As The Code Turns A Day In The Life Of A Code Yvonne Daily, CPC, CPC I Cyndi Stewart, CPC, CPC H, CPMA, CPC I Susan Ward, CPC, CPC H, CPC I, CEMC, CPCD, CPRC Chandra Stephenson, CPC, CPC H, CPMA, CPC I, CANPC, CEMC, CFPC, CGSC, CIMC, COSC Special Appearances By: Rhonda Buckholtz, CPC, CPMA, CPC I, CENTC, CGSC, COBGC, CPEDC Disclaimer The information in this presentation was current at the time the presentation was complied and does not include specific payer policies or contract language. Always consult CPT, CMS, and your payers for specific guidance in reporting services. The views expressed in this presentation are simply my interpretations of information I have read, compiled and studied. Much of the information is directly from the AMA, AAPC, CMS literature and other reputable sources. 2 1
Objectives Communication, Communication, Communication! Players Processes Guidelines Revenue Cycle Implications 3 Scenario 1 In the course of an office visit, Dr. Rhonda orders a flu shot which h is subsequently (during the same visit) administered by MA Stick. Documentation Office visit: 99213 supported in documentation for follow up on benign hypertension (401.1) Injection: Flu shot given 4 2
Coder Scenario 1 (cont.) Why was the flu shot administered? What is the patient s age? Was the patient counseled on the immunization prior to it being administered? Which flu shot (toxoid) was administered? Method of administration (IM, SC, IN, etc) 5 Scenario 1 (cont.) Biller Patient demographics Who is the Referring Provider? CMS 1500, Box 17a/b, may be Ordering Provider Who is the Rendering Provider? What insurance coverage does the patient have? Was the product (toxiod) purchased or provided by a State program? When was the patient s last flu shot? Is the patient considered high risk 6 3
Scenario 1 (cont.) 7 Scenario 1 (cont.) Compliance Auditor / Officer Does the documentation encompass the federal requirements for immunizations? http://www.cdc.gov/vaccines/recs/immunizrecords.htm 8 4
Payer Scenario 1 (cont.) Primary Reasons for Denial Claim submitted to incorrect insurance carrier Medicare primary vs. secondary Commercial vs. Medicare First listed diagnosis Correct code choice (HCPCS vs. CPT) 9 Sample EOB Denial Scenario 1 (cont.) 10 5
Scenario 1 (cont.) Codes to Report Medicare Product: Q2034, Q2035, Q2036, Q2037, Q2038, Q2039 Administration: G0008 Diagnosis: V04.81 Commercial / Other Product: 90658 Administration: 90460 or 90471 Diagnosis: i V04.81 If product provided through State program Administration: 90460 or 90471 Diagnosis: V04.81 11 Scenario 2 Mr. Jones is 92 years old and referred by Dr. Carcinoma with a recurrent lesion of his left lft temporal scalp. This was a squamous cell carcinoma removed by Dr. Lesion within the last year. Documentation PE: 1.5 cm lesion left temple, reddish, scabbed, and mobile. No lymphadenopathy of parotid gland or neck 12 6
Scenario 2 (cont.) MDM: The patient has a recurrent lesion of his scalp that is very suspicious for the recurrence of a squamous cell carcinoma. With his permission, I have drawn how we would ultimately excise this if it is a skin cancer and my best guess at the resultant flap we will use to close it. We are first going to confirm that this is in fact a squamous cell carcinoma. Like with any surgery there is a risk of infection and bleeding. His risk of bleeding is a bit higher because of his Plavix and aspirin, but I want him to stay on it. I would rather take our risk with bleeding than with him clotting his stent and he is agreeable to that. There is a risk of the cancer coming back again, but we are going to make that as low as possible by having a pathologist present to look at the edges thoroughly to make sure we have it all out. Alternatives ti to surgery would be removal by a dermatologist tor radiation therapy. I have talked to Mr. Jones and his daughter about the risk of injuring the frontal branch of his facial nerve. It is nearby and often these recurrent cancers are much more extensive than they appear and require a wider and deeper excision. Potentially, that could injure this nerve which would result in him having a permanent drooping of his eyebrow. The treatment for that typically is surgery to statically elevate, that means to put it in one position that would work. I think the chance of this is fairly low. We are going to do all we can to keep from that, but obviously, we are going to do what we have to do to get the cancer out. 13 Procedure Scenario 2 (cont.) After obtaining consent, we infiltrated the area with 0.5 cc of 1% lidocaine with epinephrine, prepped the area with Betadine and performed a 3 mm punch biopsy which we closed with 6 0 Prolene. Pti Patient tto return in 5 days for suture removal and pathology results 14 7
Coder Scenario 2 (cont.) What services were performed? Was a separate E/M service supported in the documentation? Is a modifier needed? Why was the lesion biopsied? Diagnosis i coding and linkage What was the technique used for the biopsy? Where was the lesion? 15 Biller Scenario 2 (cont.) Pre existing i condition i What insurance coverage does the patient have? Does the policy require authorization for minor procedures? Does the policy allow minor procedure and E/M same day/diagnosis? ABN? Needed? Executed appropriately? Additional modifier needed? 16 8
Scenario 2 (cont.) Compliance Auditor / Officer Does the documentation clearly delineate each service rendered? Regulatory guidelines Risk Fire the doctor or the coder? 17 Payer Scenario 2 (cont.) What s the policy regarding E/M and minor procedure? Policy edits Appeals process Re filing vs. Appealing Requests for additional information (records) Write offs / Contractual adjustments 18 9
Codes to Report Scenario 2 (cont.) Office Visit: 99202 25 Biopsy: 11100 Diagnosis: 239.2, V10.83 19 Scenario 3 Dr. Rhonda comes to office and explains to her coder that based upon a conversation she had with another physician at a recent conference that she could double her office revenue stream by hiring a physician extender to see half of her patients. The extender would be able to see patients in the office and in the hospital as well as provide minor procedures. Dr. Rhonda goes on to state that this would allow her to take a day off and give her more time to go shoe shopping while the extender takes care of patients. She explains that this is working out great for other physician is doing this, the extender sees the patient and bills for services under the physicians number. 20 10
Scenario 3 (cont.) Documentation: NPP renders and documents service provided to a new patient NPP renders and documents service provided to an established patient for a new problem (alone) NPP renders and documents service provided to an established patient for a new problem in which the MD is called in after the history is obtained NPP renders and documents service provided to an established patient for an established problem NPP renders and documents service provided to an established patient for an established problem with a change in plan of care 21 Coder Scenario 3 (cont.) Where was the service rendered? d? Where in the world was Dr. Rhonda when the service was performed?...dsw Shoe Warehouse? Incident to vs. Split/Share Office Is the patient a new patient? Is the problem a new problem? Was the plan of care followed or changed during the visit? 22 11
Coder (cont.) Hospital Scenario 3 (cont.) Did Dr. Rhonda see the patient? Did Dr. Rhonda perform and document a substantive portion of the service performed? Not just pop in to see if the patient likes her new shoes 23 Biller Scenario 3 (cont.) What insurance coverage does the patient have? Is there a payment difference for NPP provided services vs. MD services? Does the policy allow for incident to services? Does the policy allow for split/share services? Modifier? How is the performing provider identified on the claim? 24 12
Scenario 3 (cont.) Compliance Auditor / Officer What are the supervision requirements based on the prescriptive authority / state scope of practice requirements for the NPP? Are the supervision and documentation requirements being met by Dr. Rhonda? 25 Payer Policy Scenario 3 (cont.) NPP s allowed in the plan? NPP enrolled in the plan? Physician assistant Nurse practitioner Alphabet soup Will Dr. Rhonda buy me shoes to pay the claim? 26 13
Scenario Summary Scenario 3 (cont.) Who is performing the service? What can the performing provider report? Scope of practice and payer limitations What service is being performed? Where is the service being performed? What are the documentation requirements in relation to the service reported? Were all supervision requirements met? 27 Cast Doctor Coder Biller Compliance Payer Rhonda Buckholtz Cyndi Stewart Yvonne Daily Chandra Stephenson Susan Ward 28 14
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