CPT Coding Basic Principles & Practice 2016 Peter A. Hollmann, MD Email: phollmann@lifespan.org
Avoid this
And this
Somewhere between this
And this
Utility of Coding Systems Billing Research Quality Improvement Public Health Risk Adjustment (HCC) Predictive Modeling Productivity assessment/practice management
Key Systems to Know CPT AMA: to describe physician services HCPCS Level II CMS: supplies, selected procedures, PQRS (G codes) Place of Service Codes ICD-10 Diagnosis nomenclature (facilities use for procedures)
Payer policies It s Not Just Coding CMS is not the only payer Medicare Advantage plans match benefits, not payment rules Bundling, correct coding edits, globals Site of service, diagnosis, provider type Fee schedule differences Modifier acceptance Local Medicare contractor rules
CMS Medical Necessity In general, Medicare pays for services that are considered medically reasonable and necessary to the overall diagnosis and treatment of the patient s condition. Services or supplies are considered medically necessary if they: Are proper and needed for diagnosis or treatment of the patient s medical condition Are furnished for the diagnosis, direct care, and treatment of the patient s medical condition Meet standards of good medical practice and Are not mainly for convenience of the patient, provider, or supplier Medicare pays for provider professional services that are furnished in the U.S. and in the home, office, institution, or at the scene of an accident.
Important caveats Do not undercode nor upcode consider your profile It is not wrong to get paid for your service, but sometimes you will not Billing rules seem a lot like the tax code variability, risk/reward Medical necessity matters more than possible coding; coding is supported, not defined by documentation Insurance (especially Medicare) does not cover everything there is patient liability (ABN) Pay attention to your charges and payer fee schedules/allowances.
Freq Profiling Pattern Estab OV Distribution 2015 Medicare 0.5 0.45 0.4 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 1 2 3 4 5 Level
CPT Updated annually to reflect changes in medicine Organized by body system logical sequence in general Evaluation & Management section Modifiers Clinical examples (early 1990 s) Unlisted procedures (select only accurate codes)
Medicare Proposed Rule July Final Rule November and Par Status HCPCS Codes Quarterly, but main changes effective January 1 Codes semi organized MedLearn Matters, Internet Only Manuals Benefits are Statutory
CPT/CMS etc Changes 2016 Transitional Care Management bill day of E/M Advance Care Planning Prolonged Clinical Staff Services (99415, 99416) Cerumen Removal (69209, 69210) Rules for Quality Programs (Value Based Purchasing) Fee Changes Annually check for coding and benefit changes and decide participation status
Participation Options Par: 100% PFS less copay and deductibles Nonpar/accept assignment: 95% less copay and deductibles Nonpar/ do not accept assignment: 115% of 95% (109.25%) and you must collect from patient Opt out: neither provider or beneficiary get Medicare funds
Overview to E/M Codes in CPT Place/type of service Key elements: History, exam, complexity of medical decision making Contributory: time, nature of presenting problem Select a level: Some services require all three components, some only two Definitions and documentation criteria Does it take a scorecard?
99214 (DG s) Hx Detail 4HPI 2-9 ROS PE Detail 6 Organ 2 each MDM Mod Mult Diags Mod Data 1/3 PFSH 2 organ 6 each Mod Risk TIME 25 KEY 2/3
Documentation Guideline Support clinical care Why is the patient present What was done in history and exam What were your thoughts What are you planning to do, did you do Credit is given for Hx elements when patient cannot provide info eg coma
Extent of History (CPT) Problem Focused: chief complaint; brief history of present illness or problem Expanded problem focused: chief complaint; brief history of present illness; problem pertinent system review Detailed: chief complaint; extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, and/or social history directly related to the patient s problems Comprehensive: chief complaint; extended history of present illness; review of systems which is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; complete past, family, and social history
Example: History 1997 DGs History Type HPI PFSH ROS EPF brief n/a Problem pertinent Detailed Extended Pertinent Extended ROS and PFSH may in HPI ROS and PFSH can be noted as no changes ROS and PFSH can be obtained on form if confirmed Brief HPI: Extended HPI: Pertinent ROS: Extended ROS: 1-3 elements* 4 or more elements the system directly related to the HPI direct and limited number of additional systems (2-9) *Elements: Location; quality; severity; duration; timing; context; modifying factors; associated signs/symptoms
Extent of Examination (CPT) Problem focused: a limited examination of the affected body area or organ system Expanded problem focused: a limited examination of the affected body area or organ system and other symptomatic or related organ system(s) Detailed: an extended examination of the affected body area(s) and other symptomatic or related organ system(s) Comprehensive: a general multi-system examination or a complete examination of a single organ system Note: preventive medicine evaluation and management service is multi-system, but its extent is based on age and risk factors identified
Medical Decision Making (CPT) Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: the number of possible diagnoses and/or the number of management options that must be considered; the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and the risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.
Medical Decision Making (CPT) (Continued) Four types of medical decision making are recognized: straightforward; low complexity; moderate complexity; and high complexity. To qualify for a given type of decision making, two of the three elements in the following table must be met or exceeded. Cormorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless their presence significantly increases the complexity of the medical decision making.
Number of Diagnoses or Management Options Complexity of Medical Decision Making Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making minimal minimal or none minimal Straightforward limited limited low Low complexity multiple moderate moderate Moderate complexity extensive extensive high High complexity
CMS DG Table of Risk Risk Level low Example 2 or more self limited 1 stable (e.g. HTN) minor acute (UTI) moderate 1 illness w/ exacerbation 2 chronic stable 1 Acute with systemic risk (e.g. pyelo)
Trailblazer Example Patient Condition (Medical Necessity) determines H/PE/MDM and assuming you provide appropriate care determines code Use Level 4 or 5 ONLY IF 3 or more problems managed OR A problem had 50%+ chance of worsening, death or disability Use Level 5 ONLY IF 4 or more problems managed OR A problem has 50%+ chance of worsening, death or disability
Trailblazer Pocket Guide Reiterates CMS 1995 or 1997 Documentation Guidelines Quantifies Medical Decision Making more specifically than the DGs.
Example: 99213, office or other outpatient visit 99213, office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision made of low complexity Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.
Big Picture 99211 - Did not see physician/qhcp 99212 - Did not need to see 99213 - Stable problem 99214 All the geriatric patients 99215 Time based or need for complete reassessment
Time When counseling and/or coordination of care dominated (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of the patient and decision making whether or not they are family members (e.g., foster parents, person acting in locum parentis, legal guardian). The extent of counseling and/or coordination of care must be documented in the medical record.
99213 Clinical Examples Office visit for the quarterly follow-up of a 45-yearold male with stable chronic asthma requiring regular drug therapy. (Allergy & Immunology) Office visit for a 62-year-old female, established patient, for follow-up for stable cirrhosis of the liver. (Internal Medicine/Family Medicine) Office visit for an 80-year-old female, established patient, to evaluate medical management of osteoarthritis of the temporomandibular joint. (Rheumatology)
Other Key Rules in E/M New (vs. established): new or not seen in 3 years, or if a group, it is a new/different specialty Consults: requested by a physician or other appropriate source (not patient or family) with written report back Consults can be done by you on your patients (ER, pre-op) CMS does not recognize Consult Codes Domicilliary Care is not Home Care Observation care/same day discharge Report OBS if same day discharge or facility designates OBS CMS expects >8 hrs for combined code Preventive Medicine (99381 99397) is non-covered and billable to the beneficiary in traditional Medicare (be careful as most components are now covered). Admissions services typically bundle OV, ER services (see CPT) Hospital Discharge and Nursing facility Admission may be reported same day
E/M times are closest CPT vs. CMS CMS: Times are thresholds E/M codes mention face to face with the patient and/or family CMS: Patient must be present Prolonged Services Inpatient refer to unit time CMS: Count only face to face time?? Consultation Codes (99241-99245, 99251-99255) Invalid for Medicare
Bundling, CCI, Modifiers Certain services or procedures are considered part of another service/procedure or in global period CMS uses Correct Coding Initiative claims systems edits Modifiers signal that CCI and other edits do not apply and must be used properly or it may be fraud/abuse
Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Services: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance by be reported by addition the modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57.
Bill All Services Not just E/M codes Some are member liability (family conference) CPT procedure codes, G codes, supply/drugs Bill for all services of team (MNT, H&B) 99211 ($20.05) Critical Care codes Manpower shortage regions
Get up and Go/MMSE 97750 describes timed get up and go test Separately reported if. 15 minutes (8 minute threshold) Separate Written Report Otherwise is Physical Exam MMSE is NOT CNS testing It is PE
Coding Comprehensive Geriatric Assessment S Code: CGA and Planning by Team Coding by parts may be better Multiple visits or single visit / prolonged service Covered/non-covered services screenings, case management Teams Medical nutrition therapy neuropsych, health and behavior assessment PT/OT evaluations
Noncovered Services Advance beneficiary notice advised/ required --GY not covered --GA not necessary, ABN on file, written reason supplied Not all medically appropriate services are covered Rule of thumb: check fee schedule status
NON FACE TO FACE A major Source of Uncompensated Work Each Service has Pre and Post Time Most are not Bene Liability - Some are. Try to Tie the Work to a Billed Service CPT vs. CMS re: Family 90846 Family Psychotherapy (w/o patient present)
G0180 Tip: Home Health Certification Certification ($54.06) / 60d G0179 Recertification ($41.53) / 60d G0179-80: Physician [re-certification] [certification] services for Medicare-covered services provided by a participating home health agency (patient not present), including review of initial or subsequent reports of patient status, review of patient s responses to the Oasis assessment instrument, contact with the home health agency to ascertain the initial implementation plan of care, and documentation in the patient s office record, per certification period Documentation requirements not specified Not for MLP Date must match 485 start date
Face to Face Requirements Effective May 12, 2011 F2F encounter 90 days prior of 30 days thereafter Physician can certify, but encounter may be by NPP Hospital or SNF physician can certify and transfer Benefits Manual 100-2 CH 7 30.5.1.1
Tip: CPO Hospice/HHA CMS rejected CPT due to time with nonprofessionals G0181 CPO-HHA ($108.85) G0182 CPO-Hospice ($109.20) G0181-82: Physician supervision of a patient receiving Medicare covered services provided by a participate [home health agency] [hospice](patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) with other health care professionals involved in the patient s car, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more
Requirement for Modifier Hospice Enrollee Services require a GV or GW modifier GV Attending physician not employed or paid under arrangement by the patient's hospice provider GW Service not related to the hospice patient's terminal condition Deny claims for all other services related to the terminal illness furnished by individuals or entities other than the designated attending physician, who may be a nurse practitioner.
CPO Rules Requirement for a timesheet documenting over 30 minutes exclusive of certification and discussion with nonprofessionals (e.g., family) time No financial relationship with agency or hospice medical director Only one physician, not in post op global if surgeon Prior face to face encounter (was 6 months now 90d) 30 minutes/month minimum MLPs using their number may bill for these services Box 23 agency number Only Hospice and Home Health Covered G codes, not CPT
Transitional Care Management (99495, 99496) ICN908628 Reflect work of reporting professional and clinical staff Day of D/C and next 29 days Report the date of service as 30 th day or day of F2F If dies before day 30 may not report If readmitted before day 30 may report MDM for the 30 days, not the E/M Place of service is where F2F occurs Home from Hospital or NF
TCM: Required Services Interactive contact within 2 business days of D/C (attempted) Face to Face service within 14 days Medication Reconciliation by the time of F2F visit MDM of at least Moderate Complexity over the 30 days not every patient
TCM: Code Selection New or Established Patient both the same Timing of F2F and MDM for month
TCM: Included/Separate Can report Discharge codes, but not use them as the required F2F by day 14 Only first F2F is bundled. Later E/M reported separately May not report CPO/Cert (no requirement that Home Care be in place either) 99495: $164.81 99496:$232.52 99214+G0180+G0181= $271.22 99215: add $37 99205: add $100
Chronic Care Management TCM and CCM codes created by CPT for 2013 Medicare accepts TCM and CCM is B status 2014 Fee Schedule CMS proposes paying a single G code for CCM of 20 minutes or more in a 30 days period, for persons with 2 or more chronic conditions Lots of other issues included, eg PCMH and EMR certification and no link to a face to face service Apparent goal was high volume, low dollar payments for a large proportion of beneficiaries CPT responds with Medicare code 99490 Value $42 54
Chronic Care Management 55
CCM and Complex CCM CODE 99490 99487 # Chronic Conditions >2 >2 Duration of Conditions 12 months or until death 12 months or until death Clinical Staff Time > 20 minutes > 60 minutes Period of service Calendar Month Calendar Month Comprehensive Care Plan Established, implemented, revised or monitored Established or substantial revision MDM No requirement Moderate or High Medicare Payment $40.84 B Status 56
CCM- Who Qualifies 57
Role of Physician or QHCP Oversees the management and/or coordination of services, as needed, for: All medical conditions, Psychosocial needs and Activities of daily living Incident to By appropriately qualified clinical staff Or personally by provider 58
CCM Services 59
CCM Services 60
CCM Care Plan 61
CCM- Practice Requirements 62
CCM Initiation and Consent 63
CCM- EMR Requirements 64
CCM- EMR Requirements 65
CCM- EMR Requirements 66
CCM - Restrictions Not in an Advanced Primary Care Demonstration Project the Specific Patient Not with other Care Management Service Codes for same time period 67
CCM Resource (ICN 909188 - May 2015) 68
Advance Care Planning (99497-99498) 69
Advance Care Planning 70 For CY 2016, CMS has changed assignment of CPT codes 99497 and 99498 PFS status to indicator A, (defined as: Active code). The presence of an A indicator does not mean that Medicare has made a national coverage determination regarding the service. Contractors remain responsible for local coverage decisions in the absence of a national Medicare policy. Medicare allowance is $85.99 and $74.88 for 99497 and 99498 respectively.
Advance Care Plan 2016 Final Rule Separately payable with AWV; use modifier -33 so beneficiary has no cost sharing If done with AWV can also be a team service Also separately payable with E/M; use modifier -25 on E/M (does not include Critical Care) CMS allows that the service be incident to with some significant direct supervision 71
72 2016 Final Rule
ACP - additional points Standard CPT Time Rules (more than ½ way to midpoint) Do not count any time that was part of determining level of E/M as ACP time Does not require execution of a legally recognized advance directive No predetermined frequency limits No specific special training/specialty restrictions 73
Tip: Incident To General rule: Incident To Billing Physician bills as the provider of service, even though major elements of the service were performed by MLP. The payment amount is at the physician level. Certain conditions must be met: MLP is employee Physician must provide direct personal supervision. In office this means being immediately available in office; inpatient use shared visit concept only. Physician must see patient if inpatient. No incident to for SNF. Physician must initiate course of treatment and remain involved in patient s care. All the supervision rules are independent of any licensure requirement, i.e., less restrictive licensure rules are irrelevant.
Nursing Facility Services Delegation to RNP/PA Physician may not delegate initial comprehensive assessment in SNF RNP/CNS/PA may perform services prior to initial comprehensive If state law allows, non facility level - employee may do initial comprehensive for NF level Employee RNP/CNS may not certify SNF. All NF certification rules up to state. (PAs now can certify) NO incident to or shared visits in SNF MedLearn Matters: SE0418
Tip: Prolonged Services First 29 minutes free Must be face-to-face (99354-57) Office and inpatient settings have their own set In addition to other services, including E/M at any level May be appropriate when multiple hospital visits are required as only one 99221-99233 is allowed
TIP:TEAM CONFERENCES Team conference with patient present is E/M Can report as counseling and coordination of care Cautions documentation, same tax ID
Tip:Tobacco Cessation For services furnished on or after March 22, 2005, Medicare Part B covers two new levels of counseling -- intermediate and intensive -- for smoking and tobacco use cessation counseling. This coverage is beyond the minimal smoking and tobacco use cessation counseling that is already considered to be covered at each evaluation and management visit. Coverage is limited to beneficiaries who: Are competent and alert at the time services are provided and Use tobacco AND Have a disease or adverse health effect found by the U.S. Surgeon General to be linked to tobacco use or Are taking certain therapeutic agents whose metabolism or dosage is affected by tobacco use based on Food and Drug Administrationapproved information. Two cessation attempts are covered each year. Each attempt may include a maximum of 4 intermediate or intensive sessions, up to 8 sessions in a 12- month period 99406 ($13.95) 3-10 minutes; 99407 ($26.88) over 10 minutes
Preventive and Wellness Visits Initial Preventive Physical Exam First 12 months of enrollment First Annual Wellness Visit Only after first 12 months of enrollment Subsequent Annual Wellness Visit Is this a yearly physical? No Is IPPE and Initial AWV for established patients? Yes
Initial Preventive Physical Exam (IPPE) (G0402) Once per life within 12 months of effective date of Part B coverage. Fee $167.56 Extensive: full H&P including modifiable risk factors, depression, function (minimally: hearing, falls, ADL, home safety, visual acuity, BMI, EOL) EKG (G0403-5) Not req d. Education/counseling with written plan for prevention services Can bill 99201-99215, modifier 25, also G codes except rectal Physicians and NPP s Medlearn Matters Number: MM6223
Initial Annual Wellness Visit (G0438) (ICN905706) History: HRA, Medical/FH; Risk/History Mood Disorder; ask or observe hearing, ADL, fall risk, home safety; Provider & Caregiver list Exam: BMI, BP, cognition Counsel: Written Screening Schedule 5-10 yrs, Risk Factors (incl. mental health), Personalized Health Advice (lifestyle, community resources, weight, physical activity, falls, nutrition $172.58; One per lifetime
Subsequent Wellness Visit (G0439) All elements same as initial, but updates only required $117.08; one per year
AWV and HRA Health risk assessment screening tool completed by patient http://www.cdc.gov/policy/opth/hra/frame workforhra.pdf Suggestions about what to use (not required to follow)
Services Separately Reported E/M @ AWV Definition of Separately Identifiable and expectation of frequency Labs, EKG s, Immunizations (rules on co-pays and deductibles vary) Tobacco Cessation Many Preventive Services G Codes Screening Pap test/pelvic exam DRE ( except with IPPE)
It adds up Code Service Allowance G0402 IPPE $167.56 G0436 Tobacco 3-10 min $14.68 G0437 Tobacco over 10 min $27.93 G0438 AWV Initial $172.58 G0439 AWV Subseq $117.08 G0442 Alcohol Screen $18.26 G0443 Alcohol Counsel $26.14 G0444 Depression Screen $18.26 G0445 STI Counseling $27.12 G0446 IBT for CVD $26.14 G0447 Obesity $26.14
https://www.cms.gov/medicare/prevention/prevntiongeninfo/downloads/mps_quickreferencechart_1.pdf
Tobacco Counseling Preventative Benefit For those without symptoms of disease G0436 ($14.68), G0437 ($27.93) Must use diagnosis codes Four sessions, two attempts per year
Alcohol (MM 7633) Annual Screen (G0442) If positive then 4 brief F2F counseling visits (G0443) Misuse, not dependency Men 14/week or 4 on any occasion Women 7/week or 3 on any occasion Primary Care only 5 A s 99408, 99409 Invalid for Medicare
Depression Annual Screen (G0444) Primary Care Reviewed by Physician/NPP
Intensive Behavioral Therapy for Cardiovascular Disease G0446 One annually Intensive??? 15 minutes ASA BP check Counseling on diet, risk factors
IBT for Obesity (MM7641) >30 BMI, 22 visits max in 12 months G0447 ($26.14) 1 weekly F2F month one 1 QOW F2F months 2-6 1 QMo F2F months 7-12, if lost 3 kg Dx codes for BMI Primary Care 5 A s
Preventive Services Challenges How do you know AWV history of services? Benefits for Preventive Visits and Cost Sharing Not always obvious or relevant Specifications for diagnosis AAA screen no longer ONLY if IPPE related Annual Physicals
Little things? 99238 ($73.04) vs 99239 ($108.13) 99213 ($73.40) vs 99214 ($108.13) 99233 ($104.91) vs 99291($225.93, office $277.44) 99354 ($100.97) and 99356 ($98.10)
Electronic Record Warning! Only you can select the correct code Replicate notes are gaining a lot of attention Documentation must reflect actual services, including review of unchanged areas Copy and Paste has other risk management issues
Resources CMS Website: cms.hhs.gov Medicare Physician Guide: A resource for Residents, Practicing Physicians and Other Health Care Professionals (Medicare Learning Network) AMA publications Contractor Medical Director AGS GAYF Coding page
Case One A 68-year-old female is seen in the office for follow-up treatment of diabetes and hypertension. History indicated that glucometer fasting readings run 100-130 each morning. She has had no spells of weakness or diaphoresis and continues to tolerate her metformin. She follows her diet and saw the ophthalmologist for her routine exam last month. She is tolerating her lisinopril and has a mild cough, which does not bother her. She has no CP or SOB. She notes chronic left knee pain, worse with activity. No trauma. It is swelling a little. No fevers. Tylenol is ineffective.
On exam BP is 130/80, HR 68 Reg, weight is 142 stable, lungs clear, COR neg, ext no edema. Left knee FROM, stable, small effusion, no calor or erythema. The knee is tapped for 12cc of straw colored fluid and 40 mg of Aristospan and one cc of 1% lido are instilled. She is instructed to continue her current meds, to get a HgA1C and FBS. She is to report increased pain or redness in the knee or fever. She is to return in 3 months.
Questions Case 1 What E/M code should be reported? Are there any other codes for which you can get paid? Is a modifier necessary? What would one code if the whole reason the patient was there was to get an intraarticular injection?
Answers Case 1 What E/M code should be reported? D or PF history (ROS, PFSH), D or PF PE, Options/Data/Risk; 2/3; separation from injection A case can be made for 99213 or 99214. Are there any other codes for which you can get paid? 20610, J3303 (8 units) Is a modifier necessary? Modifier 25 on E/M What would one code if the whole reason the patient was there was to get an intra-articular injection? There is always some E/M in every procedure that is not separately reported.
Case Three Mrs. Smith is a 79-year-old woman with a history of CAD who presents to the office with a history of shortness of breath that is progressive. Last night she had chest heaviness and difficulty breathing. On exam she is tachypneic, has rales ½ way up and increased pedal edema. Her pulse ox is 78%. You call 911 and have the patient transported to the hospital. The ER is contacted, a med list and past EKG is faxed. She has been on ASA, a statin and metoprolol. You document the visit. After you finish with the other patients you go to the hospital.
You visit her in the hospital. A comprehensive history and exam are performed. Data indicates CHF and a small rise in troponin without EKG changes. By the time you see her she has been treated with nitrates, diuretics and ASA. She is more comfortable. Her BP is in the low 90 s systolic. Her glucose is 480 without an anion gap. Her urine had 4-10 WBCs.
Questions Case 3 What E/M is reported for the hospital admission? What E/M is reported for the office visit? What if you did the admission note the next day? What if your partner is on call for hospital admits and does the admit? What if your PA does the admit and then you come in later and complete the visit?
Answers Case 3 What E/M is reported for the hospital admission? 99223, see next question What E/M is reported for the office visit? All same day services roll up into one service, but was this critical care? Critical care can occur outside the ICU What if you did the admission note the next day? Report by date of service, not date of admission. You could report both outpatient and inpatient in this case. What if your partner is on call for hospital admits and does the admit? Your partner is the same as you What if your PA does the admit and then you come in later and complete the visit? Shared visit concept is applicable to inpatient care other than consults.
Case Four Mr. Atlas is a 68-year-old male who you last saw 4 years ago for a checkup. He states he feels great, walks 5 miles a day, lifts weights, but felt he should see you because he knew your daughter was in college and you had tuition payments to make. You review the interval history, which is negative. You confirm the past social and family histories. He does not smoke, only drinks if he goes out to dinner. He limits it to 2 glasses of wine. His diet does not include sodium rich foods and he never adds salt. A ROS checklist he filled out is negative and you confirm this. He never got a Pneumovax and his only medication is an aspirin a day, a multivitamin, and 400 IU of vitamin E. He has never had a colonoscopy or sig.
On exam, you note his BP to be 150-95. This is confirmed in both arms and after rest. You do and document a complete PE which is all negative including a negative rectal exam and stool OB. His EKG is normal. You ask him to come back in a month for a follow-up visit. You ask him to stop by a couple of times to have his BP checked before then. You order a Hematocrit, fasting lipid panel and basic metabolic profile. You give him the Pneumovax.
Questions Case 4 What E/M code(s) are reported? Is this a new patient? What other codes are reported? Is this the IPPE exam? An Annual Wellness? Do I bill the patient or the payer?
Answers Case 4 What E/M code(s) are reported? 99202-25 for elevated BP, 99387 for Preventive Exam. Not HTN, but is elevated BP. If comes back for BP check 99211? Is this a new patient? Yes What other codes are reported? FOBT (CRC screen) not performed, stool OB not medically necessary; G0102 (prostate) performed, but cannot report with E/M (CCI edit); pneumovax admin G0009 (or CPT if not Medicare) and supply 90732; 93000 (EKG). Is this the IPPE exam? AWV? Not IPPE-not new to Medicare. Not AWV- services did not conform Do I bill the patient or the payer? Who is the payer? May get paid for BOTH 99202 and 99387 by some, one E/M by others. Medicare: bill 99202 to CMS and deduct charge for 99202 from charge for 99387 and bill patient the difference. Will this be allowed with AWV benefits?
Case Five You are a carrier medical director. You note that a local geriatrician new to practice is billing 90% of his visits at a level 5. While 30% are new patients, he is billing most of his follow-up exams at 99215. You ask for five records of patients who received more than one 99215. You note he has an electronic medical record. HPI was thorough. Each visit the doctor confirms medications, PFSH, and ROS. Each PE is extremely thorough and other than rectal/genital/breast exams is complete. One patient had moderate dementia with severe behavioral problems. Phone documentation was extensive between visits. Two patients had mild-moderate dementia and were fairly stable, seen every 3-4 months.
He documented good caregiver education. One patient had compensated CHF as her primary reason for visits every 3 months. Another patient had severe COPD and anxiety. Even when seen monthly, she still was in the ER a couple of times. The records documented ER contact and retrieval of labs/x-rays however, she actually was not unstable and it appeared she needed constant reassurance. The treatment course was not changing. The doctor indicates he uses an electronic record and the computer suggested visit codes.
Question Case 5 Is this physician coding correctly?
Answer Case 5 No. All services must be medically necessary to count for each key element. An electronic carry forward of problem lists and drug lists is not taking a history. Computers really cannot assess medical decision making and relevant elements of history or exam.
Case 6 A 74 y/o male is day 2 after being admitted for CP. You see him at 7AM and he is doing well on an increased dose of beta blocker and nitrates. You spent 17 minutes on the unit. Later that day he develops more CP and ST changes are noted. He is moved to the ICU, receives heparin and intravenous NTG. You return to the hospital. You spend 48 minutes on the unit reviewing records, history/exam, talking to the cardiologist and patient/family.
Questions Case 6 How do I report two visits on one day?
Answer Case 6 As a general rule only one E/M per day may be reported. Look at descriptor per day for inpatients. Two office visits can be reported, but will look like a duplicate claim. Hospital discharge and nursing facility admit same day may both be reported. Prolonged services may apply. (NB: NF is inpatient). Record your time. CMS rules all Prolonged Service is F2F only.
Case 7 A 83 y/o patient is treated by you at a hospital. You discharge her to a nursing home where you intend to follow her. This facility has a RNP who works with all staff physicians and is available to see patients on a daily basis. The RNP sees the patient that day and does a comprehensive assessment. You review the treatment plan with the RNP and plan to personally assess the patient in 48 hrs. When you come in you document a detailed history and perform a problem focused exam given the recent complete assessment in the hospital as well as that of the RNP. Your plan is for rehab services for her THR, continuation of anticoagulation therapy,
order checking of PVRs for follow-up of a question of retention, as well as continue her HTN treatment and consider whether she requires an antidepressant for some mood problems that you feel may be limiting her recovery.
Questions Case 7 How do I code when my service does not meet 3/3 elements? Is this a shared visit? Who gets to bill, me or the RNP or both? What if I saw the patient the day of admission?
Answers Case 7 How do I code when my service does not meet 3/3 elements? Unlisted codes are technically correct. Should you add nonsense documentation or just code 99304 or use 2/3? Is this a shared visit? There are no shared visits in the SNF/NF. Some may argue that you can confirm the key components of the RNP work in your documentation in selecting the correct E/M. Who gets to bill, me or the RNP or both? Same day only one could claim. An RNP may report services prior to the admission assessment, if medically necessary. What if I saw the patient the day of admission? See above
Teaching Rules No allowance for med students Bill for what you do, not what you write or rely upon combined documentation supports the code time based codes: your time only If primary care center can bill lower codes (1-3) Even if not present in room, prompt review 4:1, PGY over 6 months Psych must have visual. Surg must be present for key component of surgery Modifiers -GC resident involved -GE ambulatory care ctr, if physician not F2F
Teaching Rules Both residents and teaching physicians may document physician services in the patient s medical record. The documentation must be dated and contain a legible signature or identity and may be dictated and transcribed, typed, hand-written, or computer-generated. The attending physician who bills Medicare for evaluation and management (E/M) services in the teaching setting must, at a minimum, personally document his or her participation in the management of the patient and that he or she performed the service or was physically present during the critical or key portion(s) of the service performed by the resident (the resident s certification that the attending physician was present is not sufficient). Students may also document services in the patient s medical record. The teaching physician may refer only to a student s E/M documentation that is related to a review of systems (ROS) and/or past, family, and/or social history (PFSH). If the student documents E/M services, the teaching physician must verify and repeat documentation of the physical examination and medical decision making activities of the service.
Teaching Rules For initial hospital care, emergency department visits, office visits for new patients, and office and hospital consultations, the teaching physician must enter a personal notation that demonstrates the appropriate level of service that the patient requires and documents his or her participation in the three key components. The three key components are history, examination, and medical decision making. If the teaching physician repeats key elements of the service components that the resident previously obtained and documented, his or her note may be brief, summarize comments that relate to the resident s entry, and confirm or revise these key elements: Relevant history of present illness (HPI) and prior diagnostic tests Major finding(s) of the physical examination Assessment, clinical impression, or diagnosis and Plan of care
Teaching Rules For subsequent hospital care and office visits for established patients, the teaching physician must enter a personal notation that highlights two of the three key components of these services. These components are history, physical examination, and medical decision making. For follow-up visits for established patients, the guidelines for initial hospital care, emergency department visits, office visits for new patients, and office and hospital consultations guidelines must also be followed.
Teaching Rules Medicare may grant a primary care exception within an approved Graduate Medical Education Program in which the teaching physician is paid for certain E/M services the resident performs when the teaching physician is not present. The primary care exception applies to the following lower and mid-level E/M services: New Patient - CPT Codes 99201, 99202, and 99203 and Established Patient - CPT Codes 99211, 99212, and 99213 Effective January 1, 2005, the primary care exception also applies to the initial preventive physical examination, also known as the Welcome to Medicare Physical - Healthcare Common Procedure Coding System code G3044, the initial preventive physical examination, face-to-face visit, services limited to new beneficiary during the first six months of Medicare enrollment.