Non-Physician Practitioner Services Coding & Reporting. Karla R. Peter, RHIT, CCS, CCS-P, CPC Avera Health September 6, 2013

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1 Non-Physician Practitioner Services Coding & Reporting Karla R. Peter, RHIT, CCS, CCS-P, CPC Avera Health September 6, 2013

2 Medical Necessity Overarching Criterion Medicare Claims Processing Manual, Chapter 12 states, Medical necessity of a service is the overarching criterion for payment in addition to the individual reuirements 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. 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 reported.

3 Evaluation & Management (E/M) Service What is an E/M service? Typically, a face-to-face encounter with a patient for the purpose of diagnosing and/or treating one or more acute or chronic problems that the patient is experiencing. E/M services involve: Taking a patient s history; Doing a physical exam; and, Exercising medical decision-making. 3

4 E/M Documentation Guidelines 1995 versus 1997 (General Multi-System & Single Organ System) 1995 Documentation Guidelines dg.pdf 1997 Documentation Guidelines TER1.pdf 4

5 E/M Code Selection - Seven Components History Examination Medical Decision-Making Counseling Coordination of Care Nature of Presenting Problem Time 5

6 E/M Code Selection - Key Components History Chief Complaint History of Present Illness (HPI) Review of Systems (ROS) Past, Family, Social History (PFSH) Examination Medical Decision-Making (MDM) Number of Diagnoses or Treatment Options Amount/Complexity of Data to be Reviewed Risk of Complications/Morbidity/Mortality

7 E/M Key Components Extent Performed & Documented History Problem-Focused (PF) Expanded Problem-Focused (EPF) Detailed Comprehensive Examination PF EPF Detailed Comprehensive Medical Decision-Making (MDM) Straightforward Low Complexity Moderate Complexity High Complexity

8 History Chief Complaint A concise statement describing the symptom, problem, condition, diagnosis, or reason for the patient s visit. DG: The medical record should clearly reflect the chief complaint. 8

9 History History of Present Illness A chronological description of the development of the patient s present illness from the first symptom to the present time. Must be documented by the billing provider. CC, ROS, and PFSH may be Recorded by Someone Other than the Billing Provider Includes elements such as Location, Quality, Severity, Timing, Context, Duration, Modifying Factors, Associated Signs/Symptoms and Extended HPI (1997 only). 9

10 History Review of Systems An inventory of body systems obtained through a series of uestions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. Includes 14 Systems (i.e., Eyes, Cardiovascular, Respiratory, Allergic/Immunologic, etc.) All Others Negative May be Documented by Someone Other than the Billing Provider 10

11 History Past, Family and/or Social History Past History Past experiences with illnesses, treatments Family History Review of medical events in patient s family, including diseases that place the patient at risk Social History Age-appropriate review of past and current activities May be Documented by Someone Other than the Billing Provider Referring to Old Records Document Specific Date so that Record can be Easily Referenced (i.e., Past Medical History is unchanged since last admission of ) 11

12 1995 Examination Body Areas Versus Organ Systems Documentation Guidelines Comprehensive General multi-system examination should include findings about 8 or more of the 12 organ systems. Problem Focused (PF), Expanded Problem Focused (EPF), Detailed specific number of organ systems not defined. 12

13 1997 Examination Problem Focused (PF) 1-5 elements identified by a bullet in one or more areas/systems Expanded Problem Focused (EPF) At least 6 elements identified by a bullet in one or more areas/systems 13

14 1997 Examination Detailed At least 6 organ systems/body areas. For each system/area selected, performance and documentation of at least 2 elements identified by a bullet is expected; or At least 12 elements identified by a bullet in two or more systems/areas Comprehensive At least 9 organ systems/body areas. For each system/area selected, performance and documentation of all elements identified by a bullet should be performed; or For each area/system, documentation of at least 2 elements identified by a bullet is expected. 14

15 Medical Decision-Making Refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: Number of possible diagnoses and/or number of management options; Amount and/or complexity of the data obtained; and Risk of complications and co-morbidities 15

16 Number of Diagnoses or Management Options Based on the number and types of problems addressed during the encounter Established/New Stable/Worsening Additional Workup Planned 16

17 Amount and/or Complexity of Data Reviewed Based on the types of diagnostic testing ordered or reviewed, the decision to review old records or obtain history from sources other than the patient Labs, x-rays, discussing tests with the performing physician, reviewing old records, independent interpretation of an image versus review of report only (i.e., radiology) 17

18 Risk of Significant Complications Based on the risks associated with the presenting problem(s), diagnostic procedure(s), and possible management options Concurrent conditions Medications Planned treatment 18

19 Three Key Components 1995 Versus 1997 History 1995 Versus 1997 One Exception Examination 1995 Versus 1997 Various Differences 1995 EPF Versus Detailed 1997 General Multi-System Versus Single Organ System Vital Signs Medical Decision-Making 1995 Versus Same 19

20 E/M Code Categories Used to Report Professional Services in a Variety of Settings Office or Other Outpatient Services (Office Visits) New Patient Versus Established Patient Hospital Inpatient Services Nursing Facility Services Skilled Nursing Facilities (SNF) Intermediate Care Facilities (ICF) Long-Term Care Facilities (LTCF) Emergency Department (ED) Services More 20

21 New Patient CPT Definition New Patient One who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. Concept does not apply to all E/M code categories (i.e., ED) Definition of same group practice Tax ID number MAC Decision 21

22 Established Patient CPT Definition Established Patient One who has 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. Any professional service means a face-to-face service by the physician/provider Does not include diagnostic interpretations (i.e., EKG interpretation) when the patient did not have a face-to-face service with the physician/provider 22

23 Office Visits New Patient Reuires 3 of 3 Key Components: PF History, PF Exam, Straightforward MDM EPF History, EPF Exam, Straightforward MDM Detailed History, Detailed Exam, Low Complexity MDM Comprehensive History, Comprehensive Exam, Moderate Complexity MDM Comprehensive History, Comprehensive Exam, High Complexity MDM

24 Office Visit Established Patient Level No Specific Reuirements of Key Components May Not Reuire the Presence of a Physician 24

25 Office Visits Established Patient Reuires 2 of 3 Key Components: PF History, PF Exam, Straightforward MDM EPF History, EPF Exam, Low Complexity MDM Detailed History, Detailed Exam, Moderate Complexity MDM Comprehensive History, Comprehensive Exam, High Complexity MDM

26 Hospital Inpatient Services Initial Hospital Care Reuires 3 of 3 Key Components: Detailed or Comprehensive History, Detailed or Comprehensive Exam, Straightforward or Low Complexity MDM Comprehensive History, Comprehensive Exam, Moderate Complexity MDM Comprehensive History, Comprehensive Exam, High Complexity MDM (**Potential for use of Subseuent Hospital Care code, , for documentation of PF or EPF history and/or exam)

27 Hospital Inpatient Services - Subseuent Hospital Care Reuires 2 of 3 Key Components: PF Interval History, PF Exam, Straightforward or Low Complexity MDM EPF Interval History, EPF Exam, Moderate Complexity MDM Detailed Interval History, Detailed Exam, High Complexity MDM Per CPT, an Interval History focuses on the period of time since the physician last performed an assessment of the patient. Patient s condition is key (i.e., Usually, the patient is stable, recovering, or improving ) along with documentation 27

28 Hospital Inpatient Services Hospital Discharge Day Management E/M Codes No Specific Reuirements of Key Components Report Based on Time Minutes or Less Greater than 30 Minutes 28

29 Nursing Facility Services Initial Nursing Facility Care Reuires 3 of 3 Key Components: Used for patients in SNF s, ICF s or LTCF s Detailed or Comprehensive History, Detailed or Comprehensive Exam, Straightforward or Low Complexity MDM Comprehensive History, Comprehensive Exam, Moderate Complexity MDM Comprehensive History, Comprehensive Exam, High Complexity MDM

30 Nursing Facility Services Subseuent Nursing Facility Care Reuires 2 of 3 Key Components: PF Interval History, PF Exam, Straightforward MDM EPF Interval History, EPF Exam, Low Complexity MDM Detailed Interval History, Detailed Exam, Moderate Complexity MDM Comprehensive Interval History, Comprehensive Exam, High Complexity MDM Patient s condition is key (i.e., Usually, the patient has developed a significant complication or a significant new problem ) along with documentation

31 Emergency Department Services Emergency Department - CPT Definition An organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. New and Established Patient Designations Do Not Apply Not Time-Based Codes 31

32 Emergency Department Services No Delineation Between New or Established Patients Reuires 3 of 3 Key Components: PF History, PF Exam, Straightforward MDM EPF History, EPF Exam, Low Complexity MDM EPF History, EPF Exam, Moderate Complexity MDM Detailed History, Detailed Exam, Moderate Complexity MDM Comprehensive History, Comprehensive Exam, High Complexity MDM Caveat

33 Consultations - Office or Other Outpatient Reuires 3 of 3 Key Components PF History, PF Exam, Straightforward MDM EPF History, EPF Exam, Straightforward MDM Detailed History, Detailed Exam, Low Complexity MDM Comprehensive History, Comprehensive Exam, Moderate Complexity MDM Comp. Hx., Comp. Exam, High Complexity MDM 33

34 Consultations - Inpatient Reuires 3 of 3 Key Components PF History, PF Exam, Straightforward MDM EPF History, EPF Exam, Straightforward MDM Detailed History, Detailed Exam, Low Complexity MDM Comprehensive History, Comprehensive Exam, Moderate Complexity MDM Comprehensive History, Comprehensive Exam, High Complexity MDM 34

35 Pre-Operative Clearance Consultation or Office Visit E/M? Potential for either (Outpatient Consults) (Office visits) Consultation is a type of service provided by a physician or nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is reuested by another physician or other appropriate source. NPPs may report consultation codes Reuest for clearance was of the NPP Reuest for clearance was of the group Within state scope of practice/licensure reuirements Consultation Documentation Criteria 35

36 Consultation Documentation Criteria Consultation Criteria Reuest Reuest documented in patient s record by consulting provider Included in the reuesting practitioner s plan of care Reason/Need Reason/Need for consultation documented Recommendation Documentation of findings/opinion, as well as services ordered or performed Report Written report communicated to reuesting physician or other appropriate source 36

37 Preventive Medicine Services New Patient = E/M Codes Established Patient = E/M Codes Age-Based 37

38 Preventive Medicine Services Preventive Medicine Service Only Preventive Medicine Along with a Separate E/M Service Corresponding Diagnosis Code(s) 38

39 Preventive Medicine Services Preventive Medicine services include: Comprehensive history and exam Anticipatory guidance and risk factor reduction Ordering of appropriate immunizations, lab/diagnostic procedures Treatment/management of insignificant problems CPT definition: Comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures 39

40 Preventive Medicine Services Comprehensive History Does not include: Chief complaint or present illness i.e., Not Problem-Oriented Does include: Comprehensive system review and PFSH Comprehensive assessment of risk factors Comprehensive Examination Multi-system exam Based on age and risk factors 40

41 Preventive Medicine and Problem-Oriented Visits Reporting an Office Visit E/M with Preventive Medicine E/M Ideally, the HPI describes the patient s current problem/symptom Reuire additional work to perform the key components Must be significant and separately identifiable Modifier

42 Preventive Medicine - Medicare Medicare does not pay for routine physicals Service paid by patient Advance Beneficiary Notices of Non-Coverage (ABN) is not reuired Routine physicals are statutorily excluded/non-covered May choose to use Notice of Beneficiary Exclusion from Medicare Benefits (NEMB) df Recommend internal facility guidelines 42

43 E/M Code Selection, Time-Based May assign level based on time when counseling and/or coordination of care dominates (more than 50%) the physician/patient encounter Documentation must include: Total Duration of Visit Amount of time spent in Counseling and/or Coordination of Care Extent of counseling and/or coordination of care

44 Prolonged Services Provider goes above and beyond in the length of time spent with a patient Documentation Duration and content of the E/M service and prolonged service Be specific Documentation by physician or NPP must show that the physician or NPP personally performed the direct face-to-face service Start and end times

45 Prolonged Services Prolonged Physician Service With Direct (Face-to-Face) Patient Contact Add-on codes Less than 30 minutes Do not report Included in base E/M code

46 Prolonged Services - Outpatient Prolonged physician service in the office or other outpatient setting reuiring direct (face-to-face) patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient E/M service) each additional 30 minutes (List separately in addition to code for prolonged physician service) 15-minutes rule (Use in conjunction with 99354)

47 Prolonged Services - Inpatient Prolonged physician service in the inpatient or observation setting, reuiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient E/M service) each additional 30 minutes (List separately in addition to code for prolonged physician service) 15-minute rule (Use in conjunction with 99356)

48 Prolonged Services Total duration of all direct face-to-face service (including the visit) must eual or exceed the threshold time Typical time plus 30 minutes Threshold time Codes and Used to report the final minutes of prolonged service Prolonged service less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

49 Prolonged Services w/time-based Services Time-based reporting Counseling/coordination of care dominates Description of counseling/coordination of care Time documented Duration of counseling/coordinating care Total duration of the visit Prolonged services may only be reported with the highest code level

50 Prolonged Services Without Direct (Face-to-Face) Contact Prolonged E/M service before and/or after direct (face-to-face) patient care first hour each additional 30 minutes Must relate to: service or patient where direct (face-to-face) care has occurred or will occur Ongoing patient management Medicare does not pay for these codes Payment bundled into other billable services

51 Global Periods Major Procedures/Surgeries 90-day global Includes E/M service on the day before and day of procedure Minor Procedures/Surgeries 0- and 10-day global Includes E/M service on the same day as procedure 51

52 Global Surgical Package Pre-operative visits After decision is made to operate Intra-operative services Complications following surgery (Medicare) Complications not reuiring a return trip to the OR Post-operative visits Post-op visits related to recovery from surgery Post-surgical pain management Supplies Miscellaneous services Dressing changes, incisional care, suture removal 52

53 Services Not Included in the Global Surgical Package Initial evaluation to determine need for surgery Visits unrelated to the diagnosis for which surgery was performed Diagnostic tests/procedures Clearly distinct surgical procedures during the post-op period i.e., Staged Procedures Treatment for post-op complications reuiring a return trip to the OR 53

54 CMS-1500 Claim Form Medicare Claims Processing Manual Chapter c26.pdf Consultation Services Box 17 Name of Referring or Ordering Physician Box 17b NPI 54

55 CMS-1500 Claim Form, Continued Box 21 Diagnosis or Nature of Illness or Injury Diagnoses relevant to the visit Box 24b Place of Service 11 Office 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room - Hospital 31 Skilled Nursing Facility 32 Nursing Facility Medicare Claims Processing Manual, Chapter 12, Section

56 Place of Service (POS) Codes These codes are used on professional claims to specify the entity where the service was rendered. Individuals payers may have reimbursement policies regarding these codes.

57 Additional Place of Service (POS) Codes 03 School 09 Prison/Correctional Facility 12 Home 51 Inpatient Psychiatric Facility 54 Intermediate Care Facility 72 Rural Health Clinic

58 CMS-1500 Claim Form, Continued Box 24d Procedures, Services, or Supplies Box 24e Diagnosis Pointer Reference only one diagnosis from Box 21 58

59 ICD-9-CM Diagnosis Coding Reported Diagnoses Must be Substantiated by Provider Documentation Symptom Coding Coding Diagnoses Documented as Probable, Questionable, Possible

60 ICD-9-CM Diagnosis Coding, Continued Acute versus Chronic Conditions Anemia Chemotherapy-Induced Acute Blood Loss Coronary Artery Disease/Arteriosclerotic Heart Disease Osteoarthritis

61 ICD-10-CM & ICD-10-PCS ICD-10-CM Diagnosis Codes ICD-10-PCS Procedure Codes Level of Detail Date of Transition

62 Resources Medicare Claims Processing Manual Chapter 9 Chapter 12 Chapter 18 Chapter

63 Resources, Continued National Government Services Medicare Wisconsin Physician Services Medicare Noridian Administrative Services - Medicare 63

64 Resources, Continued 1995 Documentation Guidelines Documentation Guidelines

65 Questions Any Questions? Karla R. Peter

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