Facilitator and Contributor: Angela Jordan, CPC Contributor s and Panel Participant s: Tracy Bird, CPC, CPMA, CPC-I, CEMC Linda Duckworth, CPC, CHC Patti Frank, CPC Rena Hall, CPC Barbara L. Hays, CPC, CPMA, CPC-I, CEMC, CFPC Cathy Jennings, CPC, CEDC, CHONC, CPC-I Tiffany Johr, CPC Sarah Reed, CPC, CPC-I Martha Tracy, CPC, CPC-I Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC Sherry Wright-Fontenot, CPC, CPMA, CEDC Patty York, CPC, CPMA, CCC, CCS-P
Disclaimer The speaker has no financial relationship to any products or services referenced in this program. The program is intended to be informational only. The speaker is not an authoritative source by law. Attendees are advised to reference payer specific provider manuals, on-line or otherwise, for verification prior to making changes to their coding, documentation and/or billing practices.
Barbara L. Hays, CPC, CPMA, CPC-I, CEMC, CFPC American Academy of Family Physicians There has been discussion on AAPC forum boards (some heated) as to whether we can legitimately bill an additional e/m with a preventive visit due to the exclusion notes for preventive visit codes now found in ICD- 10. There are some who are adamant that the exclusion notes won t allow billing both and there are others, some auditors, who don t believe that ICD-10 intent is to disallow billing for both when it meets CPT criteria. I was hoping this would be addressed at the mtg - would be interested in hearing what the panel thinks. - Kerrie Amos
CDC Updated Advice Updated October 26, 2015 ICD-10-CM: use of the preventive and problem visit diagnoses in the same encounter Excludes 1 encounter for the examination of sign or symptom code to sign or symptom General examination diagnoses are not meant to be used in place of a problem diagnosis. -- A dash is a convention in English language to indicate a clause or continuing thought. This phrase is a continued thought in the event a sign or symptom is present, code to sign or symptom. Interpretation of the Excludes 1 rule further explained by the CDC.
Sherry Wright-Fontenot, CPC CPMA CEDC St Luke's Health System AAPC of KC Education Officer You have a DX of KERNICTEROUS P57.9, which is a newborn code, but patient is an adult insurance denies dx for age. Signs and symptom are Jaundice, N/V, abd pain, malaise, and chest pain. Doctor is queried and says that is what is wrong that is why they put it as dx. What do you do since it is rare but can happen in adults not just newborns?- Shannon Barker
ICD-10 Guidelines
Pulling the Diagnosis Can a radiology coder (physician billing) and hospital employee, use the medical record for that date of service and information from the attending physician. Example: Our patient has a CT Head in the ER and clinical indication is stroke activation. We find in the medical record (encounter) for that date of service the patient experienced slurred speech, abnormal gait. We are unsure of using that information because our dictated report did not give us this information. I have felt digging for a diagnosis was not the proper thing to do.
Tiffany Johr, CPC Meritas Health AAPC of KC Vice President My questions are regarding coding for abdominal wall reconstruction. The surgeon performed an open repair of an incarcerated incisional ventral hernia with mesh. There was loss of abdominal domain. He performed bilateral component separation (lateral myfascial rectus release). Skin flaps were created with debridement of the abdominal wall. An adjacent tissue transfer was performed to close the wound. The bed of the wound measured 25 X 35cm (875 sq cm). Derma Close tissue expander applied. The CPT codes used were 49561, 49568, 15734, 15734-59, 14301, 14302 x 27 and 11960. ICD 10 codes incarcerated incisional hernia K43.0, laceration of abdominal wall, periumbilic region with penetration into peritoneal cavity S31.615A. Claim denials include MUE for 14302 x27 units, missing external cause codes for the laceration, and experimental procedure for the external tissue expander. I have run across the denial for units of 14302 previously. Most insurance carriers have a maximum of 8 units payable, I believe. Is anyone getting this covered for more units? What external cause codes do you use when the surgeon creates the laceration by opening the abdomen to complete the procedure? It's not an accident or mishap. Are the external tissue expanders not covered by most commercial plans?- Janelle Adams
MUE: MUE for a 14302 is 8 units. Anything over that will be denied every time no matter how it is originally billed. However, this particular MUE is a date of service edit. Those can be appealed with documentation to support the medical necessity of the increased units. Resources: CMS MUE tables: https://www.cms.gov/medicare/coding/nationalcorrectcodinited/mue.html CMS MUE excess instruction: https://questions.cms.gov/faq.php?id=5005&faqid=2277 Laceration: I wouldn t use a laceration diagnosis code in this scenario. The reason for all of this work is for the hernia repair so I would use the hernia diagnosis. The laceration is incidental to the repair of the abdominal wall and not necessary to code. Disclaimer: This is my personal opinion based on my experience and I don t have anything in black and white. External tissue expanders: While I don t personally have experience with this, it would be something I would address in the precertification process with the payer prior to the surgery. You would then know in advance if it is a covered service for the patient and then your clinic can make an informed decision on how to proceed.
Cathy Jennings, CPC, CEDC, CHONC AHIMA Approved ICD-10-CM/PCS Trainer Medical Revenue Solutions, LLC As a Radiology coder, I am having an issue rapping my head around the V89.2xxa code. We have multiple xrays taken on a patient involved in an automobile accident. The report indication is Trauma, MVA. In the past we used V71.89, E819.9 to show that this was auto and we were observing the patient. Now in I-10 we use Z04.3 observation but when we want to find a simple MVA code the code in I-10 V89. states person injured. We do not know by the negative report if there were other injuries. Is the V89 code accurate to use?
ICD-10-CM Coding Rules: External Cause codes are intended to provide data for injury research and evaluation of injury prevention strategies. These codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person s status (e.g., civilian, military). V89.2XXA describes the circumstance causing an injury, not the nature of the injury.
Angela Jordan, CPC Medical Revenue Solutions, LLC AAPC National Advisory Board WPS Critical Care when time split between a physician and nonphysician practitioner. Q. Both providers are in the same group, same specialty. 8:00 am to 9:00 am Dr. Jordan see s the patient that is critical, and generates a service for 99291. 4:00 pm to 5:00 pm Dr. Jordan s Nurse Practitioner, Nancy see the patient that is still critical, can she bill 99291 as well? A. The Nurse practitioner could bill the 99291 as long as all the requirements for critical care services are met.
Admission & Discharge Same Date 99234-99236 WPS GHA would expect the documentation to show two services, both the initial and the discharge. There may be some isolated cases where two visits would not be required. The documentation would show why the patient did not require two separate services. But again, this would be very rare.
Use of copy forward in an EMR/EHR Q. Can the physical exam be documented by stating, Her physical exam is unchanged from the exam dates 3/24/15. A. WPS GHA Policy staff reply: It is always important for providers to remember that a note needs to stand on its own. Using a statement indicating the exam is unchanged from the last/prior is a great summary, they must document EXACTLY what they did on that specific visit and bringing forward the previous exam does not do that. So therefore, we would not consider any portion of an exam statement that simply referred back to previous exam.
Sarah Reed, BSE, CPC Medical Revenue Solutions, LLC Flu and Pneumonia code updates CODING THE ZIKA VIRUS Per the Centers for Disease Control and Prevention (CDC), the correct code for confirmed Zika virus infection is A92.8, Other specified mosquito-borne viral fevers. Further guidance on correct coding in various clinical scenarios will be forthcoming from the CDC and posted on the CDC website. The information and the link to the CDC website will be disseminated by AHIMA as soon as it is available.
Birthday Rule The Employee Retirement Income Security Act of 1974 (ERISA), designates that the birthday rule can be applied to determine which plan is the primary health plan for the children of working parents, according to the child support guidelines from the Center for Policy Research. While the parent whose birthday comes first is still the primary insurance plan, the birthday rule does not apply to children whose parents have divorced, or are members of a blended family. A court order about children's health coverage after a divorce supersedes the birthday rule. If children live with a custodial parent and step parent, the custodial parent provides the primary insurance plan, regardless of whether the step parent's birthday comes first. http://www.insure.com/health-insurance/birthday-rule.html
Tracy Bird, FACMPE, CPC, CPMA, CEMC KaMMCO CERT In response to increased CERT and other audit error rates, CMS recently issued Change Request 9112 with a provision that allows CMS to revoke a provider s enrollment for at least one year if a provider fails to provide all records requested. http://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/Downloads/R587PI.pdf http://www.wpsmedicare.com/j5macpartb/training/on_demand/_files/em-handout-3
CERT (Comprehensive Error Rate Testing) Recent claim reviews performed by the Comprehensive Error Rate Testing (CERT) contractor have noted significant error findings for missing or illegible physician and non-physician signature on medical record documentation. In these cases, the performing physician did not sign their medical record documentation in accordance with Medicare regulations. Signature reminders: The medical record documentation should not be resubmitted to CERT with a signature added. If the signature is missing, a signature attestation statement will be accepted. If the signature is illegible, a signature attestation statement or a signature log can be submitted. An attestation cannot be used for unsigned physician orders and unsigned laboratory requisition form. Each specific laboratory or diagnostic test should be listed in the progress note and signed. For more information, refer to the CMS Internet-Only Manual, Publication 100-08, Chapter 3, Section 3.3.2.4 - Signature Requirements.
WPS Learning Center Coming soon Will be the go to location on the website for on demand sessions, enrolling in live programs. Will require one time registration Create a username and password to be used when entering the site CEU s will be available for some sessions Requires an on-line pre-test Requires on-line post-test Watch for notice of tutorial webinar March 31, 2016.
60-Day Overpayment Rule The provision comes from Affordable Care Act from March 23, 2010 Final Rule was published February 12, 2016 The clarification says: An overpayment must be reported and returned by the later of: The date which is 60 days after the date the overpayment was identified OR the date any corresponding cost report is due if applicable.
60- Day Overpayment Rule Six month investigation benchmark- This allows time to investigate and quantify the overpayment through reasonable diligent investigation. (Proactive compliance and good faith investigation) The rule allows for a total of 8 months ( 6 months for timely investigation and 2 months for reporting and returning) Allows for Extraordinary circumstances Six year look back period Originally was to be 10 years
60-Day Overpayment Rule Reporting and returning overpayments must be done according to MAC guidelines If using a statistically valid sampling and extrapolation methodology, that must be described in the reporting. Providers may request an extended re-payment schedule that can be accepted or rejected by CMS or the MAC Self-disclosure protocols under OIG Self-disclosure Protocol or Voluntary Self-Disclosure Protocol for overpayments that implicate Fraud and Abuse enforced by the OIG Implementation March 14, 2016
60-Day Overpayment Rule Steps for compliance: 1. Implement a review process in your practice watching for potential overpayments 2. Recognize that CMS allows for identification and quantification of potential overpayments under a 6 month reasonable diligent investigation period 3. Maintain records that document compliance with the rule 4. Be prepared to do a look back of the last 6 years to identify potential overpayments
Incident To Med-Learn Matters Article SE0441 Published April 9, 2013 Clarifies the rules of incident to
Incident To Rules A service furnished incident to physician professional service in the physician s office ( whether located in an office suite, or within an institution, or in a patient s home. Part of a patient s normal course of treatment during which a physician personally performed an initial service and remains actively involved in the course of treatment. Services require direct supervision
Incident To Rules The patient record should document the essential requirements for an incident to service which include: An integral part of the patient s treatment course Commonly rendered without charge ( included in the physicians bill) Type of service commonly furnished in a physician s office or clinic ( not an institutional setting An expense to you
Test Your Knowledge of Incident to EKG s, lab tests, x-rays Anti-coagulation monitoring clinic Allergy shots Other injectibles- Testosterone, B-12 )
Kansas Physician Assistants Updated language to the regulations that govern PA s in Kansas was an effort between Academy of Physician Assistants, KMS, KAOM Though the regulations have not completed the review process, there are several changes that will likely be included in the final version. The new regulations: Reflect statutory change in title from responsible to supervising physician Clarify content of written agreements between PA and physicians, delineating scope of practice ( Called an Active Practice Request Form) Add more information regarding practice location, supervising physician-pa relationship, levels of supervision and substitute supervision Add dispensing authority Remove limitation on specific number of physician assistants supervised
New HIPAA Guidance- March 1, 2016 New guidance is a result of the President s Precision Medicine Initiative OCR believes patient s should be able to easily exercise their right to their health information ( Part of the original HIPAA legislation) HIPAA s right of access critical to enabling individuals to take ownership of their health and well-being OCR has provided a fact sheet to further explain how patients can access their records
New HIPAA Guidance - Access Allows patients to see and receive copies upon request of the information in their medical record maintained by their healthcare provider or health plan. Excluded is access to PHI that is NOT part of a designated record set because it is not used to make decisions about individuals. For example peer review or provider performance evaluations. Also psychotherapy notes or information compiled for an administrative action. Providers may charge a reasonable cost based fee Patients need to know in advance what the cost will be Patient s may direct their records to a third party whom they designate
New HIPAA Guidance - Access Have 30 days to provide requested copies Must provide records in a format requested by the patient as long as the provider has the capability to transmit the information in that format http://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html Above link is a list of FAQ s that go into great detail about what you can and cannot do when providing a patients medical records at their request
Linda Duckworth, CPC, CHC Medical Revenue Solutions, LLC Stamped Signatures The method used shall be a hand written or electronic signature. Stamped signatures will be permitted in the case of an author with a physical disability who can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document. Legal signature Personally signed Electronically signed (must be secure) Controls of signature Sharing user name and password compromises/invalidates the security
Palmetto
Sharing User Name/Password HIPAA ramifications for sharing user name/pw Minimum necessary Privacy; rights are protected under OCR Risk Management When things go wrong, fingers start to point Unable to confirm what the physician did/did not do Did the physician see the test results?
WPS Dictated Notes & Use of Initials The physician must review the transcribed note to correct any errors and affirm the note's contents for it to be considered the final documentation of the service It is not sufficient that the provider is designated as dictating the note or his/her name is present in the record If an illegible handwritten signature is present and the record contains no other identification of the author (i.e., printed name below, or letterhead with name) a signature log or attestation statement must be included with your response to the documentation request If the record is missing a signature, an attestation statement must be included in your response to the documentation request A legible signature that includes the provider's full name and credentials is always the best practice Initials are acceptable if signed over a typed or printed name Without a typed name to identify the author, a signature log or attestation statement must be submitted or services may be denied
WPS Late Signatures As a reminder, providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead may make use of a signature attestation statement confirming they performed the service.
WPS Disclaimers WPS GHA has recently been informed of a new trend in medical record documentation - that of using some type of disclaimer. Examples include the following: "Due to possible errors in transcription, there may be errors in documentation"; "Due to voice recognition software, sound alike and misspelled words may be contained in the documentation"; and "I am not responsible for errors due to transcription." Providers are responsible for the medical record documentation. Disclaimers such as those above do not remove that responsibility. The provider should verify the information is complete and accurate prior to attaching his/her signature.
WPS EMR Signatures For providers using EMR systems, it is crucial that the electronic signature is affixed to the records when responding to all Medicare requests for documentation. Although CMS has not published formal regulations regarding electronic signatures, we recommend that an electronic signature be accompanied by a statement indicating that the signature was applied electronically. We also recommend including the date and time the record was authenticated. Electronic signature notations can include the following (not all-inclusive):
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