Office of Billing Compliance 2014 Professional Coding, Billing and Documentation Program Radiation Oncology Prepared by: Medical Compliance Services, Miller School of Medicine/University of Miami and Compliance Concepts, Inc. March 2014 1
What is a Compliance Program? 7 Elements of an Effective Compliance Program A centralized process to promote honest, ethical behavior in the day-to-day operations of an organization, which will allow the organization to identify, correct, and prevent illegal conduct. It is a system of: FIND FIX PREVENT The University of Miami implemented the Billing Compliance Plan on November 12, 1996. The components of the Compliance Plan are: 1. Policies and Procedures 2. Having a Compliance Officer and Compliance Committees 3. Effective Training and Education 4. Effective Lines of Communication (1-877-415-4357 or 305-243-5842) 5. Disciplinary Guidelines 6. Auditing and Monitoring 7. Detect Non-Compliance Issues and Develop Corrective Action Plans 2 2
The Government In order to address fraud and abuse in the Healthcare Field, the government has on-going reviews and investigations nationally to detect any actual or perceived waste and abuse. The Government does believe that the majority of Healthcare providers deliver quality care and submit accurate claims. However, the amount of money in the healthcare system, makes it a prime target for fraud and abuse. Centers for Medicare and Medicaid Services (CMS) Estimates > $50 Billion In Payment Errors Annually in Healthcare OIG reported that in FY 2013 that $5.8 billion was recovered from auditing providers 3 3
Health Care Laws There are five important health care laws that have a significant impact on how we conduct business: False Claims Act Health Care Fraud Statute Anti-Kickback Statute Stark Law Sunshine Act Requires manufacturers of drugs, medical devices and biologicals that participate in U.S. federal health care programs to report certain payments and items of value >$10 given to physicians and teaching hospitals. 4
False Claims Act : United States Code Title 31 3729-3733 What is a False Claim? A false claim is the knowing submission of a false or fraudulent claim for payment or approval or the use of a false record that is material to a false claim. OR Reckless disregard of the truth or an attempt to remain ignorant of billing requirements are also considered violations of the False Claims Act. 5
How do you create a False Claim? One method is to submit a claim form to the government This certification forms the basis for a false claim. 6
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What Are We Seeing Out There? Audits are being conducted for all payer types based on the medical necessity of E/M levels. The audits are generally expressed in two ways: Frequency of services (how often the patient is seen) and, Intensity of service (CPT level). 8
Elements of Medical Necessity CMS s determination of medical necessity is separate from its determination that the E/M service was rendered as billed. Complexity of documented co-morbidities that clearly influenced physician work. Physical scope encompassed by the problems (number of physical systems affected by the problems). 9
Referring Page: http://www.cgsmedicare.com/kyb/coverage/mr/articles/em_volume.html November 2012 E/M Coding: Volume of Documentation versus Medical Necessity Word processing software, the electronic medical record, and formatted note systems facilitate the "carry over" and repetitive "fill in" of stored information. Even if a "complete" note is generated, only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate level of an E/M service. Information that has no pertinence to the patient's situation at that specific time cannot be counted. An ISO 9001:2008 certified company 10
Office of the Inspector General (OIG) Audit Focus Annually OIG publishes it "targets" for the upcoming year. Included is: Cutting and Pasting Documentation in the EMR REMEMBER: More volume is not always better in the medical record, especially in the EMR with potential for cutting/pasting, copy forward, pre-defined templates and pre-defined E/M fields. Ensure the billed code is reflective of the service provided on the DOS. 11
Medical Record Documentation Standards Pre EMR: If it isn t documented, it hasn t been done. - Unknown Post EMR: If it was documented, was it really done and was it medically necessary to do. - Reviewers 12
Quality & Cost: Emphasis on Pay-for- Performance PQRS & Meaningful Use Practitioner reimbursement will likely be tied to outcomes soon. Some experts say that the CMS penalties for not participating in the Physician Quality Reporting System (PQRS) signal that the pay-for-performance trend is not fading away and will likely will be adopted by private payers. I think we re slowly transitioning out of fee-for-service and into a system that rewards for quality while controlling cost, says Miranda Franco, government affairs representative for the Medical Group Management Association. The intent of CMS is to have physicians moving toward capturing quality data and improving metrics on [them]. 13
Guidelines for Teaching Physicians, Interns, Residents and Fellows For Billing Services, All Types of Services Involving a Teaching Physician (TP) Requires Attestations In EHR or Paper Charts 14
Evaluation and Management (E/M) E/M IP or OP: TP must personally document at least the following: That s/he performed the service or was physically present during the key or critical portions of the service when performed by 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 (>30 minutes) or E/M codes where more than 50% of the TP time spent counseling or coordinating care 15 15
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 was present for the entire 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." 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 was present for the entire (or key and critical portions) of the procedure and immediately available. Medical Student documentation for billing only counts for ROS and PFSH 16 16
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 17
Working With NP's and PA's (NPP's) The NP or PA MUST BE AN EMPLOYEE OF THE PRACTICE AND CANNOT BE A HOSPITAL EMPLOYEE TO UTILIZE ANY OF THEIR DOCUMENTATION FOR PHYSICIAN BILLING AS SHARED Shared visit with an NPP may be billed under the physician's name only if: The physician provides a face-to-face portion of the visit and The physician personally documents in the patient's record the portion of the E/M encounter with the patient they provided. If the physician does not personally perform or personally and contemporaneously document their face-to-face portion of the E/M encounter with the patient, then the E/M encounter may only be billed under the PA/ARNP's name and provider number Procedures must be billed under the performing provider & not the supervisor. They cannot be shared 18
National 12 CMS Data For Speciality E/M 60% 50% 52% 40% 30% 20% 10% 0% 24% 14% 2% 7% 99211 99212 99213 99214 99215 National Dist. 19
Top Procedure Codes Billed in 2013 Top 5 Procedure All other Procedure Codes Description % RADIATION 77300 THERAPY,DOSIMETRY PLAN 26% STEREOSCOPIC X-RAY 77421 GUIDANCE 16% RADIATION,MANGEMENT,5 77427 TX'S 14% CT GUIDANCE PLACEMENT 77014 RAD THERAPY FIELDS 13% RADN TREATMENT AID(S) 77334 COMPLX 8% 12% Total 100.0% Top 5 E&M Description % All other E/M Codes 99213 OFFICE/OUTPT 50% 99204 OFFICE/OUTPT 11% OFFICE/OUTPT 99214 VISIT,EST,LEVL IV 10% OFFICE/OUTPT 99212 VISIT,EST,LEVL II 9% OFFICE/OUTPT 99205 VISIT,NEW,LEVL V 8% 12% Total 100.0% 20
2014 CPT Code Changes Review Interprofessional consultations New codes to report interprofessional ( doctor-to-doctor ) telephone/internet consulting. Code 99446 is defined as an interprofessional telephone/internet assessment and management service provided by a consultative physician, including a verbal and written report to the patient s treating/requesting physician or other qualified health care professional, and involves 5 to 10 minutes of medical consultative discussion and review. 99447: 11 to 20 minutes of medical consultative discussion and review 99448: 21 to 30 minutes of medical consultative discussion and review 99449: 31 minutes or more of medical consultative discussion and review Medicare Does Not Pay This Service 21
2014 CPT Code Changes Review Interprofessional consultations The services will typically be provided in complex and/or urgent situations where a timely face-to-face service with the consultant may not be possible. The written or verbal request, its rationale, and the conclusion for telephone/internet advice by the treating/requesting physician or other qualified health care professional should be documented in the patient s medical record. Medicare allowable $0.00 22
Machines don t treat cancer. People do. A team of specialized experts provide all aspects of patient care Radiation Oncologists Radiation Therapists Medical Phy sicists Nurses Medical Dosimetrists 23
Radiation Oncology Continuum/Flow E&M Simulation Treatment Planning Physics Checks Treatment Delivery Weekly Management Follow-up 24
CT for Placement of Fields Simulation Patient Continuum Physician Orders All Procedures need written directives ACR Treatment Planning: Brachy, 2D, 3D, IMRT Dosimetry Calcs; Micro Dosimetry Tx Devices, Continuing Medical Physics Special Physics Consult, Special Tx Procedure, Port films 25
Sample Wording for Dose Distribution Plans The signature affixed to this document signifies the physician's review and approval of the entire document, including the dose distribution plan (when applicable), basic dosimetry calculations, verification calculations, treatment devices, and medical necessity documents (3-D and IMRT treatment planning document). 26
Physician Supervision Rules General furnished under a physicians general supervision. Direct present, in area and immediately available. Personal must be in attendance and in the room.
How to Interpret Direct Supervision Professional Supervision In a hospital campus the physician must be immediately available, on campus. The physician should not be performing another procedure or involved with another patient encounter. Hospital Supervision The majority of Radiation procedures performed or supervised by a physician fall under direct supervision.
Both 77421 and 77014 have direct supervision - what does that mean? 29
Both 77421 and 77014 now have direct supervision what does that mean MORE... 30
77421 CPT Insiders View Documentation Required The documentation for the IGRT, 77421 procedure, would consist of the therapist recording exactly what was performed with the patient's name, date and signature. Remember the documentation must be labeled IGRT, what type, "Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy", who, what, when, where and why. The physician then according to the AMA will, "The radiation oncologist reviews the images daily and compares with previous shifts. Feedback by the physician is given to the therapists about the adequacy of registrations and, if necessary, about the steps necessary to improve future registrations as well as for the required treatment modifications". AMA 2006 31
Indications for IGRT Three-dimensional conformal therapy Intensity Modulated Radiation Therapy Particle Beam Therapy Stereotactic Radiosurgery (SRS) Stereotactic Body Radiation Therapy 32
Medicare Supervision Rules Apply to IGRT Codes Rules General supervision: The physician is not necessarily on-site. The services of the facility are provided under his or her supervision and control, however, and the physician is responsible for the calibration of the equipment, the training of the technologists, and overall operations. (76950-BAT) Direct supervision: The physician must be physically on the premises and in the suite of offices where the tests are being performed. In the office setting, the physician must be present in the office suite and immediately available. This is defined as within earshot (not just reachable by beeper, and not merely in the same building). (77014- IGRT/CT Based or KV IGRT 77421) 33
Medicare Supervision Summary of Common IGRT Codes 77014 (CT-guidance) : Direct supervision - Freestanding and Hospital Based can bill technical if performed and documented but packaged for Hospital must be on claim 77421 (stereoscopic x-rays: Direct Supervision Physician must approve prior to the next treatment in order to bill both technical and professional and both freestanding an hospital can bill both components if performed and documented however technical is packaged for Hospitals but must be on the claim. 76950 : BAT - General supervision : Freestanding and Hospital can bill technical when performed and documented. Packaged for Hospital but must be on claim 34
Codes for IGRT Ultrasound : CPT 76950 aka BAT Stereoscopic X-ray : CPT 77421 (KV Based IGRT) Computerized Tomography : CPT 77014 (CT based IGRT) Cone beam CT Tomotherapy CT-on-Rails Fluoroscopy 76000 Port film - 77417 35
Tomotherapy /Cone-Beam CT /CT-on- Rails ASTRO currently recommends that CPT code 77014; Computed tomography guidance for placement of radiation therapy fields, be used for CT based IGRT. It is important to note that in order to meet the criteria for CT based IGRT, a radiation oncologist, medical physicist, or trained therapist under the supervision of the radiation oncologist must review the fused CT images and supervise any patient repositioning 36
IGRT Do not bill 77421 and 77014 for the same patient on the same day Do not bill 77421 and 77417 for the same patient on the same day Do not bill 77421 and 76950 for the same patient on the same day It is critical that appropriate documentation be made for physician involvement and for the technical aspects of all IGRT codes. This work is in addition to the physician work involved with the weekly management CPT code 77427. BID (Patients Treated 2 times daily) The same repeat service modifier (76 or77) will be used on the second image guidance service performed each day. Remember that the first IGRT service performed for the patient in the morning must be reviewed and approved by the physician prior to the second treatment that day. Each IGRT service must be reviewed and approved/accepted by the physician prior to the next patient treatment, so it would not be acceptable for the physician to review both the am and pm images at the end of the day in this case, you would report a single IGRT service. 37
Who is responsible for billing? Physician Physicist Therapist Patient Bill Dosimetrist Nurse Support Staff Every discipline plays a role in the charge capture process 38
77295 Therapeutic radiology simulationaided field setting; 3-dimensional Revised Therapeutic radiology simulation3-dimensional radiotherapy plan, including dose-aided field setting volume histograms 3-dimensional CPT 2014 revised 77295 so it better reflects current practice. The code now emphasizes the physics and dosimetry planning work 39
Radiation Therapist Treatment SIMPLE TREATMENT DELIVERY Codes 77402 77406) SINGLE Port Parallel Ports No Devices SIMPLE Devices INTERMEDIATE TREATMENT DELIVERY 77407 77411) Two Separate areas treated 3 or more ports on a single area Multiple Devices (including wedges) Tangential Ports without devices COMPLEX TREATMENT DELIVERY (77412-77416) 3 or more areas treated Custom Devices Rotational Beam Compensator Special particle beam (e.g., electrons, neutrons) IMRT TREATMENT DELIVERY CODE (77418) Proton Treatment Delivery (77520-77525)
Radiation Therapist Treatment Establishment of Energy Level Photon Delivery Daily Kilovoltage Treatment Delivery Superficial and/or Orthovoltage 77401 Daily Treatment Delivery Simple 77402 Co-60, accelerator up to 5 MV maximum energy 77403 Accelerator 6-10 MV maximum energy 77404 Accelerator 11-19 MV maximum energy 77406 Accelerator, 20 MV or greater maximum energy Daily Treatment Delivery Intermediate 77407- Co-60, accelerator up to 5 MV maximum energy 77408- Accelerator 6-10 MV maximum energy 77409 - Accelerator 11-19 MV maximum energy 77411 - Accelerator, 20 MV or greater maximum energy Daily Treatment Delivery Complex 77412 - Co-60, accelerator up to 5 MV maximum energy 77412 Gamma Knife Not used MDACC 77413 - Accelerator 6-10 MV maximum energy 77414 - Accelerator 11-19 MV maximum energy 77416 - Accelerator, 20 MV or greater maximum energy 77418 IMRT any energy
Charges Associated with the Radiation Therapist The professional values are related to the amount of time and effort expended by the physician in the care of a patient during the course of radiation therapy. Technical complexity is related to the difficulty encountered by the radiotherapist on the treatment machine in terms of set up and daily treatment delivery to the patient. Institutional treatment delivery is a technical (hospital or freestanding facility) component reported under these technicalonly codes. Technical treatment delivery is reported on a daily basis by all institutions. Medicare requires that these codes be separated with the physician component being billed on a weekly basis (77427) and the treatment delivery being billed per treatment fraction.
Charges Associated with the Radiation Therapist TREATMENT DELIVERY CODING GUIDELINES A treatment delivery code is reported for each treatment session In the case of hyperfractionation, there are 2 treatment sessions on the same day, therefore 2 delivery codes could be reported. If 2 different energies are used during the same treatment session, then the single code that corresponds to the highest energy used is reported. For Electrons, since the energies vary widely, the coding is based on the maximum beam capability of the equipment. The number of treatment delivery codes reported will depend on the number of fractions delivered. Only one code reported per treatment session.
Patient Service Charges Professional Charges (Bill on CMS 1500) Charges prompted by the physician s involvement into a process designed to provide care for the patient. The physician s intellectual involvement directs not only his or her direct involvement but also the Physics charges that are required for patient care. Technical Charges (Hospital bill on UB04) Charges rendered by the treatment center for provision of all of the equipment and personnel that the physician must use to deliver treatment. These include the treatment unit, examination rooms, simulators, and other procedures not directly supplied by the physician but required via the treatment plan. 44
CMS is Comparing, so what does that mean? The professional and technical complexity level must match. Physician billing must communicate with hospitals. Must share records and documentation. Billing Staff will have to be adequately trained to on determination of complexity Billing Staff for Hospitals and Doctors must communicate 45
IMRT and Medical Necessity Each chart should contain a patient specific statement by the treating physician documenting the medical necessity of performing IMRT rather than performing conventional or 3D planning and delivery detailing patient specific goals and requirements of the treatment plan, including the specific dose constraints for the target(s) and nearby critical structures. Although it may be apparent from the patient history, each chart should meet the LCD for IMRT From First Coast: LCD ID Number L28892 LCD Title: Intensity Modulated Radiation Therapy (IMRT) 46
Modifier Reminders Modifier 25: Significant, Separately Identifiable E/M by the Same Physician/Group on the Day of a minor Procedure: on the day a procedure the patient's condition required a significant, separately identifiable E/M service above and beyond the usual care associated with the procedure that was performed. Modifier 59: Distinct Procedural Service: Under certain circumstances, indicate that a procedure or service was independent from the services performed on the same day. Modifier GC: Service involved a resident or fellow. Payment not affected. 47
CCI Audit Reviews for Radiation Oncology: Support for medical necessity of IMRT in documentation ( review LCDs and NCDs) Providing services without proper physician supervision Weekly E/M code medical necessity to repeat specific history areas Frequency of visits after treatment 48
Increased specificity of the ICD-10 codes requires more detailed clinical documentation to code some diagnoses to the highest level of specificity. Coding and documentation go hand in hand ICD-10 based on complete and accurate documentation, even where it comes to right and left or episode of care. ICD-10 should impact documentation as physicians are required to support medical necessity using appropriate diagnosis code this is not an easy situation. Will not change the way a physician practices medicine 49
ICD-10 Implementation Example 50
HIPAA Final Reminders for All Staff, Residents, Fellows or Students Health Insurance Portability and Accountability Act HIPAA Protect the privacy of a patient s personal health information Access information for business purposes only and only the records you need to complete your work. Notify Office of HIPAA Privacy and Security at 305-243-5000 if you become aware of a potential or actual inappropriate use or disclosure of PHI, including the sharing of user names or passwords. PHI is protected even after a patient s death!!! Never share your password with anyone and no one use someone else s password for any reason, ever even if instructed to do so. If asked to share a password, report immediately. 51
Any Questions 52
Available Resources at University of Miami, UHealth and the Miller School of Medicine If you have any questions or concern regarding coding, billing, documentation, and regulatory requirements issues, please contact: Gemma Romillo, Assistant Vice President of Clinical Billing Compliance and HIPAA Privacy Officer; or Iliana De La Cruz, RMC, Director Office of Billing Compliance Phone: (305) 243-5842 Officeofbillingcompliance@med.miami.edu Also available is The University s fraud and compliance hotline via the web at www.canewatch.ethicspoint.com or toll-free at 877-415-4357 (24hours a day, seven days a week). Office of billing Compliance website: www.obc.miami.edu 53