coding and billing update ioa 117 th annual convention may 3, 2014

Coding and Billing Update

IOA 117th Annual Convention

May 3, 2014

Presented by

Joy Newby, LPN, CPC, PCSNewby Consulting, Inc.

5725 Park Plaza Court

Indianapolis, IN 46220

Voice: 317.573.3960

Fax: 866-631-9310

E-mail: [email protected]

This presentation was current at the time it was published and is intended to provide useful information in regard to the subject matter covered.

Newby Consulting, Inc. believes the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the manual are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed.

The information contained in this presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

Any five-digit numeric Physician's Current Procedural Terminology, Fourth Edition (CPT) codes service descriptions, instructions, and/or guidelines are copyright 2013 (or such other date of publication of CPT as defined in the federal copyright laws) American Medical Association.

For illustrative purposes, Newby Consulting, Inc. has selected certain CPT codes and service/procedure descriptions to be used in this presentation.

The American Medical Association assumes no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this publication.

CPT Copyright 2013 American Medical Association

4

Update 2014 Medicare Fee Schedule

Pathway for SGR Reform Act of 2013 §1101 – Medicare Physician Payment Update – Replaced the 20.1% with a 0.5% update

• Only for dates service 1/1/2014 – 3/31/2014• Original update kicks in 4/1/2014

Protecting Access to Medicare Act of 2014– Continues 1st quarter fee schedule through

3/31/2015


5

Sequestration

Budget Control Act of 2011– Requires 2% payment cut for all Medicare

physician claims– Dates of service on or after April 1, 2013

Pathway for SGR Reform Act of 2013 extended the 2% cut in Medicare payments from sequestration until 2023


6

Place of Service CodesLocation where the service is rendered– Exception - for a service rendered to a patient who

is a registered inpatient or an outpatient of a hospital:• In these cases, the correct POS code - regardless of

where the face-to-face service occurs - is the appropriate inpatient POS code (at a minimum POS code 21) or the appropriate outpatient hospital POS code (at a minimum POS code 22)

• E/M services must be reported using hospital inpatient, hospital observation, or office/other outpatient CPT codes


7

POS – Cont’d

Example, when a hospital inpatient is seen in the physician’s office the POS code must be “21” inpatient hospital– Use Inpatient E/M codes– Item 32 of the claim must reflect the address and ZIP

code where the patient was seen for the face-to-face service ( in this example, the physician’s office)

– Remember, when billing POS 21, Medicare only pays for professional services

– Charges for nonprofessional services are included in the hospital’s DRG payment


8

POS – Cont’d

This rule is also applicable when a patient seen in the office setting is an inpatient in a skilled nursing facility (SNF) and is in a Part A covered stay– Report POS 31 skilled nursing facility– Use nursing facility E/M codes to report visits– Follow all other SNF Consolidated Billing instructions

• Bill all professional services to the MAC• Bill all Medicare-covered non-professional services

to the SNF


9

Date of Service

Many diagnostic services have two components; a technical and professional component – The date of service submitted to Medicare for the

technical component is the date the technical component is performed

– The date of service submitted to Medicare for the professional component is the date the professional component is performed


10

Date of Service Cont’d

When the technical and professional components of a radiology service are performed on different days, the services are not global and should be separated into their separate parts and each component should reflect the actual date performed – For example, the test should be split into two line items

when the technical component is performed on Tuesday, January 8, 2014 and the professional is performed on Wednesday, January 9, 2014


11

Skilled Nursing Facility – Part A Covered Stay – Original Medicare

Consolidated billing applies– Bill Medicare for all professional services– Bill SNF for nonprofessional services, e.g., technical

component of tests, “J” codes for injectable drugs, covered DME, etc.

This rule is also applicable when a patient seen in the office setting is an inpatient in a skilled nursing facility and is in a Part A covered stay.– Report POS 31 skilled nursing facility– Use nursing facility E/M codes to report visits


12

Complying with Coding and Billing Procedures and Documentation Guidelines

Medicare contractors are required to implement aggressive efforts to lower claims error rates by developing plans that address the cause of the errors and outline efforts for correction of these issues

The Comprehensive Error Rate Testing Contractor identified the top 20 service types with highest improper payment rates in Appendix B of the Medicare Fee-for-Service 2013 Improper Payment Rate Report


13

Definitions Used in the Report

No Documentation – Claims are placed into this category when either

the provider or supplier fails to respond to repeated requests for the medical records or the provider or supplier responds that they do not have the requested documentation


14

Definitions Used in the Report Cont’d

Insufficient Documentation Errors– Claims are placed into this category when the medical

documentation submitted is inadequate to support payment for the services billed• In other words, the reviewers at the CERT contractor could not

conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary

– Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety


15


Medical Necessity Errors– Claims are placed into this category when the

reviewers at the CERT contractor receive adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage policies


16


Incorrect Coding Errors– Claims are placed into this category when the

provider or supplier submits medical documentation supporting • a different code than that billed• that the service was performed by someone other

than the billing provider or supplier• that the billed service was unbundled• that a beneficiary was discharged to a site other than

the one coded on a claim


17

CERT Report

Office Visit New Patient– Improper payment – 18.9%

• No documentation – 0.0%• Insufficient documentation – 15.1%• Medical Necessity – 0.6%• Incorrect Coding – 84.3%


18

CERT Report

Office Visit Established Patient– Improper payment – 7.1%



19

CERT Report

Initial Hospital Visit– Improper payment – 28.3%



20

CERT Report

Hospital Visit - Subsequent – Improper payment - 18.2%

• No documentation – 4.6%• Insufficient documentation – 57.6% • Medical Necessity – 0.0%• Incorrect Coding – 37.2%


21

CERT Report

Critical Care– Improper payment – 22.9%



22

CERT Report

Nursing Home Visit– Improper payment – 13.9%



23

CERT Report

Emergency Department Visit– Improper payment – 11.6%



24

CERT Report

Musculoskeletal X-rays– Improper payment – 15.0%



25

CERT Report

Improper payment By Specialty (Not All Inclusive)– Internal Medicine – 15.3%– Family Practice – 13.7%– Nurse Practitioner – 7.7%– Physician Assistant – 12.1%– Cardiology – 11.8%– Pulmonary – 18.1%– Emergency Medicine – 10.9%– Orthopaedic Surgery – 10.0%– Psychiatry – 22.1%


26

Documentation Timeliness

Physicians/practitioners may not submit a claim to Medicare until the documentation is completed – This means the claim should not be submitted until

the physician/practitioner completes the documentation for a service, including signature


27

Documentation Timeliness Cont’d

Physician/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”– WPS interpretation “no more than a couple of days

away from the service itself”


28

Documentation Policies and Procedures

American Health Information Management Association (AHIMA)– Once the signature is applied the entry is

considered complete and the record should be locked to prevent editing including deleting and/or making changes including additions to the medical record (e.g., progress note, operative report, test interpretation)

– The only opportunity to make changes should be through an amendment or addendum to that entry


29

Addendums

Ensure the addendum is appended to each report in the same manner (e.g., at the top of the related document)

– The addendum should be clearly labeled

– The addendum should include a new signature line that the provider must sign in addition to the signature on the original document


30

Addendums Cont’d

Organizations should have clearly defined policies, procedures, and practices to ensure that the integrity of the health information remains intact, regardless of how and when information is clarified


31

CMS Documentation Warning!

There are those that believe the more you document, the higher the level of care that can be chosen to describe the service rendered to the patient

Medicare Claims Processing Manual Chapter 12 §30.6.1A – Not all-inclusive– 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


32

CMS Documentation Warning Cont’d

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 submitted. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record. [Emphasis Added]

Remember WPS timeliness standard “no more than a couple of days”


33

Review Findings EHR Progress Notes

During repeated reviews, Medicare Contractors have observed the tendency to "over-document" and consequently to select and bill for a higher level E/M code than medically reasonable and necessary – Word processing software, the electronic medical

record, and formatted note systems facilitate the "carry over" and repetitive "fill in" of stored information


34

Over Documentation

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


35

CMS Documentation Tips

Providers should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met– Beware of templates that overestimate decision-

making. Understand the logic of templates and/or computer programs used for E/M service coding


36

Correct Use of Checklists and Templates in E/M Documentation

Physicians and non-physician practitioners may use templates, checklists, and/or electronic medical records to assist in documenting services and saving time – WPS considers these formats acceptable documentation

• Caveat, the documentation submitted must be specific to the patient and the service in question

– Appropriate to evaluate the patient’s presenting problem, problems described in the HPI and ROS

– Exam findings


37

OIG Report – January 2014

Tracing authorship and documentation in an EHR may not be as straightforward as tracing in a paper record

Health care providers can use EHR software features that may mask true authorship of the medical record and distort information in the record to inflate health care claims


38

OIG Report – Copy-PastingCopy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location. – When doctors, nurses, or other clinicians copy-paste

information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers

– Inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims


39

OIG Over-DocumentationOver-documentation is the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services. – Some EHR technologies auto-populate fields when using

templates built into the system. – Other systems generate extensive documentation on the basis of a

single click of a checkbox, which if not appropriately edited by the provider may be inaccurate.

– Such features can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.


40

OIG Findings

Although EHR technology may make it easier to perpetrate fraud, CMS and its contractors have not adjusted their practices for identifying and investigating fraud in EHRs


41

OIG Recommendations

CMS should provide guidance to its contractors on detecting fraud associated with EHRs

CMS should direct its contractors to use providers’ audit logs


42

New Supplemental Medical Review Contractor

StrategicHealthSolutions, LLC– Performs and/or provides support for a variety of

tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs.

– Primary tasks will be conducting nationwide medical reviews as directed by CMS.• CMS assigns each project through Technical

Direction Letters (TDL)


43

New Supplemental Medical Review Contractor - TDLs

Project Y1P2 – Evaluation and Management (E/M) Services– This TDL was a result of an OIG report OEI-04-10-

00180 which has recommendations to review physicians’ billing for E/M services • The E/M services provided refer to visits and

consultations furnished by physician and nonphysician practitioners (providers) to assess and manage beneficiary healthcare

– This TDL is for E/M services billed with CPT codes 99214 and 99215


44

Region C RAC - Connolly

Region C - Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia and West Virginia

Auditing claims that contain higher-level CPT codes for evaluation and management services - focus on claims for 99214 and 99215– Limited Review - Statistical Sampling on

Evaluation and Management claims to calculate and project incorrectly paid claims


45

E/M Codes

Continue to account for the vast majority of physician errors– Missing chief complaint– Inadequate HPI– Missing assessment and plan– Insufficient documentation for coding by time


46

E/M Coding

Problem-oriented E/M – Based on content

• History• Exam• Medical Decision Making

– Based on time• More than 50% of time spent in

counseling/coordination of care

Time-based codes


47

E/M Chief Complaint

The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter.

Must be documented for every encounter– Subsequent hospital inpatient – Subsequent observation– Subsequent nursing facility

Must be addressed in the assessment AND plan of care


48

E/M Chief Complaint Cont’d

Not acceptable– Follow-up– Med Check– Wants to establish– 3-mo check up


49

E/M History of the Present Illness (HPI)

Physician work– Must validate the chief complaint– Must be evident information was obtained and

documented by the physician• Cannot count/use information obtained and

documented by staff


50

History of the Present Illness (HPI) Cont’d

Symptomatic patients– Obtain 4 HPI elements

• Location• Quality• Severity• Duration• Timing• Context• Modifying Factors• Associated Signs and Symptoms


51

E/M History of the Present Illness Cont’d

Asymptomatic Patients

– Documentation should include information related to the reason for the encounter, e.g., abnormal test results, follow-up visit notes patient is compliant with treatment recommendations


52

E/M History - Review of Systems

Review of symptoms– Not a review of medical problems

• Diabetes• Hypertension• Arthritis

Must document all positive findings

Must document pertinent negatives for organ system(s) related to the chief complaint

Must be evident the information was reviewed by the physician


53

E/M Past History

Prior major illnesses and injuries

Prior operations

Prior hospitalizations

Current medications

Allergies (eg, drug, food)

Age appropriate immunization status

Age appropriate feeding/dietary status


54

E/M Family History

The health status or cause of death of parents, siblings, and children

Specific diseases related to problems identified in the Chief Complaint or History of the Present Illness, and/or System Review

Diseases of family members that may be hereditary or place the patient at risk– Document who in family has problem


55

E/M Social History

Age appropriate review of past and current activities– Marital status and/or living arrangements– Current employment– Occupational history– Use of drugs, alcohol, and tobacco– Level of education– Sexual history– Other relevant social factors


56

E/M Examination

Two Guidelines– 1995

• Performance and documentation of examination elements for

– Body areas– Organ systems

– 1997• Performance and documentation of examination

elements for – General Multi-System Exam– Single Organ System Exam


57

E/M Documentation Guidelines

The Documentation Guidelines for E/M services reflect the needs of the typical adult population

For certain groups of patients, the recorded information may vary slightly from that described in the guidelines

Although not specifically defined in the documentation guidelines, variations on history and examination are appropriate for infants, children, adolescents and pregnant women


58

E/M Documentation Guidelines Cont’d

The medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area

The content of a pediatric examination will vary with the age and development of the child


59

E/M Documentation Guidelines Cont’d

Newborn example – The record may include under history of the

present illness (HPI) the details of mother's pregnancy and the infant's status at birth

– Social history will focus on family structure– Family history will focus on congenital anomalies

and hereditary disorders in the family


60

E/M Exam – General Instructions

Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented– A brief statement or notation indicating "negative"

or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s)


61

1995 - Body Areas

Head, including the face

Neck

Chest, including breasts and axilla

Abdomen

Genitalia, groin, buttocks

Back

Each extremity


62

1995 Organ Systems

EyesEars, nose, mouth, and throatCardiovascularRespiratoryGastrointestinalGenitourinaryMusculoskeletalSkinNeurologicPsychiatricHematologic/lymphatic/immunologic


63

1995 – 4 Types of Exam

Problem focused: A limited examination of the affected body area or organ system.

Expanded problem focused: A limited examination of the affected body area or organ system and other symptomatic or related organ system(s) (2-7 body areas/organ systems)

Detailed: An extended examination of the affected body area(s) and other symptomatic or related organ system(s) (2-7 body areas/organ systems)


64

1995 – 4 Types of Exam Cont’d

Comprehensive: A general multisystem examination– The medical record for a general multi-system

examination should include findings about 8 or more of the 12 organ systems

– Refer to the 1997 guidelines for single organ system exams


65

1997 Examinations

It is possible for a given examination to be expanded beyond what is defined in the documentation guidelines. – When that occurs, findings related to the additional

systems and/or areas should be documented– Other elements do not “substitute” for defined

elements


66

1997 Examinations Cont’d

General multi-system examinationSingle organ system examinations– Cardiovascular – Ears, Nose, Mouth, and Throat – Eyes – Genitourinary (Female) – Genitourinary (Male) – Hematologic/Lymphatic/Immunologic – Musculoskeletal – Neurological – Psychiatric – Respiratory – Skin


67

1997 – General Multi-Specialty4 Types of Examination

Problem Focused Examination – should include performance and documentation of one to five elements identified by a bullet (•) in one or more organ system(s) or body area(s)

Expanded Problem Focused Examination – should include performance and documentation of at least six elements identified by a bullet (•) in one or more organ system(s) or body area(s)


68

1997 – General Multi-Specialty4 Types of Examination Cont’d

Detailed Examination – should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet (•) is expected – Alternatively, a detailed examination may include

performance and documentation of at least twelve elements identified by a bullet (•) in two or more organ systems or body areas


69

1997 – General Multi-Specialty4 Types of Examination Cont’d

Comprehensive Examination – should include at least nine organ systems or body areas – For each system/area selected, all elements of the

examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination

– For each area/system, documentation of at least two elements identified by a bullet is expected


70

1997 – Single Organ Systems4 Types of Examination

Variations among these examinations in the organ systems and body areas identified in the left columns and in the elements of the examinations described in the right columns reflect differing emphases among specialties


71

1997 – Single Organ Systems4 Types of Examination Cont’d

Problem Focused Examination – should include performance and documentation of one to five elements identified by a bullet (•), whether in a box with a shaded or unshaded border

Expanded Problem Focused Examination – should include performance and documentation of at least six elements identified by a bullet (•), whether in a box with a shaded or unshaded border


72


Detailed Examination – examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet (•), whether in a box with a shaded or unshaded border – Eye and psychiatric examinations should include

the performance and documentation of at least nine elements identified by a bullet (•), whether in a box with a shaded or unshaded border


73


Comprehensive Examination – should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box. – Documentation of every element in each box with

a shaded border and at least one element in a box with an unshaded border is expected.


74

E/M Medical Decision Making

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by three elements – the number of possible diagnoses and/or the

number of management options that must be considered;

– the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and


75

E/M Medical Decision Making Cont’d

– the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options


76

E/M – Medical Decision Making Cont’d

Type of decision making is based on meeting the requirements for two of the three elements

4 Types of Decision Making– Straightforward– Low Complexity– Moderate Complexity– High Complexity


77

Number of Diagnoses or Management Options

This element is based on the following:– The number and types of problems addressed

during the encounter– The complexity of establishing a diagnosis– The management decisions made by the physician


78

Amount and/or Complexity of Data to be Reviewed

The amount and/or complexity of data or other information that must be obtained, reviewed and analyzed in order to establish a diagnosis is another indicator of complexity of diagnostic or management problems

Always remember to document the rationale for ordering diagnostic testing or other ancillary service


79

Table of Risk

The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s) ordered, and the management option selected

The highest level of risk in any category determines the overall risk


80

Table of Risk Cont’d

The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one.

The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment


81

Documenting Medical Decision Making

Reviewers depend on the documentation in the assessment and plan portion of the progress note– Assessment should include the problems pertinent

to the specific encounter– First listed should indicate the chief complaint

• Use symptoms when a definitive diagnosis has not been established

• Acceptable to include differential diagnosis when definitive diagnosis has not been established


82

Documenting Medical Decision Making Cont’d

– Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented

– If a surgical or invasive diagnostic procedure is ordered, planned or scheduled at the time of the E/M encounter, the type of procedure, eg, laparoscopy, should be documented.


83

E/M – Coding by Time

In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services


84

Coding by Time Documentation Requirements

Documentation requirements– Total face-to-face or floor/unit time (in minutes)– Amount of time spent in counseling/coordination

of care (in minutes)– Synopsis of the counseling/coordination of care

that took place


85

Time-Based Codes

Code selection is strictly based on time (list is not all-inclusive)– Inpatient discharge day management– Nursing facility discharge day management– Prolonged services– Tobacco/Smoking Cessation Counseling– Critical care– Psychotherapy


86

Discharge Day Management

Includes final examination of the patient, discussion of the hospital stay, instructions for continuing care, and preparation of discharge records (when performed on the floor/unit)– 30 minutes or less (e.g., 99238)– More than 30 minutes (e.g., 99239)

Time spent discharging the patient must be documented– Medicare teaching physician guidelines, code for time

the faculty physician personally spends discharging the patient.


87

“Incident To” OIG Settlement 1/16/2013

After it self-disclosed conduct to the OIG, Bartlett Regional Hospital (Bartlett), Arkansas, agreed to pay $1,434,664.50 for allegedly violating the Civil Monetary Penalties Law

– The OIG alleged that Bartlett submitted claims using incorrect physician names and NPI numbers and submitted claims for non-physician provider services that were billed under a physician's name and NPI number


88

Medicare Billing Options for Selected Nonphysician Practitioners

Medicare Option 1– Must bill rendering provider using NPP’s name and

NPI• New patients• Established patients with new complaints• Established patients requiring change in treatment plan• Any surgical service that has not been ordered by the

physician during a previous visit• All preventive services• Test interpretations, e.g., EKG, x-rays


89

Nonphysician Practitioner Services Incident To Billing Cont’d

Medicare Option 2– Incident to Billing

• Place of service office• Billing physician must be physically present in the

office suite and immediately available• Established patient• Physician established treatment plan for problem

during a previous visit – NPP is providing a follow-up visit

– Cannot change plan


90

Nonphysician Practitioner Services Shared Visits

Medicare Option 3– Patient seen by both the physician and NPP – Shared visit concept only applies to certain E/M

codes– Shared visit concept does not apply to (List is not

all-inclusive)• Critical care codes• Nursing facility services


91

Shared Visits Cont’d

Place of service office

– If “incident to criteria is met – can use either the physician or NPP’s name and NPI

– If “incident to” is not met – MUST be billed using the NPP’s name and NPI


92

Shared Visits Cont’d

Place of service emergency department, outpatient hospital, inpatient hospital– If both physician and NPP see the patient and

document their own services, can use either physician’s or NPP’s name and NPI

– If only seen and documented by physician – Must be billed by the physician


93

Hospital Shared Visits Cont’d

– If only seen and/or documented by NPP – Must be billed by the NPP

– If seen by NPP who documents his/her service and seen by the physician who does not document his/her own service (history, exam, MDM) – Must be billed by NPP


94

Billing Services Performed by Nonphysician Practitioners

Medicare and all federal plans that follow Medicare guidelines (list is not all-inclusive)– Tri Care– Mail Handlers Benefit Plan (MHBP) – Federal Employee Blue Cross Blue Shield– GEHA - Government Employees Health Association – NALC - Nationwide National Association of Letter

Carriers– SAMBA - Federal Employee Benefit Association


95

Nonphysician Practitioner Services Commercial Insurers

Aetna– If Medicare’s “incident to” guidelines are met, may bill

using either the physician or NPP’s name and NPI– If Medicare’s “Incident to” guidelines are not met,

MUST bill using the NPP’s name and NP


96

Injections – Documentation Required

Must be ordered by Physician/nonphysician provider– Name of medication documented– Strength documented– Dosage documented

Method of administration

Location of injection

Identity of individual administering injection


97

Injections - Insufficient Documentation

Physician Billed HCPCS J1885 (ketorolac tromethamine, per 15 mg) and J3420 (vitamin B-12 cyanocobalamin, up to 1000 mcg) – Orders received for medications, however, no

documentation received to support medications were administered


98

Vitamin B-12 Injection

The patient’s medical record must contain documentation that fully supports the medical necessity for services included within this LCD (See “Indications and Limitations of Coverage and/or Medical Necessity”). – This documentation includes, but is not limited to, relevant

medical history, physical examination, and results of pertinent diagnostic tests or procedures.

– Except for patients who have had a complete surgical resection of either the stomach or ileum OR currently receiving chemotherapy with certain drugs, documentation should include• Vitamin B12 deficiency not corrected by oral dosing


99

Vitamin B-12 Injection Cont’d

Deficiency documented by serum assay– B12 levels below 100pg/mL suggest deficiency– Test results between 100-400pg/mL may require

further testing • Tests to consider include serum homocysteine,

serum methylmalonic acid (MMA), and serum HoloTC-II (active vitamin B12) assays (Dharmarajan, et al.)


100

Vitamin B-12 Injection Cont’d

– When a patient shows neuropsychiatric abnormalities and the serum B12 is low normal, i.e., below 350 pg/ml, the physician may, in the absence of methylmalonic acid or homocysteine tests, presume a B12 deficiency and treat the patient with B12

– Likewise if MMA and/or homocysteine level (s) are available it is also appropriate to justify treatment if these levels are abnormal


101

Documentation Requirements for Diagnostic Tests

If a diagnostic test is performed in the office, be certain that the order is noted somewhere in the medical record

Test requisitions for tests to be performed by another entity must be personally signed by the provider– Exception – requisition for clinical laboratory tests do

not have to be personally signed

Some tests require a written interpretation and report, e.g., ECGs, x-rays


102

Documentation Requirements for Diagnostic Tests Cont’d

The claim must include the valid NPI of the ordering/referring physician or extender– Individual ordering the test in the medical record must

be shown as the ordering provider on the claim (Box 17 & 17b of CMS 1500) for the diagnostic test

Order for test(s) to be performed – must be specific – requisition is NOT sufficient

Date of service documented– Date of service matches date billed

Evidence physician reviewed results (e.g., x-ray reports, laboratory tests, etc.)


103

CERT - Insufficient Documentation – Physician Billed CPT 93000

Missing a copy of the 12 lead electrocardiogram interpretation report for billed date of service

– Received copy of ECG tracing


104

Medically Unnecessary Service or Treatment – Physician Billed CPT 93010 (ECG Interpretation)

No order was submitted for the inpatient electrocardiogram, routine ECG with at least 12 leads.

The ECG tracing, with the interpretation and report, were received without the order and there was no response to follow-up requests


105

Recommended Documentation for Surgical Procedures (As Appropriate)

Reason for performing the procedureConsentPrepType and amount of anesthesia (if appropriate)Description of the procedure including the location, instruments used, technique, sutures, etc

Cont’d next slide


106

Recommended Documentation for Surgical Procedures (As Appropriate)

Continued from previous slideBandageCompleted with/without complicationHow patient tolerated the procedurePostop instructions given to the patientPre and postoperative diagnoses


107

Billing and Coding for Osteopathic Manipulative Treatment

Article published in the Journal of the American Osteopathic Association (JAOA) http://www.jaoa.org/content/109/8/409.full– Somatic dysfunction is defined in the AOA-sponsored

textbook Foundations for Osteopathic Medicine as follows:• Impaired or altered function of related components of the

somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements

• Somatic dysfunction is treatable using osteopathic manipulative treatment

http://www.jaoa.org/content/109/8/409.full

http://www.jaoa.org/content/109/8/409.full


108

Billing and Coding for Osteopathic Manipulative Treatment Cont’d

The textbook further states that somatic dysfunction is “diagnosed by history and palpatory assessment of tenderness, asymmetry of motion and relative position, restriction of motion, and tissue texture change.”


109

Billing and Coding for Osteopathic Manipulative Treatment Cont’d

Except for tissue texture changes, evaluation for somatic dysfunction is part of the standard musculoskeletal physical examination. As outlined by CMS, a complete single-organ system musculoskeletal examination consists of assessing the following elements:– gait– palpation of asymmetry and tenderness– range of motion– stability– muscle strength and tone– digits and nails


110

OMT Codes

Coding is based on the number of regions treated: – 98925 for 1-2 body regions – 98926 for 3-4 body regions – 98927 for 5-6 body regions – 98928 for 7-8 body regions – 98929 for 9-10 body regions


111

OMT Coding Cont’dBody Regions:– Head– Cervical– Thoracic– Lumbar– Sacral– Pelvic– Lower Extremities– Upper Extremities– Rib Cage– Abdomen and Viscera


112

Billing an E/M on the Same Day as OMT

For the purposes of billing visits on the same day as OMT, CMS assigned “0” postoperative days making these codes “minor surgical procedures”

Must follow CMS minor surgical procedure billing rules


113

Billing an E/M on the Same Day as OMT Cont’d

Documentation Requirements– Separate the documentation for the visit (SOAP

note) and OMT– Clearly label OMT

Append modifier -25 to the visit code to indicate a significant, separately identifiable service was performed on the same day as OMT


114

WPS Clarification for Using Modifier -25

Modifier 25 is used to identify a significant, separately identifiable service on the same day as a procedure – This means the E/M is above and beyond what

would be provided as part of the procedure – The documentation must show the additional work

and someone else looking at the documentation must be able to identify that work separate from the procedure


115

National Correct Coding Initiative

Also known as “bundling edits.”

Implemented by CMS and promotes correct coding methodologies.

Controls the improper assignment of codes that results in inappropriate reimbursement.

Additional information is available on the CMS website

http://www.cms.hhs.gov/NationalCorrectCodInitEd/


116

National Correct Coding Initiative Edits

CCI Manual– The decision to perform a minor surgical procedure is

included in the payment for the minor surgical procedure and should not be reported separately as an E/M service

– However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier -25


117

CCI Manual Cont’d

The E/M service and minor surgical procedure do not require different diagnoses

If a minor surgical procedure is performed on a new patient, the same rules for reporting E/M services apply– The fact that the patient is “new” to the provider is not

sufficient alone to justify reporting an E/M service on the same date of service as a minor surgical procedure


118

CCI Example

If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E/M service is not separately reportable

However, if the physician also performs a medically reasonable and necessary full neurological examination, an E/M service may be separately reportable


119

CMS - E/M with Minor Surgical Procedure

Payment for minor surgical procedures includes payment for certain E/M services that are necessary prior to a procedure being performed– It may be necessary to indicate that on the day a

procedure or service was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed


120

CMS Decision for Minor Procedure

Modifier -25 is not used to report an E/M service that resulted in a decision to perform surgery – The -57 modifier is not used with minor surgeries

because the global period for minor surgeries does not include the day prior to the surgery

– Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit is not billed in addition to the procedure


121

Decision for Minor Procedure Cont’d

Carriers should not pay for an evaluation and management service billed with the CPT modifier -57 if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period


122

Department of Justice Settlement

April 3 - St. Luke’s University Health Network has agreed to pay $1,029,791 to resolve allegations that from January 1, 2002, through June 30, 2012, it erroneously submitted claims to the Medicare program for evaluation and management services that were not allowable under Medicare.– Medicare does not normally allow additional payment

for visits performed by a provider on the same day as a minor surgical procedure, unless the service is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure


123

Department of Justice Settlement Cont’d

• In such cases, an attachment to the claim, known as "Modifier -25," may be submitted to allow the additional payment

– In this matter, the government determined that St. Luke’s incorrectly attached Modifier -25 to Medicare claims that led Medicare to pay for evaluation and management services that were not significant and separately identifiable from the underlying procedures


124

Intravitreal Injections - OIG Findings for Fletcher Allen Health Care

The Hospital and its physicians did not always comply with Medicare requirements for separately billable E/M services related to outpatient eye injection procedures.

– The Hospital correctly billed for 15 of the 100 E/M services that we sampled. However, the Hospital incorrectly billed for the remaining 85 services. The incorrect billing resulted in overpayments totaling $8,063.

– Based on these sample results, the OIG estimated that the Hospital and its physicians received overpayments totaling $211,196 for CYs 2008 through 2010.


125

OIG Findings - Fletcher Allen Health Care Cont’d

The Hospital and its physicians were not eligible for the additional E/M payments since the services that the physician performed were not significant, separately identifiable, and above and beyond the usual preoperative work of the eye injection procedure


126

Fletcher Allen Health Care Response

The billing errors occurred because the providers believed in good faith that the care they provided included a separately billable E/M service.

In all of the sampled claims, the provider not only assessed and prepared the patient for the eye injection and provided the injection, he or she also examined the patient's other eye and assessed the potential effects of the patient's other conditions, such as diabetes and hypertension, on that eye


127

Fletcher Allen Health Care Response Cont’d

The providers feel that this approach promotes efficient and high quality medical care, and likely reduces the need for additional visits


128

OIG Findings - Fletcher Allen Health Care Cont’d

Overpayments occurred because the Hospital had inadequate billing system controls over billing E/M services related to outpatient eye injection procedures, and the Hospital’s physicians, who performed the eye injection procedures, did not fully understand the Medicare requirements for separately billable E/M services


129

OIG Recommendations – Fletcher Allen Health Care

OIG recommended that the Hospital – refund to the Medicare contractor $211,196 in

estimated overpayments – strengthen controls in the billing system to ensure

full compliance with Medicare requirements – strengthen its education to physicians regarding

separately billable E/M services related to eye injection procedures

Thanks for attending!

See you in December

coding and billing update ioa 117 th annual convention may 3, 2014

Documents