Medical Compliance Services Office of Billing Compliance Coding, Billing & Documentation 2016 Surgery - Miami Transplant Institute Surgeons
Why Are We Here? To EDUCATE and PROTECT our providers and organization To provide you with every tool you need to maximize compliance and get paid what you deserve To update you on the latest CMS/OIG activities 2
Critical Care
Documentation Timeliness http://www.wpsmedicare.com/j8macpartb/claims/submission/documentation-timelines.shtml Question to CMS: confused concerning the timeliness of my documentation in connection with the provider signature and submitting the claim to Medicare, and the timely filing rule. Can you provide more information? Answer: There are several provisions that may affect "timeliness" when talking about documentation. A provider may not submit a claim to Medicare until the documentation is completed. Until the practitioner completes the documentation for a service, including signature, the practitioner cannot submit the service to Medicare. Medicare states if the service was not documented, then it was not done. The second is that practitioners are expected to complete the documentation of services "during or as soon as practicable after it is provided in order to maintain an accurate medical record." CMS does not provide any specific period, but a reasonable expectation would be no more than a couple of days away from the service itself.
Critical Care Critical Care Services may only be billed with 99291/99292 for urgent medically necessary services that meet these definitions and criteria: 1. Critical condition: A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient s condition which requires the highest level of physician/npp preparedness to intervene urgently. And 2. Personal direct critical care treatment: Involves high complexity medical decision making to assess, manipulate, and support vital function (s) to treat single or multiple vital organ system failure and/or prevent further life threatening deterioration of patient s condition. And. Direct personal attention at the bedside or on the floor/unit where patient is housed at least 0 minutes or more Documentation must support these requirements. May be rendered in any location And: If resident has documented, teaching attestation must PERSONALLY support these requirements. 5
CMS - Medicare Focused Audits 2014 on Critical Care and Nationwide Letters 4/1/14-6/0/14: Southern California error rate: 6% for 99291 and 69% for 99292 CMS provided education and expects to see improvement. Core Issues: Failure to submit documentation Documentation was not submitted to support the claims submitted to Medicare by the time frame indicated in the Automated Development Letter. Time Total amount of TP time must be documented in patient's medical record for each DOS. Medical necessity of the service Documentation failed to support the medical necessity of the services rendered per the CMS Internet Only Manual (IOM), Publication 100-04, Chapter 12, Section 0.6.12 and the 1995 or 1997 E/M Guides. Level of service Documentation did not support the level of service of CC. Descriptive information with a clearly defined plan to assist in determining the amount and complexity of the patient management is missing. Documentation does not include orders or plan to support any changes made in management strategies and interventions. Example: "Continue current treatments and plan" with no explanation of the plan is insufficient documentation for an accurate determination of level of care. Signatures CMS rules pertaining to signatures apply to all providers of Medicare services. Lack of a valid signature is most notable when the medical record is in the electronic format. Split/Shared Services Documentation reflected that critical care was performed as a split or shared service between a physician and a qualified non-physician practitioner such as a Physician Assistant or a Nurse Practitioner. 6
Critical Care Conditions Examples of vital organ system failure: Central nervous system failure, circulatory failure, shock-like conditions, Renal, hepatic, metabolic, or respiratory failure, Unexpected postoperative complications or overwhelming infection, or Other vital system functions to treat single or multiple vital organ system failure or to prevent further deterioration. Examples of diagnoses that might support necessity for critical care services: o Acute myocardial infarction, o Seizures, acute CVA, o Multiple injuries, significant trauma, o Acute CHF, o Septicemia, post operative hemorrhage, o Postoperative respiratory failure. Even if condition is critical, 99291 may only be billed if: treatment also meets requirements and time is 0 minutes or greater 7
Critical Care Treatment: Definition/Criteria Requires physician or other qualified healthcare professional direct delivery and personal management of medical care for critically ill/ injured patient. Critical care involves high complexity medical decision making to assess, manipulate, and support vital function (s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of patient s condition. Although critical care typically requires interpretation of multiple physiologic databases and/or application of advanced technology(s) to manage patient, critical care may be provided in life threatening situations when these elements are not present. 8
Critical Care (CC) Treatment Definition/Criteria: (continued) Delivering critical care in the moment of crisis is not the only requirement for billing critical care. Treatment and management of a patient s condition, in the threat of imminent deterioration; while not necessarily emergent, is required to prevent further life threatening deterioration in the patient s condition. COMFORT MEASURES, AWAIT FOR FAMILY TO REMOVE LIFE SUPPORT, READY TO WEAN OR TRANSFER TO FLOOR/HOSPICE DO NOT GENEARLLY MEET CC TREATMENT FOR BILLING Prevention is sometimes difficult to see in notes. Critical care comprises decision making, not only interventions. If decision making is involved for an extremely tenable patient, that activity is a billable service. Reviewing the situation, weighing alternatives and making informed decisions about the care is billable even if there are no changes to the treatment and no intervention. Merely reviewing or itemizing what someone else did previously (noting drip settings, writing that the previous treatment continues, and noting that you concur with it) is not billable as critical care. 9
Critical Care Treatment Examples Thrombolytics Anti-arrhythmics Epinephrine, Atropine, Sodium Bicarbonate Cardioversion for Atrial Fibrillation or Atrial Flutter Defibrillation Fluid and/or Blood administration for shock or impending shock Narcan NTG drip Initiation of Mechanical ventilation CPAP, BiPap, or ETT An 81 year old male patient admitted to ICU following abdominal aortic aneurysm resection. Two days after surgery he requires fluids and vasopressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent. 10
Pulmonary Examples Condition Critical Care Treatment Non - Critical Care Treatment Acute lung injury High-risk medication monitoring Mechanical ventilation (CPAP, BiPap, ETT) CPR Postop ventilation that is being weaned Acute respiratory distress Acute respiratory failure Asthma exacerbation (severe) Cardiogenic shock without mention of trauma High-risk medication monitoring Mechanical ventilation (CPAP, BiPap, ETT) CPR High-risk medication monitoring Mechanical ventilation (CPAP, BiPap, ETT) CPR High-risk medication monitoring Mechanical ventilation (CPAP, BiPap, ETT) High-risk medication monitoring Pressors Mechanical ventilation (CPAP, BiPap, ETT) Postop ventilation that is being weaned Postop ventilation that is being weaned Routine vital sign checks for critically ill patient Oral prescriptions/inhalers Routine vital sign checks for critically ill patient Oral prescriptions Circulatory failure High-risk medication monitoring Routine vital sign checks for critically ill patient COPD exacerbation High-risk medication monitoring (severe) Mechanical ventilation (CPAP, BiPap, ETT) Routine vital sign checks for critically ill patient Oral prescriptions/inhalers
Neuro Examples Condition Critical Care Treatment Non - Critical Care Treatment CVA/stroke tpa monitoring that was started by ER physician tpa started by billing physician High-risk medication Postop management with no complications Oral prescriptions Subdural hematoma Subarachnoid hemorrhage AMS High-risk medication management ICP (intracerebral pressure) monitoring Mechanical ventilation (CPAP, BiPap, ETT) Blood transfusion High-risk medication management ICP (intracerebral pressure) monitoring Mechanical ventilation (CPAP, BiPap, ETT) Blood transfusion High-risk medication management Mechanical ventilation (CPAP, BiPap, ETT) Routine neuro checks Postop management with no complications Oral prescriptions Routine neuro checks Postop management with no complications Oral prescriptions Routine neuro checks Postop management with no complications Oral prescriptions Delirium High-risk medication management Routine neuro checks Postop management with no complications Oral prescriptions Loss of consciousness Ruptured brain aneurysm Traumatic brain injury High-risk medication management Mechanical ventilation (CPAP, BiPap, ETT) High-risk medication management ICP (intracerebral pressure) monitoring Mechanical ventilation (CPAP, BiPap, ETT) Blood transfusion High-risk medication management ICP (intracerebral pressure) monitoring Routine neuro checks Postop management with no complications Oral prescriptions Routine neuro checks Postop management with no complications Oral prescriptions Routine neuro checks Postop management with no complications
Cardio Examples Condition Critical Care Treatment Non - Critical Care Treatment Acute kidney failure Fluid resuscitation (bolus) Acute respiratory High-risk medication monitoring distress Mechanical ventilation (CPAP, BiPap, ETT) Acute respiratory failure AFIB CABG ICU management Cardiac arrest Cardiogenic shock without mention of trauma CPR High-risk medication monitoring Mechanical ventilation (CPAP, BiPap, ETT) CPR High-risk medication to regulate heart rate Cardioversion Fluid resuscitation (bolus) N/A If complication arises, see above list. High-risk medication monitoring Pressors Mechanical ventilation (CPAP, BiPap, ETT) CPR High-risk medication monitoring Pressors Mechanical ventilation (CPAP, BiPap, ETT) Circulatory failure High-risk medication monitoring Routine hemodialysis for patient with CKD Postop ventilation that is being weaned Postop ventilation that is being weaned Routine Coumadin PRN medication Routine vital sign checks for critically ill patient Postop management with no complications Oral prescriptions Routine monitoring after a patient has crashed (i.e. day before) and is now stable Oral prescriptions Routine vital sign checks for critically ill patient Oral prescriptions Routine vital sign checks for critically ill patient
Critical Care Time Total Duration of Critical Care Codes Less than 0 minutes Appropriate E/M codes (992X or 9925X ) 0-74 minutes (1/2 hr. 1 hr. 14 min.) 99291 X 1 75-104 minutes (1 hr. 15 min. - 1 hr. 44 min.) 99291 X 1 and 99292 X 1 105-14 minutes (1 hr. 45 min. - 2 hr. 14 min.) 99291 X 1 and 99292 X 2 15-164 minutes (2 hr. 15 min. 2 hr. 44 min.) 99291 X 1 and 99292 X 165-194 minutes (2 hr. 45 min. hr. 14 min.) 99291 X 1 and 99292 X 4 194 minutes or longer ( hr. 14 min. etc.) 99291 and 99292 as appropriate 99291: first 0-74 minutes. Report only once per calendar day per provider/same specialty group. May not be combined with NPP or resident time. 992X or 9925X for less than 0 minutes 99292: each additional 0 minutes beyond 74. May be aggregated time met by one provider or same group/specialty 14
Reportable Time Report critical care for time spent engaged in work directly related to patient s care at bedside or elsewhere on floor or unit, only if: Physician is immediately available and giving full attention to patient management. Physician may not be involved in any other patient s care during time reported. Time is 0 minutes or greater on that day by one provider. No services may be reported for any other patients concurrently during same period of time. CC time may not be combined with NP/PA s or resident s time. Time counted toward critical care services may be continuous or intermittent and aggregated. Physicians of the same group practice may bill as though they were a single physician. Time excludes time billing provider spent rendering other billable procedures, teaching or NP/PA/Resident time rendering care. 15
Time Spent With Family Members When patient is unable or clinically incompetent to participate in discussions, time spent on floor/unit or phone calls made from floor/unit with family members or surrogate decision makers may be reported as part of critical care time if it involves: Obtaining needed medical history Reviewing the patient's condition or prognosis Discussing treatment or limitation(s) of treatment The conversation must bear directly on the management of patient and must be medically necessary for determining treatment decisions. Provider must document: Patient s inability to participate in giving history and/or making treatment decisions Necessity for the discussion (e.g., "no other source was available to obtain a history" or "because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with family") Information obtained or decisions made. Note: Time to provide routine daily updates or reports to family members and/or surrogates cannot be included in critical care time no matter how lengthy. 16
Critical Care Documentation From Attending Teaching Physician INCLUDE: Critical and unstable nature of patient s condition should be accurately documented to support the medical necessity of 1 to 1 services. Nature of all problems being managed, particularly those related to organ system failure. If stabilized document ongoing critical status if applicable. All organ sustaining interventions requiring direct physician assessment and interventions. Complexity of medical decision making Patient assessment Substance of family discussions as billable CC time, if applicable. Billing provider s time spent evaluating, managing and providing CC services exclusive of procedure, resident and NPP time. Aggregation of time spent by the billing provider (if applicable) 17
Critical Care Documentation From Attending Teaching Physician Suggestions to avoid denials: Use of personal pronouns. This clarifies what the provider did that qualifies as critical care even if the treatment and settings remain constant. Use verbs to indicate what was done that day. Use accurate phrasing that shows intervention rather than ultimate result of intervention. Stable vs. hemodynamically acceptable due to stated actions personally performed Stable on pressors vs consistently on pressors Stable on a PC of 0 vs consistently requiring ventilator Stable on balloon pump vs consistently requiring balloon pump Stable, Improving, Transferring does not support that the patient is critically ill by most auditors. 18
Critical Care Documentation From Attending Teaching Physician CMS examples of acceptable TP documentation for critical care involving Resident. "Patient developed hypotension and hypoxia; I spent 45 minutes while the patient was in this condition providing fluids, pressor drugs and oxygen. I reviewed the resident's documentation and I agree with the resident's assessment and plan of care." 19
Watch for These Terms Which May Be Key Indicators of Critical Care Acidosis Anaphylactic Shock Angina, unstable, aggressive management Atrial fibrillation with tachycardia Asthma, multiple treatments with more risk Blood loss, PRBCs hung, GI bleed Cardiac arrest Comatose/unconscious, unknown cause at presentation COPD/CHF severe exacerbation Dehydration with significant metabolic/blood chemistry changes Glasgow Coma Scale below 14 Head injury, severe, unresponsive Hypoxia/hypoxemia Unstable vital signs Hypernatremia 20
Watch for These Terms Which May Be Key Indicators of Critical Care Open fracture Pneumothorax Pulmonary edema, or emboli Rapid heart rate requiring IV therapies and/or close monitoring in ED Seizure, new onset or with disorder hx, postictal with intensive drug management Sepsis/septicemia Severe bleeding, requiring transfusion Shock-unresponsive patient Status Asthmaticus Status Epilepticus Stroke Suicidal ideation, clear and immediate threat, requiring chemical/physical restraints Trauma, multiple, altered consciousness, life or limb threatened 21
Signs of Aggressive Management Anti-arrhythmics: adenocard, adenosine, atropine, bretylium, Cardizem, Inderal, lidocaine, magnesium sulphate, procainamide, verapamil, et.al; Pressors: dobutamine, dopamine, epinephrine, Levophed, Lopressor Vasodilators: nitro, Nipride, et.al. Other Meds: aminophylline, diazepam, glucagon, morphine, sodium bicarb Procedures: endotracheal intubation/rsi, CPR, CPAP, thrombolytic therapy (TPA for cardiac or stroke) cardioversion, defibrillation, thoracostomy, thoracentesis, pericardiocentesis, CVP insertion, tracheostomy, cricothyroidotomy, abdominal paracentesis, etc. 22
Common Critical Care IV Meds 2
Common Critical Care IV Meds 24
CMS Critical Care Supporting Documentation https://www.cgsmedicare.com/pdf/critical_care_fs.pdf Supporting Documentation: Critical care must be medically necessary; involve high complexity decision making Was the physician called to see the patient on an emergency basis? Does the physician s note support evidence of threat of imminent deterioration of patient s condition? Is the critical illness or injury acutely impairing one or more body systems? Was the physician s services required to prevent further decline of a life threatening condition? Does the documentation indicate that an assessment of the patient and services of the physician were provided to support vital system function? This Fact Sheet is for informational purposes only and is not intended to guarantee payment for services, all services billed 1862(a)(1)(A) of the Social Security Act Medical necessity (http://www.ssa.gov/op_home/ssact/title18/1862.htm). Originated October 2, 201 Revised June, 2014 2014 Copyright, CGS Administrators, LLC. 25
Post Operative Encounters in the ICU Usual postoperative care in an intensive care unit is inclusive to the global surgical payment and may not be billed separately. Code 99024 (Post operative Care) may be reported. Separate billing for encounters in the post-operative period is allowed for: Encounters unrelated to the specific anatomic injury or general surgical procedure performed. A diagnosis code which clearly indicates that the service is unrelated to the surgery is required. Unusual complications of the surgery. Treatment for the underlying condition or an added course of treatment which is not part of normal recovery. Critical care services unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician/npp If the unrelated encounter further meets the criteria for critical care then further documentation to support time is 0 minutes or greater, critical condition and critical treatment is required. 26
Physicians in the Same Group Practice Physicians in same group practice who have same specialty may not each report 99291 (first 0-74 minutes) for same patient on same calendar date. Total aggregated time of multiple physicians in the same group/same specialty may be used to calculate overall critical care time. Follow-up services after the first 74 minutes may be billed by another provider with the same specialty as 99292. Physicians in same group practice with different specialties: May bill separately if: Each provider provided care unique to his/her medical specialty Managed at least one of patient s critical illness(es)/injury(ies) Critical care requirements have been met Time did not overlap with other providers billing 27
Concurrent Care- Only One Claim per Aspect of Care Concurrent care by more than one physician, different physician specialties, is payable if the services all meet critical care requirements, are medically necessary, and are not duplicative (refer to Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), Section 0 (Physician Services) for concurrent care policy discussion). https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/bp102c15.pdf Page 14 of 29 The reasonable and necessary services of each physician rendering concurrent care could be covered where each is required to play an active role in the patient s treatment, for example, because of the existence of more than one medical condition requiring diverse specialized medical services. 28
Services Included in Critical Care Codes Interpretation of cardiac output measurements (9561, 9562) Interpretation of chest x-rays, (71010, 71015, 71020) Pulse oximetry (94760, 94761, 94762) Analysis of clinical data stored in computers (eg, ECGs, blood pressures, hematologic data) (99090) Gastric intubation 4752, 475) Temporary transcutaneous pacing (9295) Ventilator management (94002-94004, 94660, 94662) Not separately billable Vascular access, arterial puncture (6000, 6410, 6415, 6591, 6600) 29
Separately Billable Services: Any procedure or service, not specifically listed as included in 9291/99292. Examples: Endotracheal intubation (1500) Arterial line placement (6620) Central line placement (6556) Placement of a flow directed catheter, e.g., Swan-Ganz (950) EKG interpretation (NOT Rhythm strips) CPR Do not include time for performing billable procedures in critical care time. Include a statement such as: Critical Care time does not include the time to perform Modifier -25 must be appended to critical care service code to indicate that critical care was a significant, separately identifiable E/M service above and beyond the usual pre and post operative care associated with procedure performed. 0
Global Surgery
Global Service: 1 Payment for Procedure Major = Day before procedure thru 90 days after Minor = Day of procedure (some until 10 days after) Services Included In The Global Surgery Fee Preoperative visits, beginning with the day before a surgery for major procedures and the day of procedure for minor procedures. If decision made for surgery within 24 hours of consultation or H&P then bill E/M with a modifier 57. Complications following procedure, which do not require additional trips to the operating room. Postoperative visits (follow up visits) during the postoperative period of the procedure that is related to recovery from the surgery. Postoperative pain management provided by the surgeon. 2
Services Not Included in the Global Surgery Fee Visits unrelated to the diagnosis for which the surgical procedure is performed. Treatment for the underlying condition or an added course of treatment which is not part of the normal recovery from surgery. Append modifier -24 to the E/M code. Treatment for postoperative complications that cause a return trip to the operating room, including ASCs and hospital outpatient departments. Append modifier -78 to the procedure code for the procedure provided in the operating room. Diagnostic tests and procedures, including diagnostic radiological procedures (no modifier required). Critical Care services (codes 99291 and 99292) unrelated to the surgery, or the critical care is above and beyond the specific anatomic injury or general surgical procedure performed
Immunosuppressive therapy for organ transplants is NOT included in surgical fee Document in a separate note the immunosuppression services. Document changes, as indicated. If also provided included post-op services in the visit, clearly separate the notes from routine postop and immunosuppression service. 4
Modifiers Indicate that a separate service or procedure has been performed by the same physician on the same day (2 CPT codes submitted) Medicare is monitoring these codes! Recent report from CMS: 5% of claims using modifier -25 did not meet requirements, resulting in $58 million dollars in improper payments You will be audited if you regularly use these codes! Ensure documentation supports the E/M and significant separate procedure. 5
Common Modifiers Modifier-24 (Surgery modifier): Unrelated E/M service by the same physician during a post-op period Example: surgeon managing immunosuppression in transplant pt. Example: post-op TURP patient develops chest pain Example: Critical Care services which are UNRELATED to the surgery where a seriously injured or burned patient is critically ill 6
Common Modifiers Modifier -57 visit or consult on day of or day before a major surgery (90 days global period) when decision for surgery is made Modifier -59 two services performed at different anatomical sites on the same day on the same patient 7
Modifier 25 Be ALERT Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. The patient s condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and post-procedure care associated with the procedure or service 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. The service could be a minor procedure, diagnostic service, E/M visit with a preventive service or E/M with a Medicare Well Visit or Well-Woman service. It is STRONGLY recommended that 2 separate and distinct notes be included in the medical record to document the procedure and then the separate E/M service Only a practitioner or coder should assign a modifier 25 to a Claim Not a biller. 8
Modifier 25 Be ALERT When Not to Use the Modifier 25 When billing for services performed during a postoperative period if related to the previous surgery When there is only an E/M service performed during the office visit (no procedure done) When on any E/M on the day a Major (90 day global) procedure is being performed When a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have inherent E/M service included. When a patient came in for a scheduled procedure only 9
Modifier 22 Services performed are significantly greater than usually required", therefore its use should be exceptional. Modifier 24 Separately Identifiable E/M by the Same Physician/Group during the global period. Modifier 57 Significant, Separately Identifiable E/M by the Same Physician/Group on the Day of or within 24 hours of a major procedure. Modifier 52 Surgeries for which services performed are significantly less than usually required may be billed with the "-52" modifier Modifier 5 Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. Documentation describing the circumstances requiring the discontinuation of a procedure in the report is required. Modifier 58 Staged or planned related surgical procedures done during the global period of the first procedure. Procedure may have been: Planned prospectively or at the time of the original procedure; More extensively than the original procedure; or for therapy following a diagnostic surgical procedure. A new post-operative period begins when the next procedure in the series is billed. 40
Modifier 62: Co-Surgery Two surgeons (usually with different skills) with specialized skills act as co-surgeons. Both are primary surgeons, performing distinct parts of a single reportable procedure (same CPT code) performing the parts of the procedure simultaneously, e.g., heart transplant or bilateral knee replacements. (pays 125% of fee schedule) Co-surgery may be required because of the complexity of the procedure and/or the patient s condition The additional surgeon is not working as an assistant, but is performing a distinct part of the procedure Each surgeon dictates his/her operative note describing his/her involvement in the procedure Modifier 66: Team Surgery Team-Surgery Surgeries: Highly complex procedures (requiring the skilled services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment) are carried out under the "surgical team" concept. Such circumstances may be identified by each participating physician with the addition of the modifier 66 to the basic procedure number used for reporting services. Reimbursement is determined "By Report.
Modifier 82: Physician Assistant Surgeon in a Teaching Hospital Modifier AS: PA or NP Assistant at Surgery in a Teaching Hospital In general, the services of assistants for surgeries furnished in a teaching hospital which has a training program related to the medical specialty required for the surgical procedure and has a qualified resident available to perform the service is nonpayable. However, it is covered if such services are exceptional medical circumstances. The TP must document in the operative note that a qualified resident was unavailable for the procedure and Documentation of qualifying circumstances must be included in the operating report. Only one OP report is required and the primary attending physician must document in their OP report the specific participation of the assistant (Dr. XXX assisted me throughout the entire procedure ) If the assistant is a physician append modifier 82 to their claim. If the assistant is a PA append an AS modifier to their claim
No Modifier Required If 2 Physicians Performing Unique Surgery CPT Codes on the Same Patient If surgeons of different specialties are each performing a different procedure (with specific CPT-4 codes), multiple surgery rules do not apply. If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon's services only. If some portions of the surgery care provided with unique CPT codes and others with co-surgery or assistant, then claim could include CPT codes both with and without modifiers. 4
Billing Services When Working With Residents Fellows and Interns All Types of Services Involving a resident with a TP Requires Appropriate Attestations In EHR or Paper Charts To Bill
Evaluation and Management (E/M) E/M IP or ED: TP must personally document by a personally selected macro in the EMR or handwritten at least the following: That s/he was present and performed key portions of the service in the presence of or at a separate time from the resident; AND The participation of the teaching physician in the management of the patient. Example: I saw and examined the patient and agree with the resident s note Time Based E/M Services: The TP must be present and document for the period of time for which the claim is made. Examples : Critical Care Hospital Discharge (>0 minutes) or E/M codes where more than 50% of the TP time spent counseling or coordinating care Medical Student documentation for billing only counts for ROS and PFSH. All other contributions by the medical student must be re-performed and documented by a resident or teaching physician. 45
Unacceptable TP Documentation Assessed and Agree Reviewed and Agree Co-signed Note Patient seen and examined and I agree with the note As documented by resident, I agree with the history, exam and assessment/plan 46
TP Guidelines for Procedures Minor (< 5 Minutes & 0-10 Day Global): For payment, a minor procedure billed by a TP requires that s/he is physically present during the entire procedure. Example: I or Dr. (teaching physician) was present for the entire procedure. Major (>5 Minutes) SINGLE Procedure / Surgery When the teaching surgeon is present or performs the procedure for a single non-overlapping case involving a resident, he/she or the resident can document the TP s physical presence and participation in the surgery. Example: I (or Dr. TP) was present for the entire (or key and critical portions) of the procedure and immediately available. Presence Can Be Documented By The Resident or TP for Procedure Endoscopy Procedures (excluding Endoscopic Surgery): TP must be present during the entire viewing for payment. The viewing begins with the insertion and ends with the removal. Viewing of the entire procedure through a monitor in another room does not meet the presence requirement. Example: I was present for the entire viewing. 47
Overlapping Surgeries: CMS Requires 2 Overlapping Surgeries - CMS will pay for two overlapping surgeries, but the teaching surgeon must be present during the critical or key portions of both operations. Consequently, the critical or key portions may not take place at the same time. The teaching surgeon must personally document in the medical record that he/she was physically present during the critical or key portion(s) of both procedures When a TP is not present during non-critical or non-key portions of the procedure and is participating in another surgical procedure, he or she must arrange for another qualified attending surgeon to immediately assist the resident in the other case should the need arise (this cannot be a resident or fellow.) In the case of concurrent surgical procedures, the role of the teaching surgeon in each of the cases is classified as a supervisory service to the hospital rather than a physician service to an individual patient and is not payable under the physician fee schedule. NOTE: Under the new guidelines for Overlapping Surgeries, the surgeon must inform the patients prior to the performance of the procedure, and agree to the procedure, discuss with the patient about what critical portion of the operation means and who might be performing some of the noncritical portions of the operation. 48
Florida Medicaid Teaching Physician Guidelines TEACHING PHYSICIANS WHO SEEK REIMBURSEMENT FOR OVERSIGHT OF PATIENT CARE BY A RESIDENT MUST PERSONALLY SUPERVISE ALL SERVICES PERFORMED BY THE RESIDENT. PERSONAL SUPERVISION PURSUANT TO RULE 59G- 1.010(276), F.C.A, MEANS THAT THE SERVICES ARE FURNISHED WHILE THE SUPERVISING PRACTITIONER IS IN THE BUILDING AND THAT THE SUPERVISING PRACTITIONER SIGNS AND DATES THE MEDICAL RECORDS (CHART) WITHIN 24 HOURS OF THE PROVISION OF THE SERVICE. 49
DOCUMENTATION REQUIREMENTS- OPERATIVE REPORT Provide complete roadmap of what was done Operative report few components Where did you enter and exit? Where did you pass through? Technique and approach Open vs. closed, aspiration, percutaneous, etc. Screening vs. diagnostic vs. therapeutic Location/Site(s) Right, left, bilateral, distal, proximal, depth, single/pleural, Severity/Risk Complex/simple DEBRIDEMENT TYPE CODES Of extensive eczematous or infected skin % of body surface With fractures/dislocations Skin and sub-q Skin, sub-q, muscle fascia, and muscle Skin, sub-q, muscle fascia, muscle, and bone Regular also by depth: Skin-partial thickness, Skin-full thickness Skin and sub-q Skin, sub-q, and muscle Skin, sub-q, muscle, and bone 50
INTEGRAL SURGICAL SERVICES: Identification of anatomical landmarks Incision Evaluation of the surgical field Simple debridement of traumatized tissue Lysis of simple adhesions Isolation of structures such as bone, blood vessels, nerve, and muscles including stimulation for identification or monitoring (continued) Surgical cultures, Wound irrigation Insertion and removal of drains, suction devices, and pumps into same site Surgical closure and dressings Application, management, and removal of postoperative dressings including analgesic devices (preincisional TENS unit, institution of Patient Controlled Analgesia) Preoperative, intra-operative and postoperative documentation, including photographs, drawings, dictation, transcription as necessary to document the services provided 51
Some Procedures Have Certain Other Services Cleansing, shaving and prepping of skin Draping and positioning of patient Insertion of intravenous access Moderate sedation administration by the physician performing a procedure a procedure Local, topical or regional anesthesia administered by the physician performing the procedure PROCEDURE(S): Many Questions Unbundled, inclusive mutually exclusive Co-surgeon vs. assistant surgeon Application of multiple guidelines Repeat, unrelated, staged? Site(s) Indications for surgery REPAIR (Closure) Classifications Simple, Intermediate, Complex Instructions: Measure and record in cm Add lengths in same classification & anatomic sites grouped together 52
Ordering Labs Outside the Protocol for Post-transplant Patients All labs ordered outside of the specific patient protocol must be documented in the medical record to support medical necessity and continuity of care. All labs must indicate that they have been reviewed and notation of follow-up or significance of results should be documented by the ordering physician. 5
The Key Documentation Elements History Focus on HPI Physical Exam Medical Decision Making 54
Important! The Nature of the Presenting Problem determines the level of documentation necessary for the service The level of care (E/M service) submitted must not exceed the level of care that is medically necessary SO... Medical Decision-Making and Medical Necessity related to the Nature of the Presenting Problem determine the E/M level. The amount of history and exam should not generally alone determine the level. 55
Medical Necessity Ignoring how medical decision-making affects E/M leveling can put you at risk. According to the Medicare Claims Processing Manual, chapter 12, section 0.6.1: Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. That is, a provider should not perform or order work (or bill a higher level of service) if it s not necessary, based on the nature of the presenting problem. 56
Medical Record Documentation CMS: Each medical record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. 57
Medical Decision-Making 1. Number of Diagnoses or Treatment Options One or two stable problems? No further workup required? Improved from last visit? = LOWER COMPLEXITY Multiple active problems? New problem with additional workup? Are problems worse? = HIGHER COMPLEXITY 58
Medical Decision-Making 2. Amount/Complexity of Data Were lab/x-ray ordered or reviewed? Were other more detailed studies ordered? (Echo, PFTs, BMD, EMG/NCV, etc.) Did you review old records? Did you view images yourself? Discuss the patient with consultant? 59
Medical Decision-Making. Table of Risk Is the presenting problem self-limited? Are procedures required? Is there exacerbation of chronic illness? Is surgery or complicated management indicated? Are prescription medications being managed? 60
MDM Step : Risk Presenting Problem Diagnostic Procedure(s) Ordered Management Options Selected Min One self-limited / minor problem Low OP Level IP Sub 1 IP Initial 1 Mod OP Level 4 IP Sub 2 IP Initial 2 High OP Level 5 IP Sub IP Initial 2 or more self-limited/minor problems 1 stable chronic illness (controlled HTN) Acute uncomplicated illness / injury (simple sprain) 1 > chronic illness, mod. Exacerbation, progression or side effects of treatment 2 or more chronic illnesses Undiagnosed new problem w/uncertain prognosis Acute illness w/systemic symptoms (colitis) Acute complicated injury 1 > chronic illness, severe exacerbation, progression or side effects of treatment Acute or chronic illnesses that may pose threat to life or bodily function (acute MI) Abrupt change in neurologic status (TIA, seizure) Labs requiring venipuncture CXR EKG/ECG UA Physiologic tests not under stress (PFT) Non-CV imaging studies Superficial needle biopsies Labs requiring arterial puncture Skin biopsies Physiologic tests under stress (stress test) Diagnostic endoscopies w/out risk factors Deep incisional biopsies CV imaging w/contrast, no risk factors (arteriogram, cardiac cath) Obtain fluid from body cavity (lumbar puncture) CV imaging w/contrast, w/risk factors Cardiac electrophysiological tests Diagnostic endoscopies w/risk factors Rest Elastic bandages Gargles Superficial dressings OTC meds Minor surgery w/no identified risk factors PT, OT IV fluids w/out additives Prescription meds Minor surgery w/identified risk factors Elective major surgery w/out risk factors Therapeutic nuclear medicine IV fluids w/additives Closed treatment, FX / dislocation w/out manipulation Elective major surgery w/risk factors Emergency surgery Parenteral controlled substances Drug therapy monitoring for toxicity DNR
FOUR ELEMENTS of HISTORY Chief Complaint (CC:) History of Present Illness (HPI) location/quality/severity/duration/timing/context/ modifying factors/associated symptoms Review of Systems (ROS) Past/Family/Social History (PFSHx) 62
History 1. Chief Complaint Concise statement describing reason for encounter ( stomach pain,, follow-up diabetes ) Can be included in HPI IMPORTANT: The visit is not billable if Chief Complaint is not somewhere in the note Must be follow-up of 6
History - HPI 2. The HPI is a chronological description of the patient s illness or condition. The elements to define the HPI are: Location: Right lower quadrant, at the base of the neck, center of lower back Quality: Bright red, sharp stabbing, dull Severity: Worsening, improving, resolving Duration: Since last visit, for the past two months, lasting two hours Timing: Seldom, first thing in the morning, recurrent Context: When walking, fell down the stairs, patient was in an MVA Modifying Factors: Took Tylenol, applied cold compress: with relief/without relief Associated Signs and Symptoms: With nausea and vomiting, hot and flushed, red and itching TWO TYPES: BRIEF EXTENDED 1- elements above or status of 1-2 diagnosis or conditions 4 or > elements above or status of or > diagnosis or conditions 64
4. REVIEW OF SYSTEMS History - ROS 14 recognized: Constitutional Psych Eyes Respiratory ENT GI CV GU Skin MSK Neuro Endocrine Heme/Lymph Allergy/Immunology THREE TYPES: PROBLEM PERTINENT EXTENDED COMPLETE (1 SYSTEM) (2-9 SYSTEMS) (10 SYSTEMS) 65
History - PFSHx. PAST, FAMILY, AND SOCIAL HISTORY - Patient s previous illnesses, surgeries, and medications - Family history of important illnesses and hereditary conditions - Social history involving work, home issues, tobacco/alcohol/drug use, etc. TWO TYPES: PERTINENT: COMPLETE: 1 area (P, F or S) generally related to HPI All (P, F and S) for New patient and Initial Hospital or 2 of areas (P, F or S) for established pt. 66
History PEARLS FOR HISTORY DOCUMENTATION: Must have PAST/FAMILY/SOCIAL history for comprehensive history (ALL THREE) Don t forget 10-system review! You cannot charge higher than a level new or consult visit without COMPREHENSIVE HISTORY 67
Physical Examination 4 TYPES OF EXAMS Problem Focused (PF) Expanded Problem Focused (EPF) Detailed (D) Comprehensive (C) 68
Coding 1995: Physical Exam BODY AREAS (BA): Head, including face Neck Chest, including breast and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity CODING ORGAN SYSTEMS (OS): Constitutional/General Eyes Ears/Nose/Mouth/Throat Respiratory Cardiac GI GU Musculoskeletal Skin Neuro Psychiatric Hematologic/Lymphatic 69
Using Time to Code Time shall be considered for coding an E/M in lieu of H-E-MDM when > 50% of the total billable practitioner visit time is counseling/coordination of care (CCC.) Time is only Face-to-face for OP setting Coding based on time is generally the exception for coding. It is typically used: Significant exacerbation or change in the patient s condition, Non-compliance with the treatment/plan, Counseling regarding previously performed procedures or tests to determine future treatment options, or Behavior/school issues. Required Documentation For Billing: 1. Total time of the encounter excluding separate procedure if billed The entire time to prep, perform and communicate results of a billable procedure to a patient must be carved out of the E/M encounter time! 2. The amount of time dedicated CCC for that patient on that date of service. A template statement would not meet this requirement. 70
Time-Based Billing for CCC Outpatient Counseling Time: 99201 10 min 99202 20 min 9920 0 min 99204 45 min 99205 60 min 99241 15 min 99242 0 min 9924 40 min 99244 60 min 99245 80 min 99211 5 min 99212 10 min 9921 15 min 99214 25 min 99215 40 min Inpatient Counseling Time: 99221 0 min 99222 50 min 9922 70 min 9921 15 min 9922 25 min 992 5 min 99251 20 min 99252 40 min 9925 55 min 99254 80 min 99255 110 min 71
Counseling/Coordination of Care CCC Proper Language used in documentation of time: I spent minutes with the patient and family and over 50% was in counseling about her diagnosis, treatment options including and. I spent minutes with the patient and family more than half of the time was spent discussing the risks and benefits of treatment with (list risks and benefits and specific treatment) This entire minute visit was spent counseling the patient regarding and addressing their multiple questions. Total time spent and the time spent on counseling and/or coordination of care must be documented in the medical record. Documentation must reflect the specific issues discussed with patient present. 72
New Patients Patient not seen by you or your billing group in the past three years (as outpatient or inpatient) 7
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Subsequent Hospital Care Inpatient E/M Coding Inpatient Hospital Three levels of service: 9921, 9922, 992 9921 - Stable, recovering, improving Problem focused history or exam 9922 - Not responding, minor complication Expanded problem focused history or exam 992 - Very unstable, significant complications Detailed history or exam REMEMBER: What is medically necessary to document for that day? 75
Subsequent Hospital Visits Inpatient Hospital Medical Necessity should drive your documentation for each day s visit: What s wrong with this audit? Day 1: 9922 Day 2: 992 Day : 992 Day 4: 992 Day 5: 992 Day 6: 9929 (discharge to home) 76
Hospital Discharge IMPORTANT! Documentation should include: final examination of patient discharge instructions/follow-up preparation of referrals/prescriptions time spent If less than 0 minutes: 9928 If more than 0 minutes: 9929 (TIME must be documented) 77
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Top Compliance Issues For Documenting in EMR 79
Documentation in EMR CMS IS WATCHING EMR DOCUMENTATION Once you sign your note, YOU ARE RESPONSIBLE FOR ITS CONTENT 80
Documentation in EMR Every exam component... Every time you copy forward Family/Social History... Every HPI and ROS item you document means YOU PERFORMED THEM ON THAT VISIT... If you document something you did not do... YOU ARE PUTTING YOURSELF AND THE INSTITUTION AT GREAT RISK! 81
Top Compliance Rules for EMR Use Copy Forward with caution Each visit is unique Cloned documentation is very obvious to auditors If you bring a note forward it MUST reflect the activity for the CURRENT VISIT with appropriate editing Strongly advise NOT copying forward HPI, Exam, and complete Assessment/Plan 82
Top Compliance Rules for EMR Don t dump irrelevant information into your note ( the 10-page follow-up note ) Be judicious with Auto populate Consider Smart Templates instead Marking Reviewed for PFSHx or labs is OK from Compliance standpoint (as long as you did it!) 8
Top Compliance Rules for EMR Never copy ANYTHING from one patient s record into another patient s note Self-explanatory 84
Top Compliance Rules for EMR Only Past/Family/Social History and Review of Systems may be used from a medical student or nurse s note Student or nurse may start the note Provider (resident or attending) must document HPI, Exam, and Assessment/Plan 85
Top Compliance Rules for EMR Be careful with pre-populated No or Negative templates Cautious with ROS and Exam Macros, Check-boxes, or Free Text are safer and more individualized 86
Top Compliance Rules for EMR Link diagnosis to each test ordered (lab, imaging, cardiographics, referral) Demonstrates Medical Necessity Know your covered diagnoses for your common labs 87
Top Compliance Rules for EMR Individualize every note with a focus on the HPI and Medical Decision Making Results is correct coding with the focus of an E/M selection on medical necessity 88
Redemption Tips for Copy and Paste Physicians 89
Copy/Paste Philosophy: Your note should reflect the reality of the visit for that day 90
Use Specific Dates Don t say Today, Tomorrow, or Yesterday Write specific dates, i.e., ID Consult recommends ceftriaxone through 9/, instead of six more days, which could be carried forward inaccurately Heparin stopped 6/20 due to bleeding will always be better than Heparin stopped yesterday, which can be carried forward in error 91
Use Past Tense Neuro status remains stable, will discontinue neuro checks can be copied forward in error Better Neuro checks stopped on 2/24 Added heparin on 4/26 uses past tense and specific date for better accuracy 92
Refresh/Update HPI Everyday Progressive cumulative daily HPIs become unreadable and cumbersome Temptation exists to add no new information If a previous HPI is needed, it is easily found in the EMR on a past note 9
Delete the Prior Review of Systems DO NOT COPY FORWARD REVIEW OF SYSTEMS! This leads to contradictions and inconsistency, and danger of documenting something you didn t do HPI Patient reports nausea this morning Templated ROS same day No nausea, no vomiting 94
Document the Exam ACTUALLY PERFORMED Always better to document fresh exam every day If copied forward or templated, review the exam closely and make corrections to items you did not perform Credibility is questioned when ear exam is documented every day, or when amputee has 2+ pulses in bilateral lower extremities 95
Copy / Paste Summary Copy/Paste can be a valuable tool for efficiency when used correctly There are major Compliance risks when used inappropriately, including potential fraud and abuse allegations, denial of hospital days, and adverse patient outcomes Make sure your note reflects the reality and accuracy of the service each day 96
Non-Physician Practitioners (NPP s) or Physician Extenders Who is a NPP? Physician Assistant (PA) Nurse Practitioner (NP) 97