1 Coding Tips Changes & Challenges What s s New in 2008 CPT, ICD-9? Perinatal Workshop April, 2008
2 Code idea Perinatal Coders COCN AAP CPT Application CPT Panel Facilitation RUC for Value Federal Register Published CPT
3 Disclosure I have the following financial relationships with the manufacturer(s) of commercial product(s) and/or provider(s) of commercial services discussed in this CME activity: My content will/will not include discussion/ reference of any commercial products or services. I do/do not intend to discuss an unapproved/ investigative use of commercial products/devices.
4 What will we discuss? Major renumbering for 2009! New codes Code revisions Code language changes Needed codes? Areas of compliance attention Repeated questions, concerns
5 Renumbering The following codes will be brought to a separate section of CPT (code numbers series) Normal newborn Delivery room management Critical care transport Critical care services Intensive care services
6 Medical Team Conferences Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by non-physician qualified health care provider Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician
7 Medical Team Conferences Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family not present, 30 minutes or more, participation by non-physician qualified health care provider 9936X4 Medical team conference with patient/family and physician present (REJECTED)
8 Medical Team Conferences Face to face requirement Minimum of (3) health care participants Must be different specialties Must provide services to patient Must provide services within the last 60 days Physicians may report patient/family present care with other E/M services Counseling represents >50% Global code reporting?
9 Medical Team Conferences Must document their participation and their suggestions May not report if you are contractually connected to the hospital/facility Starts at the beginning of the review and ends at the conclusion at the review Do not add report generation or record keeping time
10 New Telephone Codes Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days or leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion minutes of medical discussion minutes of medical discussion
11 New Telephone Codes Telephone evaluation and management service provided by a qualified non-physician health care professional to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days or leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion minutes of medical discussion minutes of medical discussion
12 Communications Online evaluation and management service provided by a physician to an established patient, guardian, or health care provider not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network (Do not report when using , for the same communication s])
13 Sick Admit Code Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or less, who requires observation, frequent interventions and other intensive care services For the initiation of inpatient care of the normal newborn report For initiation of the care of the critically ill neon ate use For initiation of inpatient hospital care for the neonate not requiring intensive observation, frequent interventions or other intensive care services use
14 PICU Expanded Age Two new PICU codes approved and valued this year: age 2 through X1: admit code RVU s Times: 30/105/ X2: subsequent days 6.75 RVU s Times: 20/65/20
15 Infusion Services Guidelines Therapeutic infusion services codes have been revised to indicate that these codes are not intended for physician reporting in the facility setting. Rather in the facility these codes are reported by the non-facility only. This means in an office because the major value of the code is the office PE expense
16 Modifier Language Revisions
17 Renumbered Codes Next Year Old Code New Code Descriptor Aspiration bladder; by needle Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent Thoracentesis with insertion of tube with or without water seal Tube thoracostomy with or without water seal
18 New Code Proposals What Have We Missed???
19 New Code Proposals Transitional care v. consultations Intensive care for infant >5 kg How many? What upper weight? Medical team conference with the family and physician present Reinstate the 4 th code? Others?
20 Unvalued Services How do I value? Could choose time based consult code, time based ED code
21 Compliance Attention
22 Consultations Have been defined for the next year or two as the primary area of investigation and audit review by CMS and the OIG. The main target is academic medical centers coding return visits for established patients as consults Also under review repetitive inpatient consults by same specialist Medicaid will follow at the state level and has also begun to focus on this area
23 CMS Consult Rule Changes NPP may order and provide consults IP consults only ONCE per hospital Subsequent care OP consult may be repeated Written request must be included in the plan of care (OP) and in the orders (IP) If verbal request received both requester and consultant must document this in the record Consult cannot be routinely ordered May request consult from another in your group
24 Consultations A consultation initiated by a patient and/or family, and not requested by a physician Or other appropriate source (eg, physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer, insurance company) e.g. prenatal consult Is not reported by the consultation codes but by the office, home, domiciliary or rest home codes
25 Consultations If subsequent to the completion of the consultation the physician assumes responsibility for a portion or all of the patient(s) condition, the appropriate E/M codes for the site of service should be reported. In the hospital setting the consulting physician should use the appropriate inpatient consultation code for the initial encounter and then subsequent hospital codes. In the office setting the physician should use the appropriate office or other outpatient consultation codes and then the established patient office or other outpatient services code
26 Resources Coding for Pediatrics Coding Hotline AAP CPT 2008 Medicare RBRVS 2008 Coding Companion AAP CPT Assistant AMA
27 Continued Reduction in CMS Work RVU s
28 5Yr Review w-rvuw Work Re-value Of Discharge & Consult Codes Code W-RVU W-RVU
29 5Yr Review w-rvuw Work Re-value Of Transport & Critical Care Codes Code W-RVU W-RVU
30 5Yr Review w-rvuw Work Re-value Of The Inpatient Codes Code W-RVU W-RVU
32 Missouri Medicaid State Medicaid decided to allow submission and payment of the global codes ONLY paid if the neonatologists are in house for 24 hours!!!
33 CPT Assistant January 2008 It is appropriate to report normal newborn services on the same day that sick, intensive or critical care services are reported if the services are separated by time. The critical care global codes do NOT require a 24/7 in house presence to report them; direct physician supervision does not require an in house presence.
34 Language Changes Associated with Renumbering If two separate groups report critical services on the same date the referring physician reports hourly critical care services and the receiving nursery reports the global charge. It is appropriate to report procedures that are part of the resuscitation even if the neonate is admitted and receives a global critical care code on the date of admission.
35 Coding Quagmires
36 Surfactant Intrapulmonary surfactant administration by a physician through endotracheal tube Not part of resuscitation Cannot be given as convenience; must be clear evidence that the dose cannot wait until the newborn is admitted to the nursery We do not wish to risk loss of ET and Lines in the DR
37 Billing at 2 Sites Same group cannot bill for services provided at more than one site to the same patient on the same date of service Group is considered single physician Services related to the same illness provided in the office, ED, observation and hospital on the same date of service by the same physician or group only reports the hospital admit
38 Documentation Minimal audit requirements: Critically ill ; requires intensive care services ; continues to require hospital care Present body weight Physical presence Physical exam, can be focused Frequent evaluation (critical, intensive) Review of data, studies, results Review of care plan with team Clear involvement in MDM
39 EMR Reporting Carry over notes with repetitive data from previous days not useful and concerning Often notes have contradictory data and do not apply to the child s condition on date of service Clear documentation of attendance Cannot be assumed by note or signature Match template to requirements Physical presence, frequency of evaluation, condition, weight, new data, exam, assessment, medical decision making, team discussion
40 The PATH Guidelines Getting it Right!
41 Using NNP Notes NNP s are NOT covered by PATH! Two questions to ask: Can the NNP practice independently? State nursing Board makes decision NNP must be approved for scope of practice Is the NNP employed by the hospital or the neonatal group?
42 NNP Notes Licensed for independent practice and hospital employed Can only use PFSH and ROS No different from bedside nurse NNP costs already rolled into the Medicare and Medicaid cost reports double dipping Stark violation
43 Correct Coding Practices
44 Critical Care Does the note state the child is critical? Do the parents understand the child is critical? Does the status indicate critical? Is nursing staffing consistent with critical? Is there truly highly complex medical decision making involved?
45 Critical Care How much face to face care was required? How many lab tests were required/reviewed? How much data was needed for review? How comprehensive was the physical exam? What technology is required? How unstable was the child? How many organ systems are involved?
46 The CPT Definition Critically ill or injured patient Acutely impairs one or more organ systems High probability of imminent or life threatening deterioration Highly complex medical decision making Both the illness and the treatment must meet the definition Interpretation of multiple physiologic parameters required
47 Critical Care Times / RVU s CODE Intra-service time Work RVU s
48 Use the Modifier -63 Only for those procedures that are NOT specific to neonates, e.g.: Lumbar puncture Bladder taps Bladder catheterization Thoracocentesis Thoracostomy Pericardiocentesis Peritoneocentesis
49 Immunization Counseling CPT and the RUC approved physician work for counseling parents when immunizations are provided Pediatric specific codes MD work: = 0.17 (<8yr, im/sc, first) = 0.15 (each additional) = 0.17 (<8yr, po/in, first) = 0.17 (each additional)
50 1 or 2 Admissions?? Well newborn examined in the morning and then gets sick later in the day. Same doctor: (2) admissions Hospital sick care admit later becomes critical Same doctor: (1) code only upcode or to 99295
51 1 or 2 Admission(s)?? Admitted to floor early in the day; later becomes critical and admit to NICU. Different doctor: (2) admissions or and Admitted sick, hospital (1); admit critical hospital (2) Same group: (1) code Different group: (2) admit codes or and 99295
52 1 or 2 Admission(s)?? Critical care admit hospital (1); transfer to hospital (2) for critical care (higher level) Different group: (2) admissions or or Critical care admit hospital (1); transfer to hospital (2) for critical care (higher level) Same group: (1) admission or 99295
53 1 or 2 Admission(s)?? Initial hospital sick code; (2) days subsequent hospital care codes; day (4) child becomes critical Same group: or on day (1) or on day (2,3) 99296
54 But I Spent A Lot More Time! Global codes do NOT allow for additional time beyond the surveyed means Cannot switch back and forth from sick hospital codes and critical care codes simply based upon time you spend at bedside Can utilize either the -25 modifier or the prolonged service codes (time based face to face or non-face to face) for hospital sick care or consultative codes (not critical) Modifiers are NOT time based
55 But I Am Not Being Paid! Correct coding must be utilized for fraud/abuse purposes EVEN IF the code is not being paid (NCCI edits/oig) HIPAA gives private insurers same audits The AAP and its reimbursement committees must be informed and intervene for you State chapters of the AAP can help HIPAA can help with uniform reporting and payment policies Individual state Medicaid codes will disappear
56 Neonatology 2008 Coding Modifier 59: : Distinct Procedural Service Used to identify procedures/services which are distinct or independent from other services or procedures performed on the same day. This may represent: 1. A different session or patient encounter 2. A different procedure or surgery 3. A different site or organ system
57 Questions?? Thank you!