisconsin Compliance Office Compliance is Everyone s Concern 103 Medical College of Wisconsin Compliance Office Contacts Telephone: 414 805 6360 Fax: 414 805 6372 Located Lab Building 2 nd Floor 9200 W. Wisconsin Avenue Milwaukee, WI 53226 Please visit our website: http://infoscope.mcw.edu/compl iance.htm 104 52
References http://www.aafp.org/fpm/2012/0700/p12.html 105 E/M Coding Exercises 53
Interactive Coding Practice Take out your examples and work with your group. 10 minutes per example. We will review each example together. 107 Example #1 Using your iclicker, choose one of the following: 1. 99214 2. 99213 3. 99386 4. 99385 5. Other 108 54
Example #2 Using your iclicker, choose one of the following: 1. 99214 2. 99213 3. 99386 4. 99385 5. Other 109 Example #3 Using your iclicker, choose one of the following: 1. 99214 2. 99213 3. 99386 4. 99385 5. Other 110 55
Example #4 Using your iclicker, choose one of the following: 1. 99214 2. 99213 3. 99386 4. 99385 5. Other 111 Example #5 Using your iclicker, choose one of the following: 1. 99214 2. 99213 3. 99386 4. 99385 5. Other 112 56