tips for effective and compliant coding in the family...

Tips for Effective and Compliant Coding in the Family Practice/

Internal Medicine/PediatricInternal Medicine/Pediatric Scenario

AAPC Regional ConferenceNashville TNNashville TN

September 2011

Disclaimer

Information contained in this text is based on CPT® ICD-9-CM and HCPCS rules andCPT®, ICD 9 CM and HCPCS rules and regulations. However, application of the information in this text does not guarantee claims payment. Payers’ interpretation may vary from those found in this text. Please note that the law, applicable regulations, payer’ instructions interpretations enforcement etcinstructions, interpretations, enforcement, etc., may change at any time. Therefore, it is crucial to stay current with all local and national regulations and policies.

Billing Coding Pitfalls

• Office policies not clearly established

–Patient payments and co-pays

–Verifying insurance information

–Self pay patients (i.e “cash” patients)patients)• What to charge?

• When to collect?


• Billing policies and contractual issues not shared with office

–Approved reference labs

–Verifying insurance information

–How to handle physicals


• Basic coding knowledge not h dshared

–Local Carrier Coverage Decisions–National Coverage Issues–Correct Coding Initiative–Modifiers–Add-on codes


Diagnosis CodingP id di l it• Provides medical necessity

• Describes severity/acuity• Inaccuracies lead to denials• Linkage

–Advanced Beneficiary Notices (ABN)


NPPs“I id t t ” l• “Incident to” rules – MD must establish plan of care– NPP may not see new patients– NPP may not see established patients

with new problems• Know your contract language for how

this scenario is to be handled for non-Medicare carriers


Basic CPT• Modifier usage• Modifier usage

– -24, -25, -58, -76, -77• Do not use ER codes (99281 – 99285)

unless your facility is an emergency room• Knowledge of evaluation and management

level of service requirementslevel of service requirements• Choosing a level of service based on time• Established versus new patients


Basic CPT

Aft h d• After hours code usage–Choose based on whether outside

of your posted hours or just outside of normal business hours.These are added to the E/M code–These are added to the E/M code describing the visit that did take place.


Front Desk• This is your front line person y p

– Answers questions from patients?– Collects co-pays?– Collects payments from self pay

• Will this person need to calculate a total payment?– Enters patient demographic information?

Verifies insurance information?– Verifies insurance information?– Handles referrals?

• Does this person also key charges?

Evaluation and Management

READ THE GUIDELINESMedicare, OIG and CPT


READ THE GUIDELINES – Medicare Documentation Guidelines

GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATIONThe principles of documentation listed below are applicable to all

types of medical and surgical services in all settings.

For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation

varies by• type of service, place of service and the patient's status.

The general principles listed below may be modified to account for these variable circumstances in providing E/M services.


READ THE GUIDELINES – Medicare Documentation GuidelinesGuidelines

1. The medical record should be complete and legible.2. The documentation of each patient encounter

should include:1. reason for the encounter and relevant history, physical

examination2. findings and prior diagnostic test results;3. assessment, clinical impression or diagnosis;4. plan for care; and5. date and legible identity of the observer.


READ THE GUIDELINES – Medicare i id liDocumentation Guidelines

date and legible identity of the observer.

as of January 1, 2010, Medicare will no longer accept signature stamps. Signature stamps have been a controversial subject. They have been allowed across the nation based on following state guidelines of their use—meaning in essence, if the state you reside in allows them, then we will allow them as well. That will no longer be the case.


READ THE GUIDELINES – Medicare Documentation GuidelinesDocumentation Guidelines


Released August 5, 2009 • The CERT review process is now strictly enforcing a long standing rule

that requires a legible signature on all clinic notes, orders and other documentation (e.g. procedure notes) used to substantiate a claim billed to Medicare. Section 1833(e) of the Social Security Act states that contractors must be able to identify the provider who performed the service i d t CMS d fi l ibl i t l t i i tin order to pay. CMS defines a legible signature or electronic signature as the appropriate ways of identification.

• Failure to have a written or electronic signature on these items will result in a denial regardless of the medical necessity.


READ THE GUIDELINES – Medicare Documentation GuidelinesDocumentation Guidelines


• The Centers for Medicare & Medicaid Services (CMS) issued CR 6698 to clarify for providers how Medicare claims review contractors review claims and medical documentation submitted by providers. CR 6698 outlines the new rules for signatures and adds language for E-Prescribing. See the rest of this article for complete g g g pdetails. These revised/new signature requirements are applicable for reviews conducted on or after the implementation date of April 16, 2010. Please note that all signature requirements in CR 6698 are effective retroactively for Comprehensive Error Rate Testing (CERT) for the November 2010 report period


READ THE GUIDELINES – Medicare D e tati G ideli eDocumentation Guidelines

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or consulting physician.g g p y

5. Appropriate health risk factors should be identified.



6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.



8. The ROS and/or PFSH may be recorded by ancillary staff (or a student) or on a form completed by the patient. To document that the physician reviewed thedocument that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.


READ THE GUIDELINES – OIG Compliance Policy for Physician Practicesfor Physician Practices

Medical Record Documentation. In addition to facilitating high quality patient care, a properly documented medical record verifies and documents precisely what services were actually provided.

The medical record may be used to validate: (a) The site of the service; (b) the appropriateness of the services provided; (c) the accuracy of the billing; and (d) the identity of the care giver (service provider).


READ THE GUIDELINES – CPT Guidelines


CPT GuidelinesThe information and definitions provided

in the manual address the issue of the amount of work that was provided. The CPT manual does not address the CMS guidelines which were introducedCMS guidelines which were introduced to show proof of the work that was provided.


CPT GuidelinesThe guidelines for the E&M section supply the

necessary definitions for determining the level of service based on the work provided. There are four types of each of the three key components in selecting the level of service. Each type is defined within the guidelines toEach type is defined within the guidelines to assist the user in determining the extent of history, examination and medical decision making.

Evaluation and Management Services

• Categories within this section are b dbased on:

Type of service

Place of service

Status of patientp


• Code selection can be based on:Level of service

Time based

Type of service

Evaluation and Management ServicesPhysician office visits

N bli h d i i iNew versus established patient visits

• New patient (99201 – 99205)

• Established patient (99211 – 99215)– The three year rule


Physician office visits

– The three year rule: a patient who has not received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

Evaluation and Management ServicesCredit for Work Done

Document what was done

Describe all events

Tell why!

This is all you will have when appealing a denial or when someone is selecting a code.


Coding Based on Level of Service

• History – Problem Focused, Expanded Problem Focused, Detailed, Comprehensive

• Exam - Problem Focused, Expanded Problem Focused, Detailed, Comprehensive

• Medical Decision Making – Straightforward, g gLow, Moderate, High


99213

EPF (history and exam), Low MDM

99214

D (history and exam), Mod MDM

Only 2 out of 3 requirements needed


• Coding Based on TimeOffice and outpatient scenarios

If over 50% of the face-to-face time is spent in counseling and coordination of care then time may be used as the indicator for the code selection.

NOT DOCUMENTED NOT DONE


• Coding Based on TimeUnit/floor Time

If over 50% of the floor/unit time is spent in counseling and coordination of care then time may be used as the indicator for the code selection.

H it l b ti i ti t h it l i ti t lt tiHospital observation, inpatient hospital, inpatient consultations, nursing facility



Hospital Services

Choosing the correct level of service is important in hospital setting also.

Hospital Charges• How are they tracked/followed?

• Does the diagnosis tell your part of the story?

• Do you provide the patient information from the hospital for your staff.


Hospital admission (99221 – 99223)

• Code selection based on level of service

• Do not bill for other related E&M services on same date of admission

• Describes the first inpatient encounter with the patientthe patient.

Subsequent Hospital Visits

• 99231, 99232, 99233

• Every note stands alone

• Why are you there?

• What are you doing?

• Time

• How is the patient?

• Was the patient discharged?


• 99231– Problem Focused Interval History and Problem– Problem Focused Interval History and Problem

Focused Examination– S or L Medical Decision Making

• 99232– Expanded Problem Focused Interval History and

Exp Problem Focused ExaminationModerate Complexity Medical Decision Making– Moderate Complexity Medical Decision Making

• 99233– Detailed Interval History and Detailed Examination– High Complexity Medical Decision Making


• 99231 – 15 minutesUsually the patient is stable recovering or improving– Usually the patient is stable, recovering or improving

• 99232 – 25 minutes– Usually the patient is responding inadequately to

therapy or has developed a minor complication.

• 99233 – 35 minutes– Usually the patient is unstable or has developed a

significant complication or a significant new problem.


Do not play it safe by just using 99231


99231Medicare allows $32.56




E l 100 b t h it l i itExample: 100 subsequent hospital visits80 99231 - $ 2605

10 99232 - $ 532

10 99233 - $ 756Total: $ 3893


Example: 100 subsequent hospital visitsp q p

60 99231 - $ 1954

30 99232 - $ 1595

10 99233 - $ 756Total: $4305


Discharge Services

• Two codes– 99238, 30 minutes or less

– 99239, more than 30 minutes

• Document time spent

It i i t t t h it l• It is appropriate to report hospital discharge on same day as nursing home admit


• Observation (99217, 99218 – 99220, 99224 99226)99224-99226)

• Discharge day management (99217)

• Initial Observation care (99218 – 99220)

• Subsequent observation care (99224 –99226)99226)

• Code selection is based on level of service or time for subsequent levels only


• Observation (99217, 99218 – 99220)

• If the decision to “admit” to observation is made in the course of an encounter in another site; bill only the observation admit

• If the decision to “admit” to inpatient status is made on the same date of service; then bill only ythe hospital admission code

• Normally considered part of surgical post-op global package


• Observation or Inpatient Care (Admit d Di h S D t f S i )and Discharge Same Date of Service)

(99234-99236)

• This is for same date not 24-hour stay

• Includes work for admission and discharge


• Critical care (99291 – 99292)Ti b d d t d t ti• Time–based code; must document time in medical record

• Definition of critical care has been revised• Note bundled codes listed in subsection • Patient in a “critical care” unit does notPatient in a critical care unit does not

constitute critical care being billed


Consultations

Evaluation and Management Services-Consultations

Effective January 1, 2010 Medicare will no longer reimburse consultation CPT codes.


For Medicare:

Consultations in the outpatient setting will be coded as new or established patient visits.


For Medicare:

Initial consultations in the inpatient setting will be coded using either

1. Admit codes 99221 – 99223

2. Subsequent visit codes 99231 - 99233


For Medicare:

New modifier to identify the actual admitting physician on record.

AI(Two letters not alphanumeric)


For all other carriers:

1. Ask

2. And just in case consult CPT codes are still allowed…

Medicare Consultations –Office/Outpatient – new patients

HX EX M (T)

99241 PF PF S 15HX EX M (T)

99201 PF PF S 10

99242 EPF EPF S 30

99243 D D L 40

99244 C C M 60

99201 PF PF S 10

99202 EPF EPF S 20

99203 D D L 30

99204 C C M 45

99245 C C H 80 99205 C C H 60

Medicare Consultations –Office/Outpatient – new patients- 2010 wRVU

99241 .64 99201 .48

99242 1.34

99243 1.88

99244 3.02

99202 .93

99203 1.42

99204 2.43

99245 3.77 99205 3.17


Codes based on Place and Type of Service

Office and Other Outpatient : 99241 - 99245

Office, ER (without admit), observation

Inpatient: 99251 – 99255

Inpatient, ER (with admission)

CONSULTATIONS

Know the Rules

Know the RulesConsultations

Know the three R’s

Request made to

Render an opinion

Respond that opinion back


Know the RulesConsultations Pre-op Physicals

R’Remember the three R’sRequest by made _________

Render preoperative clearance

Respond that opinion back to requestingRespond that opinion back to requesting provider


Know the RulesConsultations

Know when to use consultation codes.

When seeing a patient in the ER, and the decision is to admit, you may use the inpatient consultation codes or the hospitalinpatient consultation codes or the hospital admission codes.

Evaluation and Management Services – Prolonged Care

+ 99354• Office or other outpatient setting

• Face to face patient contact beyond the usual service

• First hour (at least 30 minutes)

• Use +99355 for each additional 30 minutes

Evaluation and Management Services – Prolonged Care

+ 99356• Inpatient setting

• Face to face patient contact beyond the usual service

• First hour (at least 30 minutes)

• Use +99357 for each additional 30 minutes

Know the Rules

Care Plan Oversight

Know the Rules

Care Plan Oversight (CPO) is physician supervision (non face to face) of the care for a patient who is

1. Under care of a home health agency

2. Enrolled in a Medicare certified hospice

3. Under care of a nursing facility

Evaluation and Management Services – Care Plan Oversight

It is a billable service provided a total of 30 minutes or more is accumulated in a calendar month. Services which contribute to CPO are…


• Complex and multi-disciplinary modalities that require physician development and revision of the plan care p y p p

• Time spent reviewing laboratory and other diagnostic studies

• Communication (face to face or telephone) with other health care professionals involved with the patient’s care

• Integration of new information in the treatment plan that requires adjustment of medical therapies

• Medicare CPO does not apply for patients receiving skilled care in a nursing home.


• SERVICES THAT CONSTITUTE CPO:

• Review of charts, reports, treatment plans, or lab or study results

• Telephone calls with other health care professionals (does not include patient/family calls)patient/family calls)

• Team conferences (must document time spent per individual patient)


• SERVICES THAT CONSTITUTE CPO:

• Telephone or face to face discussions with a pharmacist

• Medical decision making

• Activities to coordinate services

• Documenting the service provided in the patient chart.


DOCUMENTATION:Date, service and time spent must be documented in the patient chartp


• NOTE:

O l th ti th tt di h i i d• Only the time the attending physician spends on care plan oversight can be counted towards the 30 minute total

• The physician is required to see the patient within 6 months prior to the initial billing for care plan oversightplan oversight

• The physician who signed the plan of care must be the same as the one who bills for CPO


• NOTE:

• Only one physician per month may bill CPO

• The physician may not be an employee of the hospice

Nurse practitioners physician assistants• Nurse practitioners, physician assistants and clinical nurse specialists may bill for CPO

Evaluation and Management Preventive Medicine????

• Well visit• Well visit

• Well woman– Medicare

– Non Medicare

• School/sports• School/sports

• IPPE

• AWV

E/M Preventive

Prevent ProblemsKnow what is expected when the

appointment is made

Be sure to repeat to patient the reason for the visit


Preventive Medicine Services

Code selection is determined by patient status (new or established) and patient age

New Patient : 99381 – 99387

Established Patient : 99391 99397Established Patient : 99391 - 99397



The 2002 CPT manual provided new verbiage within the guidelines found in the Preventive Medicine Services subsection that defines the exact nature of the physical examination performed duringphysical examination performed during this type of encounter.



“ The ‘comprehensive’ nature of the Preventive Medicine Service codes 99381 – 99397 reflects an age and gender appropriate history/exam and is NOT synonymous with the ‘comprehensive’synonymous with the comprehensive examination required in Evaluation and Management codes 99201 – 99215.


Preventive Medicine Services performed h bl h iwhen a new problem or a chronic

problem is addressed:

1. Use the -25 modifier on the “problem” visit CPT code

2 Two notes outlining the separate work2. Two notes outlining the separate work performed


Just Getting to Know You…

New patients that present with no complaints and want to “get to know you.”

For any new patient level of service, all three work requirements must be metwork requirements must be met.

If there is no chief complaint or HPI then it will be difficult to have a visit code at all.

E/M Preventive Visits

School or Sports Physicals

Call it what it is

Do not waver

Be clear to patient

Patient can choose a full CPE

E/M Preventive

Well Woman??? What is that ????

• Medicare

• Non-Medicare

• Is it a CPE with a PAP?• Is it a CPE with a PAP?

E/M Preventive Medicare

General InformationGeneral Information

https://www.cms.gov/MLNProducts/Downloads/education_products_prevserv.pdf

E/M Preventive MedicareIPPE

• http://www cms gov/MLNProducts/downlo• http://www.cms.gov/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf

AWF

• http://www cms gov/MLNProducts/downlohttp://www.cms.gov/MLNProducts/downloads/Annual_Wellness_Visit.pdf

Medicare AWV

Medicare Modifier

IPPE

INCIDENT TO

INCIDENT TO

• The NPP must be an employee of the physician (leased or contracted); ( );

• The initial visit (for that condition) must be performed by the physician .

• This does not mean that on each occasion of an incidental service performed by an NPP, that the patient must also see the physician.

• It does mean there must have been a direct, ,personal, professional service furnished by the physician to initiate the course of treatment of which the services being performed by the NPP is an incidental part.

INCIDENT TO

• There must be direct personal supervision b th h i i i t l t f thby the physician as an integral part of the physician’s personal in-office service.

• The physician must be physically present in the same office suite and be immediately available to render assistanceimmediately available to render assistance if that becomes necessary

INCIDENT TO

• The physician has an active part in the i f th ti tongoing care of the patient.

• Subsequent services by the physician must be of a frequency that reflects his/her continuing active participation in, and management of, the course of themanagement of, the course of the treatment.

INCIDENT TO

• The non-physician practitioner may only t bli h d ti tsee established patients.

• The physician must show, through documentation, active participation during a non-physician’s encounter with an established patient with:established patient with:– a change in prescription

– an exacerbation of an existing problem

INCIDENT TO

• The physician must have provided an i iti l i t th ti t f th illinitial service to the patient for the illness or injury for which the “incident to” service is being provided. Only the physician can see an established patient with

– a NEW problema NEW problem

INCIDENT TO

• Diagnostic tests must be performed under th t ti i i i tthe testing supervision requirements: general, direct and personal, which are designated by CPT code.

INCIDENT TO

9921199211Sometimes referred to as a “nurse visit” 99211 is

the first of the five levels of established patient visits within the Evaluation and Management section of CPT. By CPT definition the service

may or may not require the presence of amay or may not require the presence of a physician. The presenting problem is minimal

and the time of the encounter is normally about 5 minutes.

INCIDENT TO

9921199211There must be a note in the patient’s chart

explaining why the patient presented (diagnosis) and what service was

rendered.

INCIDENT TO

9921199211The name of the person (signature) who

delivered the service must be clearly indicated along with their credentials and

the date of service.

INCIDENT TO

9921199211Medical decision making is still a key

component. The physician must document their involvement in the care

even if there was no “face to face” time on that date of service.

INCIDENT TO

9921199211If the physician changes a prescription or

writes one based on the information obtained by someone else, then that must be indicated by a note by the prescribing y y p g

physician.

INCIDENT TO

9921199211The key is that the physician must indicate

participation in the decision making process by noting in the medical record

their involvement in the patient care.p

ProceduresNote?

Depth – epidermis, dermis, subcutaneous, p p , , ,etc.

Site – anatomical

Size – measured in centimeters

Work – what was accomplished

Patient status – risk Issue

Procedures

CPT code descriptions are based on these identifying issues. This is all you will to support anything that was done.

Lab and Radiology

• Must make the “order” a part of the plan.

• Must have medical necessity.

Immunizations

Administration codes along with the code for th d tthe product.

90460 – First component with counseling, through 18 years of age

90461 – each additional component, with counseling through 18 years of agecounseling, through 18 years of age

90470 – H1N1 admin, includes counseling if performed

Immunizations

Administration codes along with the code for th d tthe product.

90471 – 90474

• Route of administration

• Per the vaccine administered, not componentcomponent

• Any age

• No Counseling noted in description

Know the Rules

Modifiers

Basic understanding of when one may be needed and the documentation required to

support the use

Know the Rules -Modifiers

-25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on theManagement Service by the Same Physician on the Same Day of the Procedure or Other Service

• Modifier is used on E&M codes ONLY.• Same provider as the MINOR surgery(10 day

global). • Separate diagnosis codes are NOT required; per

HCFA d AMAHCFA and AMA.• Submission of documentation may be required

by some third party carriers.

Know the Rules -Modifiers

Modifier – 24U l t d E l ti d M tUnrelated Evaluation and Management

Services by the Same Physician During a Postoperative Period

• This modifier is used on E&M codes ONLY.

• Select diagnosis code appropriately.• Some third party carriers my require

documentation submitted with the claim.

Correct Diagnosis Coding


Basic Documentation Rules to Code by for Physician PracticesPhysician Practices

When coding from the medical record or source document only code those items clearly stated; DO NOT code anything listed as

• “possible”, • “probable”• probable ,

• “maybe”,

• “suspected”


Basic Documentation Rules to Code by f hfor Physician Practices

There are no “rule-out” codes



Be as specific as possible; code acute conditions as “acute” and chronic

conditions as “chronic”

And be sure they are noted that way in the chart



When a concise diagnosis cannot be made, code based on signs and symptoms

Signs and symptoms do not have to be separately listed if they are an integral part of the p y y g punderlying diagnosis or condition already coded.



• Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.

C d f d ll diti th t• Code for any and all conditions that were treated or affected treatment.



Be sure to code all manifestations and complications.

SEVERITY & MEDICAL NECESSITY


Basic Documentation Rules to Code by for Ph i i P iPhysician Practices

It is the responsibility of the provider of care to link the diagnosis to the CPT code whether it be on the encounter form or whatever “billing” form is in use.b g

Incorrect linkage leads to denials based on medical necessity.



Personal history (V-codes) explain a patient’s past medical condition that

– No longer exists

– Is not receiving any treatment

– Has the potential for recurrence

Thank YouJ i J h CPC CEMC CPMA CPC IJaci Johnson, CPC, CEMC,CPMA, CPC-I,

CPC-HPractice Integrity LLC, Owner

[email protected] 467 1554

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