getting it right the first time coding and documentation - 2013 [email protected] steven...

Getting It Right the First TimeGetting It Right the First TimeCoding and Documentation - 2013Coding and Documentation - [email protected]@ingaugehsi.com

Steven Allen AdamsSteven Allen Adams

Discussion PointsDiscussion Points

• Incident ToIncident To• E and M Coding for:E and M Coding for:

Office VisitsOffice Visits Pre-operative ConsultationsPre-operative Consultations

• ModifiersModifiers E/M OnlyE/M Only Surgery OnlySurgery Only Global PeriodsGlobal Periods

• Preventive ServicesPreventive Services• Transitional Care ManagementTransitional Care Management

Incident ToIncident To

Incident To Billing Using MD #Incident To Billing Using MD #

4 standard criteria for Incident To:

1.Physician must be in office

2.Must be an established patient

3.Must not change anything from previous plan of care

4.Doctor should see patient every 3rd or 4th visit (shows active participation)

E&M CodingE&M Coding

Code SelectionCode Selection

Medical necessity of a service is the overarching Medical necessity of a service is the overarching criterion for payment in addition to the individual criterion for payment in addition to the individual requirements of a CPT code. It would not be requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher medically necessary or appropriate to bill a higher level of evaluation and management service when level of evaluation and management service when a lower level of service is warranted. a lower level of service is warranted. The volume The volume of documentation should not be the primary of documentation should not be the primary influence upon which a specific level of service is influence upon which a specific level of service is billedbilled. Documentation should support the level of . Documentation should support the level of service reported. The service should be service reported. The service should be documented during, or as soon as practicable documented during, or as soon as practicable after it is provided in order to maintain an after it is provided in order to maintain an accurate medical record.accurate medical record.

A Word on “Cloning”A Word on “Cloning”

Cloning occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. This “cloned documentation” does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information.

Office – Outpatient Office – Outpatient ServicesServices

Outpatient VisitOutpatient Visit

New / ConsultsNew / Consults99201 - 9924599201 - 99245

““Requires Requires All ThreeAll Three Key Key Elements”Elements”

New/Consultation Patient Visits (3 out of 3)

Code Minutes History Examination Decision-Making

99201 10

Problem FocusedCC1HPI

Problem Focused1995 –(1)

1997 – (1 check)

StraightforwardDiagnosis – MinimalData – Minimal or NoneRisk – Minimal

99241 15

99251 20

99202 20

Exp. Problem FocusedCC1 HPI1 ROS

Exp. Problem Focused1995 – (2 – 7)

1997 – (6 checks)

StraightforwardDiagnosis – MinimalData – Minimal or NoneRisk – Minimal

99242 30

99252 40

99203 30

DetailedCC4 HPI or status of 3 chronic conditions2 ROSMedical or Family or Social History

Detailed1995 – (4-7 – need 4x4)

1997 – (12 checks)

LowDiagnosis – LimitedData – LimitedRisk – Low OTC, Short-term Meds, Minor Surgery

99243 40

99253 55

99204 45

ComprehensiveCC4 HPI or status of 3 chronic conditions10 ROSMedical, Family, Social History

Comprehensive1995 – (8)

1997 – (2 checks from 9 areas); or1997(all checks in border & 1 check in others)

ModerateDiagnosis – MultipleData – ModerateRisk – Moderate Long term Rx or Major Surgery

99244 60

99254 80

99205 60

ComprehensiveCC4 HPI or status of 3 chronic conditions 10 ROSMedical, Family, Social History



HighDiagnosis – ExtensiveData – ExtensiveRisk – High

99245 80

99255 110

New Patient DefinitionNew Patient Definition

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.

New Patients – Think:New Patients – Think:

• 99202 – No treatment• 99203 – Short term meds, OTC, minor surgery• 99204 – Long term meds, major surgery• 99205 – Sick enough to admit / major surgery

with risks / extensive data

Also check grid to make sure you document correct history and examination!!

Initial VisitsInitial Visits

Importance of HistoryImportance of History

•Medical necessity of an Evaluation and Management (E/M) encounter is often visualized only when viewed through the prism of its characteristics captured in specific History of Present Illness (HPI) elements.

•Staff can do the past medical history, family history, social history but we expect the provider to do the chief complaint in the history of present illness

Unable To Obtain HistoryUnable To Obtain History

The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document some of the history components (past medical, family, social).

Normal and NegativeNormal and Negative

For the examine and the review of system(s) related to the presenting

problem - do not describe as "normal" or "negative."

Other IssuesOther Issues

Extended HPI – 4 HPI or Status of 3+ chronic or inactive conditions.

Complete ROS (lots of questions on the ROS.

1995 – Comprehensive (8)1995 – Comprehensive (8)1. Const: Vital signs listed above. Well developed, well nourished and in no acute distress.

Alert and oriented X’s 3. No mood disorders noted, calm affect.

2. Eyes: Sclera white, conjunctiva clear, lids are without lag. PERRLA. Pupils and irises are equal and round without defect.

3. ENT: TMs intact and clear, normal canals, grossly normal hearing. Oropharanx clear and moist without erythema. Gums pink, good dentition.

4. Lymph/Neck: No masses, thyromegaly, or abnormal cervical notes. No bruit. Tracheal midline.

5. Cardio: RRR, Normal S1, S2 w/o murmurs, rubs or gallops. Skin warm and dry. No peripheral edema.

6. Respiratory: Chest symmetrical, respirations non-labored. No dullness or flatness. Clear bilaterally to auscultation, non-tender to palpitation.

7. Musculo: No deformity or scoliosis noted. No frank gait disturbance noted. No cyanosis or edema. Pulses normal in all 4 extremities. No atrophy or abnormal movements. Appropriate muscle strength bilaterally.

8. Neurologic: No focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone.

9. GI/Abdomen: Soft, non tender, non distended, no hepatosplemomegaly, normal bowel sounds, no masses noted.

What Doesn’t Count (8) - 1995What Doesn’t Count (8) - 1995

• Head• Neck• Thyroid• Abdomen• Extremities• Back

• Under the 1995 Guidelines CMS and the AMA want you to examine “ORGAN SYSTEMS” and not body areas with regard to any code with the number (8) in the exam criteria

Expanded vs. ExtendedExpanded vs. Extended

• The difference is not the number of systems examined. Two to seven systems are required for both examinations.

• The difference is the detail in which the examined systems are described.

1995 – Detailed 4-7 (4x4)1995 – Detailed 4-7 (4x4)1. Const: Vital signs listed above. Well developed, well nourished and in no acute distress.

Alert and oriented X’s 3. No mood disorders noted, calm affect.

2. Eyes: Sclera white, conjunctiva clear, lids are without lag. PERRLA. Pupils and irises are equal and round without defect.

3. ENT: TMs intact and clear, normal canals, grossly normal hearing. Oropharanx clear and moist without erythema. Gums pink, good dentition.

4. Lymph/Neck: No masses, thyromegaly, or abnormal cervical notes. No bruit. Tracheal midline.

5. Cardio: RRR, Normal S1, S2 w/o murmurs, rubs or gallops. Skin warm and dry. No peripheral edema.

6. Respiratory: Chest symmetrical, respirations non-labored. No dullness or flatness. Clear bilaterally to auscultation, non-tender to palpitation.

7. Musculo: No deformity or scoliosis noted. No frank gait disturbance noted. No cyanosis or edema. Pulses normal in all 4 extremities. No atrophy or abnormal movements. Appropriate muscle strength bilaterally.

8. Neurologic: No focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone.

9. GI/Abdomen: Soft, non tender, non distended, no hepatosplemomegaly, normal bowel sounds, no masses noted.

1997 “Bullet Guidelines”1997 “Bullet Guidelines”

• Allow you to document systems and areas, however you have to be very specific about what you document about those systems and areas.

• Most EMRs are based on the 1997 guidelines but are not compliant

1997 Guidelines - Correct1997 Guidelines - Correct

• EYES: [ ] Sclera white, conjunctive clear. Lids are without lag. [ ] PERRLA.

• ENT: [ ] Tympanic membranes translucent, non-bulging and mobile. Canal walls pink, without discharge. [ ] Mucosa and turbinates pink, septum midline. [ ] Lips pink / symmetric.

• This would be 5 bullets and compliant

1997 Guidelines – Not Correct1997 Guidelines – Not Correct

• EYES: [ ] Sclera white, [ ]conjunctive clear. Lids are without lag. [ ] PERRLA.

• ENT: [ ] Tympanic membranes translucent, non-bulging and mobile. [ ] Canal walls pink, without discharge. [ ] Mucosa and turbinates pink, septum midline. [ ] Lips pink [ ] Lips symmetric.

• This would be 8 bullets and not compliant

What To DoWhat To Do

• I’ll have a copy of those guidelines posted on my web site and I’ll give you a link on medicalofficeblog.com

• Make sure that you are only getting credit for what the government says you get credit for documenting.

• THIS IS A CRITICAL COMPONENT OF YOUR EMR COMPLIANCE

New Patients – Think:New Patients – Think:

• 99202 – No treatment• 99203 – Short term meds, OTC, minor surgery• 99204 – Long term meds, major surgery• 99205 – Sick enough to admit / major surgery

with risks / extensive data

Also check grid to make sure you document correct history and examination!!

Outpatient VisitOutpatient Visit

Established PatientEstablished Patient99211 - 9921599211 - 99215

““Requires Requires Two of ThreeTwo of Three Key Key Elements”Elements”

Established Patients – Think:Established Patients – Think:

• 99212 – One stable condition• 99213 – Two stable or one unstable problem• 99214:

3 chronic stable on meds 2 unstable on meds 1 stable and one unstable on meds

• 99215 – Sick enough to admit/extensive dx with risk or data

Also check grid to make sure you document correct history and examination or counseling

time!!

Established VisitsEstablished Visits

Established Patient Visits (2 out of 3)

99211 N/A N/A N/A N/A



1997 – (1 check)

StraightforwardDiagnosis – Minimal 1Data – Minimal or None 1Risk – Minimal 1 1 stable problem

99212 10



1997 – (6 checks)

LowDiagnosis – Limited 2Data – Limited 2Risk – Low 2 2 stable problems 1 unstable problem

99213 15



1997 – (12 checks)

ModerateDiagnosis – Multiple 3Data – Moderate 3Risk – Moderate 3 3 stable problems on meds 1 stable and 1 unstable on meds 2 unstable problems on meds New problem requiring major surg

99214 25




HighDiagnosis – Extensive 4Data – Extensive 4Risk – High 4Very sick patient with extensive data review and high risk

99215 40

Counseling DominatedCounseling Dominated

3 standard criteria for time:

1. Total Face-to-Face time of provider

2. That more than 50% was counseling

3. Topics you discussed

“If the level of care is being based on time spent with the patient for counseling/coordination of care documentation should support the time for the visit and the documentation must support in sufficient detail the nature of the counseling”

Signature RequirementsSignature Requirements

• Make sure you properly SIGN all your notes, orders, test results; all documentation that supports a claim in the patient chart should have the provider’s signature. If the provider is initialing this documentation he/she must also print their name by the initials or circle the typed name on an office form . This lets the reviewer clearly see that who documented the medical record.

Established Patients – Think:Established Patients – Think:

• 99212 – One stable condition• 99213 – Two stable or one unstable problem• 99214:

3 chronic stable on meds 2 unstable on meds 1 stable and one unstable on meds

• 99215 – Sick enough to admit/extensive dx with risk or data

Also check grid to make sure you document correct history and examination or counseling

time!!

Hospital – Inpatient / OutpatientHospital – Inpatient / Outpatient

Initial Hospital Visits3 out of 3




1997 – (12 checks)

Straightforward / LowDiagnosis – MinimalData – Minimal or NoneRisk – Minimal

99221 30




ModerateDiagnosis – MultipleData – ModerateRisk – Moderate

99222 50





99223 70

Subsequent Hospital Visits2 out of 3



1997 – (1 check)


99231 15



1997 – (6 checks)


99232 25



1997 – (12 checks)


99233 35

Hospital Discharge

99238 30 Hospital Discharge

99239 > 30 Hospital Discharge > 30 minutes – {Must document time}

Definitions

99221 Admission – Low Risk

99222 Admission – Moderate Risk

99223 Admission – High Risk

99231 Patient is responding well

99232 Pt is responding inadequately to therapy / developed a minor complication

99233 Pt is unstable or has developed a significant complication / significant new problem

Per Change Request 5794, the Hospital Discharge Day Management Service (CPT code 99238 or 99239) is a face-to-face evaluation and management (E/M) service with the patient and his/her attending physician. Therefore, the time must be spent with the patient.

Time - 99239Time - 99239

Observation Observation CodingCoding

Observation/Hospital Discharge Same Day - 3 out of 3




1997 – (12 checks)


99234 40





99235 50





99236 55

Observation - 3 out of 3 (first day of a multiple day observation service)

Detailed / ComprehensiveCC4 HPI or status of 3 chronic conditions2 ROSMedical or Family or Social History


1997 – (12 checks)


99218 N/A





99219 N/A





99220 N/A

Subsequent Observation Care Visits - 2 out of 3 (day(s) after first till day before discharge)



1997 – (1 check)


99224 15



1997 – (6 checks)


99225 25



1997 – (12 checks)


99226 35

Observation Discharge (final day of observation)

99217 N/A Observation care discharge on date other than initial observation day

The physician shall satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. In addition to meeting the documentation requirements for history, examination, and medical decision making documentation in the medical record shall include:

1.Documentation stating the stay for observation care or inpatient hospital care involves 8 hours, but less than 24 hours;

2.Documentation identifying the billing physician was present and personally performed the services; and

3.Documentation identifying the order for observation services, progress notes, and discharge notes were written by the billing physician.

When a patient receives observation care for less than 8 hours on the same calendar date, the Initial Observation Care, from CPT code range 99218 – 99220, shall be reported by the physician. The Observation Care Discharge Service, CPT code 99217, shall not be reported for this scenario.

In the rare circumstance when a patient receives observation services for more than 2 calendar dates, the physician shall bill a visit furnished before the discharge date using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.

ModifiersModifiers

Global PeriodGlobal Period

• 0-10 days = minor (-25 on E&M)• 90 days = major actually 92 days (-57 on E&M)• MMM = maternity codes• XXX = global concept doesn’t apply (x-ray/lab)• YYY = up to carrier (unlisted codes)• ZZZ = always included in global of another

service (add on codes)

E&M Only ModifiersE&M Only Modifiers

• 24 – Unrelated E&M24 – Unrelated E&M• 25 – E&M and minor surgery same day25 – E&M and minor surgery same day• 57 – E&M day before or day of major surgery57 – E&M day before or day of major surgery

Use of the 25 modifier means the Use of the 25 modifier means the procedure note is separate from the procedure note is separate from the

E&M noteE&M note

Surgery Only ModifiersSurgery Only Modifiers

• 58 – Anticipated at time of initial procedure58 – Anticipated at time of initial procedure• 78 – Related to initial procedure78 – Related to initial procedure• 79 – Unrelated to initial procedure79 – Unrelated to initial procedure

Use of the 78 modifier means the Use of the 78 modifier means the second procedure will be reducedsecond procedure will be reduced

78 y/o woman presents to physicians office to have her HTN and DM addressed. She also complains of having several skin tags on her neck. The physician addresses the HTN and DM and removes 5 skin tags from the right side of her neck:

A. 99213-25, 11200B. 11200C. 99213, 11200-25D. 99213-57, 11200-25

E&M and Minor SurgeryE&M and Minor Surgery

One week later the patient returns for follow-up visit for his elevated BP and to have the skin tag sites examined. During the visit the patient asks to have a brown lesion on their right arm examined. The physician documents the exam and changes the BP medicine and then destroys a pre-malignant lesion on the patient’s right forearm. Code for the second visit:

A. 99213-24-25, 17000B. 99213-24,25, 17000-79C. 17000D. 99213-25, 17000-51

E&M in GlobalE&M in Global

66

Preventive Medicine ServicesPreventive Medicine Services

Prevention ServicesPrevention Services

• CMS is proposing to develop separate Level II HCPCS codes for the first annual wellness visit, to be paid at the rate of a level 4 office visit for a new patient (similar to the IPPE), and for the subsequent annual wellness visits, to be paid at the rate of a level 4 office visit for an established patient.

IPPE- Welcome to MedicareIPPE- Welcome to Medicare

1. Review Medical and Social History.

2. Review Risk Factors for Depression and Mood Disorders.

3. Review Functional Ability and Level of Safety.

4. Height, Weight, BP, VA, BMI.

5. End-of-life Planning If Needed

6. Education, Counseling and Referrals Based on Above

7. Education, Counseling, and Referrals for Other Listed Services

New AWV CodesNew AWV Codes• G0438 (Annual wellness visit; includes a personalized

prevention plan of service (PPPS), first visit); and

• G0439 (Annual wellness visit; includes a personalized prevention plan of service (PPPS),subsequent visit).

• We note that practitioners furnishing a preventive medicine E/M service that does not meet the requirements for the IPPE or the AWV would continue to report one of the preventive medicine E/M services CPT codes in the range of 99381 through 99397 as appropriate to the patient's circumstances, and these codes continue to be noncovered by Medicare."

In the CY 2011 PFS final rule with comment period (75 FR 73411), we stated “that when the Health Risk Assessment is incorporated in the AWV, we will reevaluate the values for HCPCS codes G0438 and G0439”. As discussed in the CY 2011 PFS final rule with comment period, the services described by CPT codes 99204 and 99214 already include ‘preventive assessment' forms. For CY 2012, we believe that the current payment crosswalk for HCPCS codes G0438 and G0439 continue to be most accurately equivalent to a level 4 E/M new or established patient visit; and therefore, we are proposing to continue to crosswalk HCPCS codes G0438 and G0439 to CPT codes 99204 and 99214, respectively.

AWV - InitialAWV - Initial1. Health Risk Assessment

2. Establishment of an individual's medical and family history.

3. Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual.

4. Measurement of an individual's height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history.

5. Detection of any cognitive impairment that the individual may have.

6. Review of the individual's potential (risk factors) for depression, Review of the individual's functional ability and level of safety, based on direct observation.

7. Review of the individual's functional ability and level of safety, based on direct observation

8. Establishment of the following:

++ A written screening schedule, such as a checklist, for the next 5 to 10 years

++ A list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended.

8. Furnishing of personalized health advice to the individual and a referral, as appropriate.

9. Any other element determined appropriate through the National Coverage Determination process.

AWV - SubsequentAWV - Subsequent1. Health Risk Assessment

2. An update of the individual's medical and family history.

3. An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing personalized prevention plan services.

4. Measurement of an individual's weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history.

5. Detection of any cognitive impairment, as that term is defined in this section, that the individual may have.

6. An update to both of the following:

++ The written screening schedule for the individual as that schedule was developed at the first AWV providing personalized prevention plan services. CMS-1503-FC 761

++ The list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway for the individual as that list was developed at the first AWV providing personalized prevention plan services.

6. Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs as that advice and related services are defined in paragraph (a) of this section.

7. Any other element determined through the NCD process.

Has Pt. Had Medicare for More than 12 Months

Has Pt. Received An Initial AWV From Medicare

G0438

Yes G0402No

Yes No

G0439

Breast / Pelvic ExamBreast / Pelvic ExamThe HCPCS Code:• G0101 – Pelvic and Breast Exam

The Diagnosis Codes

V72.31

Routine gynecological exam

V76.47

Screening for neoplasm of the vagina

V76.49

Screening of woman without a cervix

V76.2

Screening for neoplasm of cervix

V15.89* - Every Year

Presenting health hazards

Four QuestionsFour QuestionsCERVICAL CANCER HIGH RISK SURVEY

Was your first sexual activity prior to the age of 16? Yes No

Have you had more than 5 sexual partners? Yes No

Do you have a history of sexually transmitted disease

(including HIV) infection? Yes No

Have you had fewer than 3 negative pap smears within

the previous seven years? Yes No

Exam RequiredExam RequiredFemale G/U: (7 of the following 11)

Breasts symmetrical. No masses, lumps, tenderness, dimpling or nipple discharge.

Rectal exam exhibits even sphincter tone, no hemorrhoids or masses.

Pelvic

No external lesions. Normal hair distribution.

Urethral meatus pink, no lesions or discharge.

Urethra intact, no tenderness, masses, inflammation or discharge.

Bladder without tenderness or masses, no incontinence.

Vaginal mucosa moist and pink, without lesions or discharge.

Cervix pink, no lesions, odor, or discharge.

Uterus midline, non-tender, firm and smooth.

No adnexal masses, nodules or tenderness.

Anus and perineum intact. ___ No lesions, rashes, fissures, fistulas or external hemorrhoids.

Wet Prep __________________ Hemoccult Pos. Neg.

Obtain Pap SmearObtain Pap SmearThe HCPCS Code:• Q0091 - Obtaining screen pap smear

The Diagnosis Codes

V72.31

Routine gynecological exam

V76.47

Screening for neoplasm of the vagina

V76.49

Screening of woman without a cervix

V76.2

Screening for neoplasm of cervix

V15.89* - Every Year

Presenting health hazards

Tobacco Cessation CodesTobacco Cessation Codes

The CPT Codes:

• 99406: Smoking and tobacco cessation counseling; intermediate, greater than 3 minutes, up to 10 minutes,

• 99407: Smoking and tobacco cessation counseling; intensive, greater than 10 minutes,

The Diagnosis Codes

• Medical dx of the patient at the time of the visit the tobacco is affecting

• If used with E/M, don’t forget modifier 25

New Tobacco Cessation CodesNew Tobacco Cessation Codes

The HCPCS Codes:

• G0436: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes,

• G0437: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes,

The Diagnosis Codes

• ICD-9 code 305.1 (non-dependent tobacco use disorder), or • ICD-9 code V15.82 (history of tobacco use).

Home Health CertificationHome Health Certification

The HCPCs Codes:

• G0179 – Re-certification for Medicare-covered home health under a plan of care, including contacts with home health agency and review of reports of patient status required by physician to affirm plan of care …

• G0180 - Certification for Medicare-covered home health under a plan of care, including contacts with home health agency and review of reports of patient status required by physician to affirm plan of care …

Content of the Physician's Certification• The home health services are because the individual is confined to

his/her home and needs intermittent skilled nursing care (other than solely for venipuncture for the purposes of obtaining a blood sample), physical therapy and/or speech-language pathology services, or continues to need occupational therapy;

• A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; (next slide)

• The services are or were furnished while the individual was under the care of a physician.

• The need for skilled oversight of unskilled services (management and evaluation of the care plan). The physician must include a brief narrative describing the clinical justification of this need as part of the certification and recertification or as a signed addendum to the certification and recertification.


Content of the Plan of Care Signed by Physician• The patient's mental status;• The types of services, supplies, and equipment required;• The frequency of the visits to be made;• Prognosis;• Rehabilitation potential;• Functional limitations;• Activities permitted;• Nutritional requirements;• All medications and treatments;• Safety measures to protect against injury;• Instructions for timely discharge or referral; and• Any additional items the HHA or physicians choose to include.• The physician who signs the plan of care must be the same physician to sign the physician

certification.


Time Frame Requirements• The encounter must occur no more than 90 days prior to the

home health start of care date or within 30 days after the start of care.

Encounter Documentation Requirements• The documentation must include the date when the physician

or allowed NPP saw the patient, and a brief narrative composed by the certifying physician who describes how the patient's clinical condition as seen during that encounter supports the patient's homebound status and need for skilled services.


Care Plan OversightCare Plan Oversight

The HCPCS Codes:

• G0181 – Supervision of patient receiving Medicare-covered home health agency requiring complex multidisciplinary care…30 minutes or more

• G0182 - Supervision of patient receiving Medicare-approved hospice care requiring complex multidisciplinary care…30 minutes or more

CMS and TCMCMS and TCM

• 99495 Transitional Care Management Services with the following required elements:

Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.

Medical decision making of at least moderate complexity during the service period.

Face-to-face visit, within 14 calendar days of discharge.• 99496 Transitional Care Management Services with the following

required elements:

Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.

Medical decision making of high complexity during the service period. Face-to-face visit, within 7 calendar days of discharge.

Discussion PointsDiscussion Points

• Incident ToIncident To• E and M Coding for:E and M Coding for:

Office VisitsOffice Visits Pre-operative ConsultationsPre-operative Consultations

• ModifiersModifiers E/M OnlyE/M Only Surgery OnlySurgery Only Global PeriodsGlobal Periods

• Preventive ServicesPreventive Services• Transitional Care ManagementTransitional Care Management

Questions?Questions?

Any Questions

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