1 Coding, billing and documentation tips for effective reimbursement Beth Milligan, MD, FAAFP, CHCOM, CPE
2 Objectives Explain the importance of clinical documentation Understand the principles of documentation Understand the contents of the medical record Discuss how documentation impacts quality of care, health care outcomes and appropriate reimbursement
3 Billing and coding tips Many health care providers miss the opportunities to maximize reimbursement. Under-coding, omitting modifiers and submitting claims without the documentation needed to support them are everyday events.
4 Documentation matters CMS (Medicare) requires that all medical conditions evaluated and treated, as well as a patient s health history, past and present illness, and outcomes are documented in the medical record.
5 Fast track Beware of the tendency to code according to the complexity of the diagnosis rather than the extent of decision making involved. To bill for a Level 4 established patient visit, CPT (current procedural terminology) guidelines require you to fulfill 2 out of 3 following components: a detailed history, a detailed physical examination and medical decision making of moderate complexity.
6 99214 When the history and medical decision-making indicate a higher level of complexity, you can bill for a visit without having to count or document individual body systems or detailed exam elements. A new diagnosis with a prescription, an order for laboratory tests or X-rays, or a request for a specialty consult are all examples of moderate complex decision making.
7 99203/99204 In 2006, CMS data showed that family physicians billed 43.9 percent of new patient visits as Level 3 (99203) and just 28.5 percent as Level 4 (99204). Unlike a level 4 visit for an established patient, a code new patient visit is requires all 3 components-a detailed history, a detailed physical examination, and a moderate complex decision making.
8 99203/99204 A new patient visit for a 57-year-old female with congestion and cough and chest pain may warrant a if her medical history of obesity, hypertension and reflux made it necessary to rule out a cardiovascular disorder. This must be documented.
9 Modifier 25 Proper documentation is critical when using modifier 25 (procedure). In 2002, Medicare approved approximately 29 million claims using modifier 25, then disallowed nearly 35 percent of them for failing to meet the documentation requirements.
10 Modifier 25 If modifier 25 is used with Medicare, two separate progress notes and the work performed for each need to be clearly defined. Lesions needs to have the dimensions, depth and location documented in the targeted evaluation and management.
11 Know when to bill for prevention Patients who present for yearly health maintenance examinations with a new complaint may indicate using a modifier 25. The note must indicate significant and separate services.
12 Know when to bill for prevention Sometimes, the distinction can be harder to establish. If the acute or chronic problem evaluated is stable and closely related to the prevention examination, then it may not be necessary to submit an E/M code. If the problem or complaint is an exacerbation requiring a significant history, physical exam and treatment beyond what is typically performed during a routing preventative visit, then the E/M should be coded.
13 Time Sometimes a higher level E/M code based solely on time, regardless of the complexity of the medical history, physical exam, or decision making If more than half the time spent with the patient is devoted to counseling and coordination of care, time may be considered the key or controlling factor to qualify for a particular level of E/M service, according to CPT guidelines. Describe in detail the nature of the counseling or activities to coordinate care.
14 Dermatology procedures Focus on measurements. Generally the larger lesion has greater reimbursement. A biopsy generally indicates that only a portion of a lesion was removed to obtain a histologic diagnosis as in the case of a punch biopsy. Location also dictates the scale of reimbursement, which is typically lower for procedures involving the trunk, arms or legs than those on the face or anogenital region. Malignant lesions also generate higher charges
15 Welcome to Medicare exam Known when and how to bill a Welcome to Medicare visit This exam is within the first six months of enrollment and has seven elements, all of which are required for full reimbursement. To appropriately conduct and bill for this exam, create a template listing all the elements.
16 Prioritize diagnoses Patients present with multiple diagnosis during a single routine office visit. ICD-9 coding guidelines state that physicians should list first the ICD-9 CM code for the diagnosis, condition, problem or other reason for the encounter in the medical record to be chiefly responsible for the services provided, and then list additional codes that describe coexisting condition.
17 Prioritize diagnoses Listing the codes in order of importance lets the third-party payers known how to prioritize patient care. Define conditions which are acute, chronic and stable.
18 ICD-9 CM is outdated ICD-9 CM is 30 years old and technology is changing. Many of the existing categories are full and not descriptive enough.
19 ICD-10 CM Reimbursement Would enhance accurate payment for services rendered Quality Would facilitate evaluation of medical processes and outcomes
20 ICD-10 CM Fracture of wrist with ICD-9 does not identify left versus right and requires additional documentation. ICD-10 CM describes left versus right, initial encounter and subsequent encounters. It also describes routine healing, delayed healing, nonunion or mal-union
21 ICD-10 CM Incorporates much greater specificity and clinical information which results in: Improved ability to measure health services Increased sensitivity when refining grouping and reimbursement methodologies Enhanced ability to conduct public health surveillance Decreased need to include supporting documentation with claims Pat Brooks, CMS
22 ICD-10 CM 1990 Endorsed by World Health Assembly (diagnosis only) 1994 Release of full ICD-10 by WHO January 1, 1999 U.S. implemented for mortality (death certificates) 2002 ICD-10 published in 42 languages (including six official WHO languages) Implementation in 138 countries for mortality and 99 countries for morbidity
23 Documentation Why is it important? If it was not documented, it was not done Critical for patient care Serves as a legal document Quality reviews Validates the patient care provided Well-documented medical records reduce the re-work of claims processing Compliance with CMS and other payers regulations and guidelines Impacts coding, billing and reimbursement
24 Background CMS anticipated facilities would focus on documentation improvement in order to capture severity of illness and to increase their reimbursement 2011 Documentation and Coding Adjustment (DCA) was introduced by CMS
25 Background Determined that increase in reimbursement was due to better documentation and not due to the treatment of sicker patients Negative adjustments in reimbursement rate 5.8 percent in 2012
26 Bad documentation habits Documentation shortcuts are tempting for busy clinicians, and the innovations of EHRs have allowed for easier movement of information and made it easier to reuse previous documentation with a single click. The practice of reusing previous information can lead to serious consequences for both patient care and reimbursement.
27 Dangers of copy/paste The practice goes by several names copy and paste, cloning, carrying forward but it has the same effect on the integrity of the medical record. Without careful review of the information being copied from a previous encounter, it can cause contradictions in a patients record. It has been repeatedly observed that information may be copied that is not accurate. Past complaints or symptoms in current documentation can lead to a host of errors.
28 Dangers of copy/paste Many times physicians have clearly cut and pasted large blocks of text or even complete notes from other physicians. Copying the information can show repeat claims for services that were only performed once and can lead to over-reimbursement. Once copy and paste gets into the record, its credibility is compromised, and the auditor doesn t know what is accurate and how much work was actually done during the visit (versus a past visit).
29 Scribing Scribing can be harder to recognize in some EHR systems. In some instances, authenticating notes made by another person can be fraudulent if not acknowledged.
30 Scribing E.g. a medical assistant may complete a history and physical on a patient in totality, and the physician may log in to the record and electronically sign the document in a way that overwrites the presence of the medical assistant. This overwriting misrepresents who provided the service which can alter the amount that is billed. This can be fraud.
31 Documenting by exception Using pre-built text in an EHR or documenting by exception can cause problems. Poorly designed systems and poor practice can speed physicians past steps in performing and documenting care.
32 Team effort and communication Good communication between the medical staff and the coder is essential if invoices are to be completed accurately and efficiently. It includes billers and coders in staff meetings and especially when issues of efficiency and errors are on the agenda.
33 Team effort and communication Increasing the access of one party to the other will reduce errors and lost revenue. Many physicians have moved to outsourcing their billing and coding practices, and while this may save on costs, it limits communication between two parties, increasing the likelihood of mistakes and lost revenue.
34 Payers are taking notice Some payers have already enacted broad policies that condemn carrying forward documentation in any medium, electronic or paper. Clearly defined policies against copy/paste in the electronic record have not been established at some of the major insurance providers in this country. However, specific payer policies will probably increase as more providers use EHRs
35 Stopping bad habits Stopping bad documentation habits can be tough. Some EHR manufacturers have altered their systems to make practices like copy/paste impossible. Understand that the EHR is a tool for documentation but not an answer to documentation problems.
36 Be prepared Hospitals and clinics need to prepare for changes in future payment methodologies. Complete and concise documentation leads to correct coding, and correct coding leads to appropriate reimbursement.
37 Improving documentation Conduct an assessment of your current department by evaluating staffing needs and reviewing current medical record processes Identify areas that need improvement Benchmark performance Review coding and compliance policies and procedures Start a documentation improvement program or make improvements to your current one
38 Resources The Clinical Documentation Improvement Specialist s Handbook, Marion Kruse/Heather Taillon, 2011 Documentation Strategies to Support Severity of Illness, Robert Gold, MD 2005 Eliminating Waste and Fraud in Medicare and Medicaid, Deborah Taylor, 04/22/09,