Billing and Coding Conference

Transcription

1 Billing and Coding Conference February 26 th 2013

2 Agenda 1. Hospital Medicine Coding Pattern 2. Tips to maximize individual billing 3. Billing audit 4..SPLITSHAREDNPPVISIT 5. Basic Coding Guidelines focus on Decision Making examples from 6. Observation Coding 7. Advanced Coding / Billing 8. ICD 10 update 9. Q&A

3 Levels of Service Admission FY2014 Level % Level % Level % Subsequent Level % Level % Level % Discharge Level % Level %

4 Levels of Service Admission FY2014 FY2012 Level % 5.1% Level % 12.5% Level % 82.4% Subsequent Level % 1.5% Level % 19.6% Level % 78.9% Discharge Level % 97.2% Level % 2.8%

5 Levels of Service Admission Subsequent Day Discharge RVUs Billed $296 $399 $489 Collected $84 $114 $152 RVUs Billed $150 $212 $289 Collected $33 $61 $88 RVUs Billed $221 $276 Collected $56 $83

6 CPT description 2012 TABLE CPT (wrvu) high level in-patient admit high level in-patient consult high level in-patient follow-up >30 minutes in-patient discharge critical care initial critical care add on prolonged service initial in-patient prolonged service add on in-patient central line paracentesis lumbar puncture thoracentesis CPR/Resuscitation smoking cessation counseling 3-10 min smoking cessation counseling > 10 min

7 CPT description 2012 TABLE CPT (wrvu) # high level in-patient admit ,242 high level in-patient consult high level in-patient follow-up ,994 >30 minutes in-patient discharge critical care initial critical care add on prolonged service initial in-patient prolonged service add on in-patient central line paracentesis lumbar puncture thoracentesis CPR/Resuscitation smoking cessation counseling 3-10 min smoking cessation counseling > 10 min

8 Billing tips for maximizing individual billing We used the top 3 billers comments from FY2013 to assembly this list 1. I keep list of my patients with level of billing noted if I don t bill in the day of service 2. I try to bill higher level supported by documentation every single time 3. I bill extended visit for family meetings 4. I bill critical care when I can 5. On busy days I tend to take extra patients or minimize the hands off to nights while on Bridge 6. I bill for smoking counseling, prolonged care, critical care whenever possible

9 Billing Audit Weekly billing audit - We use Schedule vs Billing report and after a 7 day grace period we report number of days delayed for each day on service without billed encounters - We compare the billing data with census data and we eliminate the shifts that could have 0 billable encounters (Bridge, LG, Weekend nights) - Currently we report deindentified data and follow-up on the effect of this measure - We will automate the process with a series of 3 s at one, two and three weeks, escalating the recipients for each

10 .SPLITSHAREDNPPVISIT When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient s medical record) then the service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim. * Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners (Rev. 2848, )

11 .SPLITSHAREDNPPVISIT Documentation by the attending physician should include: 1. an attestation that unequivocally demonstrates their personal encounter with the patient 2. the name of the individual with whom the service is shared/split 3. each provider must document their portion of the rendered service 4. date and legibly sign their corresponding note I personally performed a substantive portion of this patient encounter in conjunction with ***. The patient presents with ***. On physical examination, I personally found ***. My impression/plan is ***.

12 Basic Coding Guidelines Medical Decision Making Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering the following factors:

13 Medical Decision Making University of Chicago

14 CPT Documentation Requirements HISTORY C/C and 4 elements of the HPI (character, onset, location, duration, associated signs etc or the status of 3 chronic medical conditions. and 2 review of systems and 1 area from Past Medical, Medications, Allergies, Family, Social history AND EXAM Extended exam of the affected body area and other symptomatic or related organ systems or 6 areas (2 bullets each) or 2+ areas (12 bullets total). Documenting three vitals is considered a bullet AND DECISION MAKING One diagnosis University of Chicago Example C/C: My leg is red HPI 28 yo Male with 3 day history left calf pain. 6/10, dull, constant. Associated edema, erythema. PMH Smoker Exam 120/ temp, well appearing heart: RRR without murmur, good femoral pulses lungs: clear to auscultation, normal effort abdomen: soft, no palpable liver Skin: erythema lines marked and noted, induration present Musculoskeletal: normal ROM knee, no clubbing, cyanosis ROS: No CP or SOB Labs none. No xrays Impression Cellulitis Plan IV access and antibiotic administration

15 CPT Documentation Requirements HISTORY C/C and 4 elements of the HPI (character, onset, location, duration, associated signs etc or the status of 3 chronic medical conditions. and 10+ review of systems and All 3 areas documented: Past History (things like medical, medications, allergies) AND Family History AND Social History AND EXAM 1995 Guidelines: 8 or more systems documented 1997 Guidelines: 9 areas with two bullets each AND DECISION MAKING 2 out of 3 Number of diagnoses and management options: 3 points Amount and complexity of data to be reviewed: 3 points Table of risk: Moderate risk. University of Chicago Example C/C: My leg is red HPI 28 yo Male with 3 day history left calf pain. 6/10, dull, constant. Associated edema, erythema. PMFSH On no meds. Smoker, Mother with eczema ROS Except as dictated above, all other systems were reviewed and otherwise negative Exam 120/ temp, well appearing (HENT): Normal Eyes: Normal CV: Normal Respiratory: Normal GI: Normal Psychiatric: Normal Skin: Edema, warmth, redness right leg, lines consistent with cellulitis, marked with skin marker. Labs WBC 13K Impression Cellulitis Plan Antibiotics. Reviewed with ER physician.

16 CPT Documentation Requirements HISTORY C/C and 4 elements of the HPI (character, onset, location, duration, associated signs etc or the status of 3 chronic medical conditions. and 10+ review of systems and All 3 areas documented: Past History (things like medical, medications, allergies) AND Family History AND Social History AND EXAM 1995 Guidelines: 8 or more systems documented 1997 Guidelines: 9 areas with two bullets each AND DECISION MAKING 2 out of 3 Number of diagnoses and management options: 4 points Amount and complexity of data to be reviewed: 4 points Table of risk: High risk. University of Chicago Example C/C: My leg is red HPI 28 yo Male with 3 day history left calf pain. 6/10, dull, constant. Associated edema, erythema. PMFSH On no meds. Smoker, Mother with eczema ROS Except as dictated above, all other systems were reviewed and otherwise negative Exam 120/ temp, well appearing (HENT): Normal Eyes: Normal CV: Normal Respiratory: Normal GI: Normal Psychiatric: Normal Skin: Edema, warmth, redness right leg, lines consistent with cellulitis, marked with skin marker. Labs WBC 13K Venous doppler report reviewed. No clot. Impression Cellulitis Plan Antibiotics. Reviewed with ER physician.

17 CPT Minimum Documentation Requirements 2 OUT OF 3 HISTORY 1 element of the HPI (character, onset, location, duration, associated signs etc) or the status of 3 chronic medical conditions. EXAM 1 organ system DECISION MAKING 2 out of 3 Number of diagnoses and management options: 1 points Amount and complexity of data to be reviewed: 0 points Table of risk: Minimum risk. University of Chicago Example 1 No pain 120/80 80 Tmax 98.9 (three vital signs) A P Example 2 S 120/80 80 Tmax 98.6 HTN, controlled P

18 CPT Minimum Documentation Requirements 2 OUT OF 3 HISTORY One HPI (Character, onset, location, duration...) OR the status of three chronic medical condition and One ROS University of Chicago Example 1 sharp pain in abd, no SOB 120/80 70 Tm 98.6 Alert, reg pulse, no wheezing, no leg edema, no rash (6 bullets) A P EXAM 2 organ system (1995 Guidelines) 6 bullets (1997 Guidelines) DECISION MAKING 2 out of 3 Number of diagnoses and management options: 3 points Amount and complexity of data to be reviewed: 3 points Table of risk: Moderate risk. Example 2 No SOB 120/80 70 Tm 98.6 Alert, reg pulse, no wheezing, no leg edema, no rash HTN, stable COPD, stable CAD, stable P

19 CPT Minimum Documentation Requirements 2 OUT OF 3 HISTORY 4 HPI (Character, onset, location, duration...) OR the status of three chronic medical condition and 2 ROS EXAM 6 areas with 2 bullets each or 12+ bullets in 2+ areas DECISION MAKING 2 out of 3 Number of diagnoses and management options: 4 points Amount and complexity of data to be reviewed: 4 points Table of risk: High risk. University of Chicago Example 1 RLQ abdominal pain, sharp, started yesterday, constant no CP, no SOB 120/80 80 Tm 98.6 Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness, no clubbing, no synovitis, no rash A P Example 2 S 120/80 80 Tm 98.6 Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness, no clubbing, no synovitis, no rash Labs INR 1.7 on coumadin CXR film personally reviewed-normal Discussed antibiotic options with Dr Smith A P

20 CPT 99238/99239 University of Chicago Face-to-face evaluation and management (E/M) service between the attending physician and the patient. The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified nonphysician practitioner even if the patient is discharged from the facility on a different calendar date. Only one hospital discharge day management service is payable per patient per hospital stay. Example Patient seen and evaluated in the day of discharge D/C time 35 minutes Only the attending physician of record reports the discharge day management service. Physicians or qualified nonphysician practitioners, other than the attending physician, who have been managing concurrent health care problems not primarily managed by the attending physician, and who are not acting on behalf of the attending physician, shall use Subsequent Hospital Care (CPT code range ) for a final visit.

21 Observation Coding Guidelines Scenario Observation care for less than 8 hours on the same calendar date Admitted for observation care and discharged on a different calendar date Observation care for 3 days Observation care for a minimum of 8 hours, but less than 24 hours, and is discharged on the same calendar date CPT Code to be used Initial Observation Care ( ); Observation Care Discharge Service (99217) shall not be used Initial Observation Care ( ) and Observation Care Discharge (99217). Initial Observation Care ( ) and Subsequent Observation Care ( ) and Observation Care Discharge (99217) Admission and Discharge Services ( )

22 Observation Coding Guidelines Scenario Patient admitted to inpatient status before the end of the date on which the patient began receiving hospital outpatient observation services Patient admitted to inpatient status from hospital outpatient observation care subsequent to the date of initiation of observation services CPT Code to be used Initial Hospital Visit ( ) Initial Hospital Visit ( ) shall not bill the hospital observation discharge management (99217) or other codes The physician shall satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. * Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners (Rev. 2848, )

23 Advanced Billing University of Chicago 1. Billing 2 E/M Codes in the same group in the same day When a hospital inpatient or office/outpatient evaluation and management service (E/M) are furnished on a calendar date at which time the patient does not require critical care and the patient subsequently requires critical care both the critical Care Services (CPT codes and 99292) and the previous E/M service may be paid on the same date of service CMS 2. Smoking Cessation Counseling If the patient is symptomatic for greater than 3 minutes up to 10 minutes of counseling (intermediate) for greater than 10 minutes of smoking cessation counseling (intensive)

24 Advanced Billing University of Chicago 3. Prolonged Service Codes CPT (inpatient prolonged service codes) 30 to 60 minutes of additional time past the threshold time of the original code ( min, min, min) CPT (inpatient additional prolonged service codes) once you have met the threshold for (60 minutes) you can bill a for every additional 30 minutes (minimum of 15 minutes). You must document the total time spent during the face-to-fact portion of the encounter, and the additional unit or floor time in an additional note or one cumulative note.

25 ICD 10 updates University of Chicago Billing System - DOM Billing system will receive a facelift in the next couple of months - Improved patient list management easier to build your list and maintain it updated, last date billed, etc - Enhanced charge entry options - ICD 10 Epic search engine will be integrated into the billing system - The ICD 10 search engine is an interactive tool that asks for required details in order to generate the right diagnosis code (e.g. CHF / Systolic / Acute vs Chronic, etc) - Mercy billing integration to follow EPIC Billing Module - At least 2 years away Provider training - The Precise learning system provider training for all MDs/NPP to start in the next couple of months

26 Questions and Answers University of Chicago