February Jean C. Russell, MS, RHIT Richard Cooley, BA, CCS

February 2013 Jean C. Russell, MS, RHIT jrussell@epochhealth.com Richard Cooley, BA, CCS rcooley@epochhealth.com 518-430-1144

2 2013 E/M Codes Deleted Codes New Codes Changed Codes Agenda Documentation Requirements Clinic Reporting New versus Established Guidelines Development of E/M Technical Guidelines Modifiers

3 Deleted Codes None

4 New E/M Codes

5 Transitional Care Codes Encourage the provision of primary care and care coordination to Medicare beneficiaries 99495 - Transitional Care Management Services - required: Communication (direct contact, telephone, electronic) with patient and/or caregiver within 2 business days of discharge, Medical decision making of at least moderate complexity, Face-to-face visit within 14 calendar days of discharge 99496 - required: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge, Medical decision making of high complexity, Face-to-face visit within 7 calendar days of discharge

6 Transitional Care Codes 99495 APC 605 Status V APC Rate 73.68 99496 APC 606 Status V APC Rate 96.96 Both also paid on the MPFS with a Place of Service Differential Designed for use during transition from inpatient hospital (including rehab, LTC and acute), observation, SNF or nursing facility to a patient s community setting (home, assisted living) Starts on date of discharge through next 29 days

7 Transitional Care Codes Must have at least one face-to-face meeting w/in the specified timeframe Plus other non-face-to-face services by physician or qualified staff under his/her direction Billed technically and professionally when faceto-face is provided in a hospital-based clinic Reimbursed technically like a 99213 (level III clinic visit) or 99214 (level IV clinic visit)

8 Transitional Care Codes Paid like a clinic visit Includes much more in the services provided Care should be taken when charging for this service, especially if you use a mark-up of APC or MPFS rates to set charges Charge should reflect all the non-face-to-face work provided in addition to the clinic visit Should be higher than the clinic visit alone This is the only way rates will eventually reflect the services provided

9 Complex Chronic Care Codes 99487 - Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no faceto-face visit, per calendar month 99488 - ; first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month 99489 - ; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

10 Complex Chronic Care Codes Designed to be used for care coordination for patients with complicated, ongoing health issues Care is received within a patient-centered medical home, accountable care organization or other relatively new medical service delivery model

11 Complex Chronic Care Codes Allows billing for time that is not necessarily face-toface Includes time spent connecting patients to community services and Transitioning them from inpatient care and preventing readmissions Reported only once per month Include all the non-face-to-face complex care coordination services Time is billed based on CPT Time Definition (i.e., 60 minutes starts with at least 31 minutes)

12 Complex Chronic Care Codes Packaged (APC status N) under OPPS Do not have an associated MPFS rate for professional billing Medicare does not currently reimburse on these codes The MPFS has an RVU status indicator of B Bundled Code - No RVU or professional payment amount for B codes

13 Transport Care Codes 99485 - Supervision by a control physician of interfacility transport care of the critically ill or critically injured pediatric patient, 24 months of age or younger, includes two-way communication with transport team before transport, at the referring facility and during the transport, including data interpretation and report; first 30 minutes 99486 - ; each additional 30 minutes (List separately in addition to code for primary procedure) Status B under APCs/OPPS Reported professionally only

14 G0379 Direct Referal G0379 Direct referral to observation, moved to APC 608, payment increased from $53.84 to $175.79 2012 - reimbursed as a 99211 (APC 604) 2013 - reimbursed as a 99205 new patient clinic level V Better reflection of the cost associated with direct referrals to observation

15 Observation Billing and Payment 15

16 Observation Observation is a Service not a status Outpatient is the Status Short term treatment and/or assessment to determine if admission is needed Not expected to require more than 24 to 48 hours except in unusual cases

17 Observation is a Timed Service Reported by the hour Starts: physician order time and date Clear order to admit as inpatient vs admit as observation Nursing documentation clearly indicating observation care has started Ends: physician order time and date to discharge from observation or hospital Note that discharge after consult or other critical medical test should be clearly documented However, waiting for a ride is not considered part of observation time

18 Observation is a Timed Service Medicare reporting Units reflects the number of hours Must be calculated Documentation review required to ensure accurate orders and reporting of units Other payers may not recognize observation or may have different requirements such as a single unit regardless of the length of time

19 Observation is a Timed Service Time Away Medicare requires that time observation spend receiving certain diagnostic and therapeutic services must be deducted from the total observation time [Medicare Transmittal 1445, CR 5946] Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure (e.g., colonoscopy, chemotherapy). How to do this is a challange

20 Observation Coverage Ordered by a clinician authorized by the State and hospital regulations to admit to the hospital or to order outpatient tests Medically reasonable and necessary

21 Observation Coverage Should not be billed for monitoring and care during standard postoperative recovery period (e.g., 4-6 hrs) Can be billed for unusual circumstances requiring extended postsurgical recovery care But will not be reimbursed for the composite rate when there is a surgery prior to the observation

22 Observation Payment (Medicare) Single Extended Assessment and Management composite payment that covers an episode of care involving more intense assessment and management, includes: A high-level clinic or ED visit, direct admission to observation, or critical care service 8 hours or more of observation services Other associated services (packaged)

23 APC 8002 - Level I Extended Assessment and Management G0378-8 or more units Revenue code 762 - observation Reported with: G0379 - direct referral, on the same date of service, or 99205 / 99215 - level V clinic visit, on the same date or day before Reported without: Surgical (Status T) procedure on the same day or day before No diagnosis requirement

24 APC 8003 - Level II Extended Assessment and Management G0378-8 or more units Revenue code 762 - observation Reported with: 99284 / 99285, high-level ED visit, or 99291, critical care, or G0384, high level Type B ED visit On the same day or day before the observation Reported without: Surgical (Status T) procedure on the same day or day before No diagnosis requirement High Level E/M

25 Medicaid Observation Observation Waiver Required APG 450 Must be referred through ED no direct admits Must have minimum of 8 hours, maximum of 24 hours Must have distinct Observation space (swing beds not authorized) (exclusions for CAHs) Under the Direction of the ED and located near the ED Inpatients are placed in a different area 25 25

26 Medicaid Observation Governor Cuomo signed an Observation Service Bill in October 2012 New law makes important improvements, and leaves unfinished business Can now be a scatter bed rather than designated unit Does not need to have ER oversight DOH has to develop payment methodology for observation Working on the timing Source: http://www.hanys.org/communications/elerts/?elertid=4624

27 NY Medicaid or Medicare Clinic Billing Unique Considerations

28 Language Interpreter Services October 1, 2012 - Medicaid Fee-for-Service coverage of medical language interpreter services for Medicaid recipients with limited English proficiency (LEP) and communication services for recipients who are deaf and hard of hearing started December 1, 2012 - Medicaid Managed Care and Family Health Plus plans also covers these services in accordance with rates established in provider agreements or, for out-of-state network providers, at negotiated rates Source: http://www.imiaweb.org/uploads/docs/ron_bass_nysdoh_medicaid_coverage_presentation_12_14_2012.pdf

29 Language Interpreter Services Provided in these locations: Article 28, 31, 32 and 16 Outpatient Departments that bill with APGs Hospital Emergency Rooms Diagnostic & Treatment Centers (D&TCs) Federally Qualified Health Centers (FQHCs) Office-based Practitioners Source: http://www.imiaweb.org/uploads/docs/ron_bass_nysdoh_medicaid_coverage_presentation_12_14_2012.pdf

30 Language Interpreter Services Provided by a third party interpreter who is employed by or contracts with the Medicaid provider Provided either face-to-face or by telephone Interpreter must demonstrate competency and skills in medical interpretation techniques, ethics and terminology Recommended, but not required, that they be recognized by the National Board of Certification for Medical Interpreters (NBCMI) Source: http://www.imiaweb.org/uploads/docs/ron_bass_nysdoh_medicaid_coverage_presentation_12_14_2012.pdf

31 Language Interpreter Services Provided for: Medicaid recipients with limited English proficiency Patients whose primary language is not English and who cannot speak, read, write or understand the English language at a level sufficient to permit such patients to interact effectively with health care providers and their staff, or Medicaid recipients who are deaf and hard of hearing Source: http://www.imiaweb.org/uploads/docs/ron_bass_nysdoh_medicaid_coverage_presentation_12_14_2012.pdf

32 Language Interpreter Services HCPCS code T1013, sign language and oral interpretation services Billable when provided by a third party interpreter during a medical visit One unit - minimum of 8 and up to 22 minutes, $11.00 Two units - 23 or more minutes, $22.00 Need for services must be documented in the medical record. Source: http://www.imiaweb.org/uploads/docs/ron_bass_nysdoh_medicaid_coverage_presentation_12_14_2012.pdf

33 Medicaid: After Hours Add-on payment effective 1/1/2009 Evenings, weekend and holiday visits Evening is one that occurs (starts) after 6:00 pm Weekend is one that occurs Saturday/Sunday Holidays must be designated national holiday

34 After Hours CPT 99050, Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service CPT 99051, Services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service Both add-on codes, must report primary service as well

35 Medicaid: Vaccines Vaccines Flu and pneumococcal vaccines provided in an Article 28 clinic or hospital outpatient department must be billed as ordered ambulatory service All other vaccines (except VFC) are reimbursed under APGs Under APGs the vaccine administration codes will not pay separately at the line level

36 Medicaid: Vaccines VFC Vaccines for Children are state-supplied vaccines for Medicaid enrollees under age 19 Bill for the vaccine administration as ordered ambulatory Reported using the vaccine code appended with modifier SL (state supplied) Reimbursed at $17.85 for the administration

37 VFC Recent Changes Medicaid VFC: Effective 1/1/2013 Bill vaccination administration with 90460 Continue to bill the vaccine code with the SL modifier Administration w/o the vaccine will not be paid More than one vaccination is reimbursable under 90460 on a single date of service Source: https://www.emedny.org/providermanuals/communications/h-052-10881_att1_change_in_billing_for_vaccine_administration_12-20.pdf

38 Vaccines for Adults Recent Medicaid: Effective 1/1/2013 Changes Bill vaccination administration with 90471/90472/90473/90474 G0008/G0009 will no longer be reimbursed Bill the vaccine code at acquisition cost No longer should add $2.00 to the charge for the vaccine as previously instructed Source: https://www.emedny.org/providermanuals/communications/h-052-10881_att1_change_in_billing_for_vaccine_administration_12-20.pdf

39 Vaccines with E/M Visit Medicaid: When appropriate, may modify the E/M visit code with a modifier 25, significant, separately identifiable E/M service on the same day of the procedure or other service Vaccinations cannot be reported with a 99211, E/M established patient, level 1 Source: https://www.emedny.org/providermanuals/communications/attn Pract_Prov_Add_Vaccine_Info_1-15-13.pdf

40 Smoking Cessation Medicare covers for patients that: Use tobacco, regardless of whether they have symptoms of tobacco-related disease Are competent at the time of counseling Whose counseling is provided by a qualified physician or other Medicarerecognized practitioner Source: https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads//r2058cp.pdf

41 Smoking Cessation CMS allows two individual tobacco cessation counseling attempts per year Each attempt may include a maximum of four intermediate OR intensive sessions Total benefit covering up to 8 sessions per year Can choose between intermediate (more than 3 minutes but less than 10 minutes), or intensive (more than 10 minutes) for each attempt Source: https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads//r2058cp.pdf

42 Smoking Cessation 99406 - Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407 - greater than 10 minutes Report for the symptomatic patient 42

43 Smoking Cessation G0436 - Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes G0437 - greater than 10 minutes For the asymptomatic patient 43

44 Smoking Cessation Charting Requirements Time spent on the counseling Symptomatic codes need diagnosis for why the patient needed the counseling Condition that is adversely affected by tobacco use, or Condition being treated with a therapeutic agent whose metabolism or dosing is affected by tobacco use Asymptomatic codes need diagnosis V15.82, history of tobacco use, or 305.1, non-dependent tobacco use disorder Source: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads//clm104c32.pdf

45 Smoking Cessation Charting Requirements Do not report when counseling for smoking cessation is less than 3 minutes in duration Must document counseling in the medical record (including time spent on it) Patient medical history must support the counseling

46 Medicaid: Smoking Cessation Effective January 1, 2010, Medicaid will cover smoking cessation counseling during a medical visit to pregnant and postpartum women and children and adolescents ages 10 to 21. Services must be provided face to face. ONLY for pregnant females, women up to 6 months postpartum, and children and adolescents ages 10 21 who smoke.

47 Medicaid: Smoking Cessation Diagnosis of pregnancy 630 677, V22, V23, V28 Must also report one of these ICD 9 dx codes: 305.1 Tobacco use disorder (children and adolescents ages 10-21) 649.03 Tobacco use disorder complicating pregnancy, childbirth or the puerperium antepartum. (Pregnant women who smoke) 649.04 Tobacco use disorder complicating regnancy childbirth or the puerperium postpartum. (Post partum women who smoke).

48 Medicaid: Smoking Cessation Pregnant women allowed up to 6 within a continuous 12 month period (pregnancy) Postpartum women allowed 6 during the 6 month postpartum period Children and adolescents allowed 6 in a continuous 12 month period. 99406 and 99407 Only one procedure code per day may be billed

49 New Versus Established Clinic E/M Levels

50 50

51 Split Billing Professional Bill Technical Bill

52 Medicare Regulations Medicare expects hospitals to Bill professional charges on a CMS-1500 and Technical charges on a CMS-1450 (UB-04) When the services are performed as an outpatient in a provider-based clinic by a clinician (physician, NP or PA) that is employed by the hospital Source: Medicare Claims Processing Manual, Chapter 3, Section 10, Chapter 25 and Chapter 26 52

53 Medicaid regulations For NY Medicaid, physician services are carved out of the APG payment for all services provided in hospital outpatient settings Billed separately using the Medicaid Physician Fee Schedule Billed on the HIPAA 837P or 1500 Note Exception for OMH 53 Source: NY Medicaid APG Provider Manual, http://www.health.state.ny.us/health_care/medicaid/rates/apg/docs/apg_provider_manual.pdf

54 New Vs. Established New Clinic E/M 99201 New Pt Lvl 1 99202 New Pt Lvl 2 99203 New Pt Lvl 3 99204 New Pt Lvl 4 99205 New Pt Lvl 5 Est Clinic E/M 99211 Est Pt Lvl 1 99212 Est Pt Lvl 2 99213 Est Pt Lvl 3 99214 Est Pt Lvl 4 99215 Est Pt Lvl 5 Primary service performed/reported in a hospitalbased clinic is a medical visit Reported as a clinic E/M and split billed professionally and technically.

55 New Vs. Established CMS Technical guidelines Established patient registered patient at the hospital w/in the past three years, that is, the patient has a medical record number that has been used within three years Specifically, beginning in CY 2009, the meanings of new and established patients pertain to whether or not the patient has been registered as an inpatient or outpatient of the hospital within the past 3 years. A patient who has been registered as an inpatient or outpatient of the hospital within the 3 years prior to the visit would be considered to be an established patient for that visit, while a patient who has not been registered as an inpatient or outpatient of the hospital within the 3 years prior to the visit would be considered to be a new patient for that visit. (source: Federal Register /Vol. 73, No. 223 /Tuesday, November 18, 2008 /Rules and Regulations 68677)

56 New Vs. Established NYS DOH Technical guidelines DOH reimburses outpatient hospital services on APG Medical visit reimbursement is based on the primary dx code Therefore the specific E/M level and new versus established does not directly drive reimbursement However, the charges will likely vary so the reported code may impact future reimbursement Reasonable to utilize either (1) a system similar to Medicare for reporting the E/M level or (2) a system similar to the commercials (i.e., professional guidelines)

57 New Vs. Established NYS Medicaid OMH Technical guidelines For OMH clinics, under Medicaid APGs, professional guidelines are used for determining the technical (facility) E/M level. OMH has stated that the E/M codes reported must be based on complexity and not time for both psychotropic medication treatment and psychiatric assessment. The professional E/M guidance that allows time as a factor when more than 50% is spent on counseling and coordination of care cannot be utilized. Source: NEW YORK STATE OFFICE OF MENTAL HEALTH - 14 NYCRR Part 599 - Clinic Treatment Programs - Interpretive/Implementation Guidance 01-04-2012. Website: http://www.omh.ny.gov/omhweb/clinic_restructuring/part599/guidance.pdf

58 New Vs. Established CPT Professional guidelines There is a decision tree in the book (2013 CPT ) A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years (pages 4 and 5, CPT 2013 Professional)

59 New Vs. Established CMS Professional guidelines A Definition of New Patient for Selection of E/M Visit Code - Interpret the phrase new patient to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. Source: Chapter 12, Medicare Claims Processing Manual, Section 30.6.7, http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

60 New Vs. Established NYS Medicaid OMH Professional guidelines No professional bill OMH reimburses for professional services based on modifiers AF, AG or SA reported on a technical bill Source: NEW YORK STATE OFFICE OF MENTAL HEALTH - 14 NYCRR Part 599 - Clinic Treatment Programs - Interpretive/Implementation Guidance 01-04-2012. Website: http://www.omh.ny.gov/omhweb/clinic_restructuring/part599/guidance.pdf

61 New Vs. Established Must keep each of these requirements in mind as you develop your technical (facility) clinic E/M guidelines

62 Development of Technical (Facility) Clinic E/M Guidelines

63 Hospital Technical Guidelines No national visit technical reporting guidelines - Must create and use hospital internal guidelines Critical that hospital develop and follow and audit against their own technical E/M guidelines Develop for Emergency department Type B emergency departments ( fast track ) And hospital based clinics

64 Technical E/M Guidelines 1. Follow the intent of the CPT code descriptor (designed to relate the level to the resource intensity) 2. Based on hospital (not physician) resources 3. Usable for compliance purposes and audits 4. Meet HIPAA requirements 5. Only require documentation that is clinically necessary for patient care 6. Not facilitate gaming or up-coding 64

65 Technical E/M Guidelines 7. Written/recorded, well-documented, and provide the basis for selecting a specific code 8. Applied consistently 9. Not frequently changed 10.Readily available for FI or MAC review 11.Usable to verify coding decisions (either by other staff or outside sources) 65

66 Options to Consider Diagnosis Driven Common in the ER Point System Other - Suggestions Must be based on technical services, must be documented, must be consistent Directly impacts Medicare reimbursement Must appropriately report new versus established E/M

67 Critical Care (99291) Exception Hospital must follow the CPT definition of 99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes Critical care services provided for less than 30 minutes must be reported with an alternative E/M code (e.g., 99285) Time reported as critical care is the time spent by MD and/or hospital staff engaged in face-to-face critical care of a critically ill or injured patient Source: http://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c04.pdf

68 Modifiers

69 69 Modifier - 25 Separately Identifiable Medical Visit Needed when an E/M is reported in conjunction with an APC status S (significant procedure) or T (surgical procedure) Drug injection and vaccination codes are APC status S

70 E/M Medical Visit Clinic or ED E/M (e.g., 99214, 99285) Requires a modifier 25 when reported in addition to infusion services (status S or T) Report an E/M service only if a separately identifiable medical visit has been provided Do not report for standard nursing care provided as part of the infusion services

71 EKGs EKGs are APC status S (93005) If performed with a separately identifiable medical visit, the E/M will require a modifier - 25

72 Modifier - 59 Distinct Procedural Service Indicates a procedure or service was distinct or independent from others performed on the same day Documentation must support: Different session Different procedure/surgery Different site or organ system Separate incision/excision Separate lesion Separate injury [CPT book]

73 Modifier - 59 Required when two procedures that are related are performed separately and distinctly Used when the combination generates a CCI edit or an MUE edit and they warrant a distinct procedure modifier

74 Thanks for Coming!!!

75 Richard Cooley Contact Us Phone: 518-430-1144 Email: RCooley@EpochHealth.Com Jean Russell Phone: 518-369-4986 Email: JRussell@EpochHealth.Com

76 http://www.epochhealth.com/

77 CPT Current Procedural Terminology (CPT ) Copyright 2012 American Medical Association All Rights Reserved Registered trademark of the AMA

78 Disclaimer Information and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary.