V. Coding Rules: Documentation

Transcription

1 SportsCoder Master This application is for educational uses only. It should not be used as a definitive guide to coding and billing. The authors are not coding and billing experts, and are not responsible for any consequences resulting from the misuse of this application. The intent of the application is to teach proper coding, not how to game the system. AMSSM is not liable for any information in this application. CM/JM 2007 Updated: 1/20/07 I. Attention! Billing (coding) and Collecting are two different things Just because you bill it does not mean you collect it Experts (physician and non-physician expert coders agree only 50-60% of the time), zones of gray (many definitions ambiguous), constant change Variable reimbursements Considerable geographic and insurance plan variability Considerable differences in collections If you get 2 insurance companies to obey the same set of rules, you are doing well If you ve seen one insurance company, you ve seen one insurance company You may have to fight (appeals)! II. Coding 101 Basics: Definitions It s not about changing how you treat patients, it s about getting paid for the work you already do CPT (Current Procedural Terminology) provides uniform language describes medical, surgical, diagnostic services reliable communication among physicians, patients, and third parties E & M codes: for Evaluation and Management Services above & beyond E & M = generate additional fees ICD-9 (International Classification of Diseases) Diagnostic codes Be as specific as possible List as many codes as possible Insurance company software screens to see if codes listed support E/M code, really can t conclude support of E & M from ICD-9 list alone (is why appeal with office note often successful) Inappropriate ICD-9 coding may lead to more denials and bundling Less important & less complicated than E & M codes for billing Don t memorize, are computerized indexes & cheat sheets

2 HCPCS Level II National Codes Hick-Pick codes HCFA (health care financing administration)commonproceduralsystem Find codes for: Medical and surgical supplies, dme, misc. J codes: injection supplies L codes: orthotic devices, arch supports and additions Other: TLSO, cervical collars, orthopedic shoes, braces, etc. III. Coding 101 Basics: Notes Many physicians lose significant income by undercoding (30-35%) Know how to code advantageously Do your own coding Audits and self-audits Mid-levels: teach them No excuses: Learn the codes! Be careful: Non-physician expert coders Only ~50% agreement among all (physician and non-physician) coders Over and under-coding both common Prevalent in physician and non-physician coders New patients over-coded Established patients under-coded Know your E & M criteria! IV. E & M Code Definitions Established patient codes: Rare: or Most common: Many of these can be billed New patient codes: Consultation codes : Medicare eliminated these codes 1/1/10. Many commercial carriers are following suit. Confirmatory consultation codes: omitted 2006 V. Coding Rules: Documentation

3 Coding broken up into 3 areas: H istory, exam, decision making Documentation for respective code must satisfy criteria in each area Established patients: Only 2 of 3 areas required New Patients and new consults: 3 of 3 areas required Time Billing for Time (face-to-face) Particularly useful in sports medicine rehabilitation and return to play issues specialty imaging, coordinating care Established patients more practical Time requirements for new patients/consults longer Many sports visits may qualify for (25 min) >50% of visit must be spent counseling and/or coordinating care Document: type of counseling (rehab), prognosis, differential diagnosis, risks and benefits of Rx, compliance, risk reduction, discussion of care with another provider, etc. VI. Components of Visit: History

4 VII. Components of Visit: Exam Detailed list of requirements available Careful exam and documentation usually eliminates need for list sports visit requires detailed exam from at least 2 areas or satisfy single organ system exam criteria Detailed exam can contribute to 99214, 99203, and (all reimburse well) Need 12 elements from at least 2 systems/areas or 2 bullets from at least 6 systems/areas or 12 elements for single organ system Detailed exam in sports medicine: Usually 12 elements from 2 or more systems/areas in sports Pertinent areas in sports: Constitutional (3 vital signs) Musculoskeletal: 6 areas plus gait & digits Head and neck (one) Spine, ribs, and pelvis (one) Each extremity one area (RUE, LUE, RLE, LLE) Bilateral extremity comparison exams Examine gait and station Exam digits and nails Other: neurological, skin, cardiovascular, pulmonary, psychiatric VIII. Components of Visit: Decision Making Complexity of decision making essentially determines level of code if not billing for time History and exam usually follow suit, but double check documentation Many providers and auditors use scoring worksheets (like those below), but realize that Medicare guidelines do not incorporate worksheets

5 and that they will not likely ensure safety in an audit DM a complex area: often misunderstood and underutilized 3 areas: A. Number of diagnoses or treatment options B. Amount and/or complexity of data to be reviewed C. Risk of complications and/or morbidity or mortality (table of risk) Need 2 of 3 areas to meet code level; highest risk determines level in (C) Mod Complex with sports visit is usually New Probl to examiner (A) & Prescription Drug Mngmt (C) *Red solid boxes represent areas usually pertinent to sports visits *Red broken boxes represent areas occasionally pertinent to sports visits C. Risk of Complications and/or Morbidity or Mortality (Table of Risk) C. Risk of Complications and/or Morbidity or Mortality (Table of Risk)

6 C. Risk of Complications and/or Morbidity or Mortality (Table of Risk) Level of Risk Minimal Low Moderate High Presenting Problems -One self-limited or Minor problem (e.g., cold, insect bite) -Two or more selflimited or minor problems -One stable chronic illness -Acute uncomplicated illness or injury -One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment (e.g., asthma) -Two or more stable chronic illnesses -Undiagnosed new problem with uncertain prognosis (e.g., lump in breast) -Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis) -One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment -Acute or chronic illnesses or injuries that may pose a threat to life or bodily function -Abrupt change in neurologic status (e.g., TIA, seizure, weakness, sensory loss) Diagnostic Procedures Ordered -Lab tests requiring venipuncture -Chest x-rays -EKG/EEG -Urinalysis -Ultrasound -KOH prep -Physiologic tests not under stress (e.g., PFT s) -Non-cardiovascular imaging studies with contrast Superficial needle biopsies -Clinical lab tests requiring arterial puncture Skin biopsies -Physiologic tests not under stress (e.g., PFT s) -Non-cardiovascular imaging studies with contrast (e.g., barium enema) -Deep needle or incisional biopsy -Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac cath.) -Obtain fluid from body cavity (e.g., lumbar puncture, thoracentesis) -Cardiovascular imaging studies with contrast with identified risk factors -cardiac electrophysiological tests -Diagnostic endoscopies -Discography Management Options Selected -Rest -Gargles -Elastic bandages -Superficial dressings -Over-the-counter drugs -Minor surgery with no identified risk factors -Physical therapy -Occupational therapy -IV fluids without additives -Minor surgery with identifiable risk factors -Elective major surgery (open, percutaneous or endoscopic) with no additional risk factors -Prescription drug management Therapeutic nuclear medicine -IV fluids with additives -Closed treatment of fracture or dislocation without manipulation -Elective major surgery (open, percutaneous or endoscopic) with identified risk factors -Emergency major surgery (open, percutaneous or endoscopic) -Parenteral controlled substances -Drug therapy requiring intensive monitoring for toxicity -Decision not to resuscitate or to deescalate care because of poor prognosis

7 IX. Summary: Documentation requirements most common nonconsult visits Remember: Established patients: 2 of 3 areas New patients/consults: 3 of 3 areas similar $ charge to more $ than above 99213:EPF history & exam, LC DM; 15m 99214:D history & exam, MC DM; 25m 99215:C history & exam, HC DM, 40m 99202: EPF history & exam, SF DM, 20m 99203:D history & exam, LC DM; 30m 99204:C history & exam, MC DM; 45m 99205: C history & exam, HC DM, 60m Totals History and Exam Problem Focused Exp. Prob. Focused Detailed Comprehensive HPI Brief (1-3 elements) Brief ROS None Pertinent to problem (1 system) PFSH None None Pertinent (1 history area) Exam 1-5 elements > 6 elements > 2 elements from 6 areas/systems OR > 12 elements from at least 2 systems/areas (> 12 elements for single Medical Decision Making A. Number diagnoses or management options B. Amount and complexity of data Straightforward Extended Extended (> 4 elements or status of > 3 chronic or inactive conditions) Extended (2-9 systems) Complete (> 10 systems, or some systems with statement all others negative ) Complete ( 2 or 3 history areas) > 2 elements from 9 areas/systems (all elements for single system exams) system exams) Low Complexity Moderate Complexity High Complexity < > 4 < > 4 C. Highest risk Minimal Low Moderate High

8 X or 99214? Visits often support in sports medicine (2 ways) Hx and DM documentation Code for time Charge where appropriate Inaccurate to undercode Reasons for undercoding lack of knowledge inappropriate documentation fear of audit (myth v. reality) 1. Documentation Route: History HPI usually satisfies PFSH: Hx sports injury, contributing probs, meds, RX, smoking, exercise program, activity Hx, FHx joint/back probs, etc. ROS: constitutional, musculoskeletal, neurological, cardiovascular, pulmonary, integumentary, all others negative Exam May support in sports if more detailed, if uses comparison exams (joints), easier to use other areas Decision Making (DM) Show me the money! Sports visits frequently Mod. Complex. (99214) via: A: New problem to examiner (no additional w/u planned) C: Prescription drug management Decision Making: if lack other 2 in A and C, look here: A: Number of Diagnoses or Treatment Options Self-limited or minor (stable, improved, or worsening) (1) Est. problem (to examiner); stable, improved (1) Est. problem (to examiner); worsening (2) New problem (to examiner); add. w/u (4)

9 B: Amount and/or Complexity of Data to be Reviewed Review and or order of tests in the radiology section of CPT (1) Decision to obtain old records and/or obtain history from someone other than patient (1) Independent visualization of image, tracing or specimen itself (not simply review of report) (2) Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider (2) C: Table of Risk One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment (e.g., asthma, back pain) Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis (e.g., lump in breast, lump in arm, radiculopathy, etc.) Acute illness with systemic symptoms (e.g., pyelonephritis, asthma, colitis) Abrupt change in neurologic status (e.g., TIA, seizure, weakness, sensory loss) (H) 2. Time Route: Frequently used in sports medicine on initial visit (est. pt.) and/or visits where rehab taught 99213: 15 min 99214: 25 min 99215: 45 min 99202: 20 min 99203: 30 min 99204: 45 min Use especially if visit component documentation criteria can t support (2 ways to get there) Counseling: rehab programs, RTP issues, teaching, etc. Coordination of Care: arrange specialized imaging or f/u, review case with colleague, etc. Document >50% encounter time and specifics XI. Consultation Codes Always bill as consultant if appropriate Fees are frequently more than double office visit of similar level (e.g., v ) Don t have to be specialist to code consult! (from requirement standpoint) On 1/1/10, Medicare eliminated payment for consultation codes. As

10 of the time of this update (3/10), several large commercial carriers have already voiced their intention to follow suit. Thus, you will need to track which commercial payers still allow billing under these codes and limit use of the consultation codes to these carriers. Consultations under Medicare and other carriers eliminating these codes should be billed as either new patients or established patients depending on which is appropriate. Medicare is offsetting the elimination of these codes somewhat by increasing reimbursement on other office visit codes by 6%. Warning: If you bill a consultation code on a patient who has Medicare as secondary coverage, the secondary payment will be denied. Policy in this area is volatile and subject to change. Caveat: new referrals from outside practice of primary care Private payers will only infrequently reimburse consultations by another primary care physician if non-listed primary provider in HMO; PPOs usually okay Many family and sports medicine physicians bill consults successfully through orthopedic group b/c are listed and reimbursed as orthopedic specialist within HMO, or through own primary care group because listed as primary provider Depends on type of insurance plan (HMO v. PPO v. other), specialty designation SHOULD NOT matter Reimbursement in non-ortho office variable: May need to seek dual credentials/specialties (HMO s) Success here varies with individual insurance companies Consultation: Definition Type of service provided by physician whose opinion or advice regarding evaluation and/or management of specific problem is requested by other physician or appropriate source (safest to check with regional Medicare office to confirm what constitutes appropriate source) Many sports visits & preoperative exams Consultation: Requirements Written or verbal request from referring physician or other appropriate source documented, 2006: Medicare requires written Consultant s evaluation & opinion: Document in patient record Communicated by written report to referral source Consultations: Codes Documentation & time requirements differ from non-consult E/M codes for respective levels 99242: EPF hx & exam, SF DM, 30m 99243: D hx & exam, LC DM, 45m 99244: C hx & exam, MC DM, 60m 99245: C hx & exam, HC DM, 80m

11 Follow up visits go back to non-consultation codes: 99213, etc. Consultations: How to Bill Insurance Companies Just do it Meet criteria, code & bill, track, troubleshoot prn: only fight battle when it comes to you Be aware that Medicare will deny these codes for secondary coverage Dual Credentials/Specialty Qualification (fighting the battle) Likely need to seek specialty status with private payers (HMOs) if accepting consults from outside practice if not pcp If ask insurance co. to pay more, may say no In the short-term, Medicare is increasing payments to primary care physicians by 10% for the period between 2011 and This in combination with the loss of consultation coding makes primary care designation financially preferable in the short-term for sports medicine physicians who practice in a highly-penetrated Medicare environment. More cumbersome: negotiations with insurance companies not easy Responses/successes vary among individual insurance co s and statewide/regionally Look to the AMSSM membership: many AMSSM experienced here, for better or worse In the long-term, our interests as a specialty are probably best-served through consistent specialty designation as Sports Medicine. American Board of Medical Specialties recognizes sports medicine as specialty Sports Medicine Business Practice Tools Good overall review with links: FAQs, negotiation tips (members only) XII. Modifiers Indicate that service or procedure altered by some circumstance, but not changed in definition or code Added to primary E/M code Supposed to make it hard for insurance co s to ignore extras Wider use of the Correct Coding Initiative edits is ongoing, linking certain CPT codes for automatic rejection when billed together unless the appropriate modifier is used. For a list of these linked codes, go to the Medicare website: OfPage Responses vary, track, appeal Specific Modifiers

12 -25 significant separately identifiable E&M service on same day of procedure or other service (above & beyond) most common sports med modifier (e.g., injections, casts, taping, etc.) Could the additional service stand on it s own? 2006: documentation must satisfy relevant criteria -24 unrelated E&M service by same physician during a postoperative period service performed during postoperative (post-procedural?) period for reason(s) unrelated to original procedure May eliminate unrelated problems that arise during global period (for operation/procedure) from being lumped into global care package -32 mandated services Services related to mandated consultation and/or related services (e.g., third party payer, etc.) -50 bilateral procedures -51 multiple procedures -52 reduced services -54 surgical or initial Fx care -55 post-op or post-fx care -57 when E/M service results in decision for surgery (Fx management) -59 distinct procedural service (e.g., needed to cast sprained wrist, but also used cast for fracture care for opposite ankle) -21 prolonged E/M and management services (99358 prolonged E/M, 30 min above highest level, usually a or a preventive care visit) Maximal billable time for non-consult E/M code (before adding 99358) is 45 min XIII. Procedures Diversify and generate income 1. Fracture care Common cast/splint codes (use 25 modifier with these for nonfracture care): Applic Short Arm Splint Applic Short Leg Cast Applic Short Arm Cast Applic Short Leg Cast,W Applic Long Arm Splint Applic Long Leg Cast Applic Long Arm Cast Applic Long Leg Cast,W Applic Long Leg Splint Add Walker, Prior Cast Applic Short Leg Splint Windowing Cast A4590 Cast Supplies Wedging Cast A4570 Splint Supplies Q4005 Medicare (cast/splint) Applic Finger Splint; Static (29130), Dynamic (29131) L3917 Galveston metacarpal brace

13 Fracture care: Know the codes Higher reimbursement, but one time only Can charge 2 ways: Whether you charge global or by visit depends on your level of reimbursement for the global without the initial cast fee v. the initial visit fee and cast fees and the number of predicted follow-ups First cast/splint included in global fee, then you may charge for additional cast/splint changes X-ray charges are paid at follow up visits even with fracture care (can vary with specialty and private payer) Fracture follow-up: any extras? (What about that URI? You can charge) The sequenced order of ICD-9 codes becomes important in this instance, as the primary diagnostic code should align with the extra diagnosis to avoid denial. Charge global fx charge or non-fx CPT E/M code ( alternative method)? o Know global fees o Partners, follow-up and other problems o Associated injuries and prolonged f/u o Patient needs o Payer requirements o Individualize! Global fx charge o Initial E/M service with modifier -57 within global period essentially adds a charge o Modifier -54 used for initial fx care if splitting (grabs part of global charge) o Modifier -55 used for f/u fx care (what if ortho uses consult charge within global you triggered?) o Charge for f/u cast changes and materials only Alternative CPT E/M method o May use when fx not primarily a procedure (e.g., closed rx w/o manipulation) o Use new, established patient, or consult CPT E/M codes with added cast/splint charges and materials fees o Modifier -25 may be helpful Casting and splinting tips Separate fee billed in addition to visit fee (except initial fx care) Use modifier 25 if non-fx care or billing fx using alternative method; no 25 for cast change with global fx care unless other problem; if not reimbursed in global period for cast change may try modifier -58 Track these reimbursements to avoid bundling or denial!

14 Casting/Splinting: may charge for changes (even with fx care) Cast supplies separate charge: o payer-preferred supply code can vary: o A4950 (casting), A4570 (splinting), Q4005 (Medicare) 2. Taping/Strapping (use modifier 25 after primary E&M code with these codes; e.g., & ) Ankle/Foot Knee Toes Low Back Hand/Finger Elbow/Wrist Shoulder Hip Unlisted Proc Casting/Strapping 3. Injections/Arthrocentesis (use modifier -25 if with initial or f/u evaluation of problem; e.g., & ). Don t forget to code for the injected drug Small joint or bursa Fingers, toes Intermediate joint or bursa AC, wrist, elbow, olecranon, ankle Major joint or bursa Shoulder, subacromial, hip, knee Injection(s); single tendon sheath, ligament, or aponeurosis Plantar fascia Single tendon origin/insertion Injection, therapeutic, carpal tunnel Injection(s); single or multiple trigger point(s), 1 or 2 muscles Injection(s); single or multiple trigger point(s), 3 or more muscles Aspiration and/or injection of ganglion cyst(s), any location 4. Miscellaneous Procedure & Ancillary Codes (use modifier 25 after primary E&M code with most of these codes; e.g., & other ancillary code plus -25)

15 Therapeutic Exercise: PT code; exercise/rehab program-md, PT, other? May take away from limited PT visits Paid by many private payers Athletic trainers used to be able to provide this service under a physician s supervision, but Medicare changes have generally been accepted by private third party payers, making this an unreimbursable service if provided by an ATC. Some plans still pay however, so know your regional policies. Avoid in plans with small number of visits vs. annual $ limit Other miscellaneous therapeutic codes neuromuscular re-education manual therapy (myofascial release) therapeutic activities (dynamic to improve functional performance) work hardening 97810/11/13/14 acupuncture Orthotics Various ways to charge Gait Training (97116) may be applicable Review EOB, if orthotics not covered, you may charge patient May fit at separate visit or during visit for f/u of specific problem (then may charge private payer for visit, if other problem than fitting orthotics) Special coverage instructions often apply (e.g., may be benefit, but with podiatrist or pedorthotist, or with certain medical conditions) Are various L-codes (HCPCS book) for orthotics, additions, and shoe modifications; common categories listed: L3000-L3031 Foot Inserts, Removable L3040-L3060 Arch Support, Removable L3300-L3334 Lift, Shoe Modification L3340-L3420 Wedges, Shoe Modification L3430-L3485 Heels, She Modification Durable Medical Equipment and Orthotic Devices It s a business ; More difficult to distribute and charge for products if vested interest Private payer reimbursement varies, and many plans lump DME into office charge Track & appeal inappropriately denied or bundled charges, but be aware that individual payer contracts may prevent physicians from charging for DME (e.g., if ins. co. contracted with specific

16 DME supplier) If not listed as covered benefit in EOB, may charge patient Special coverage instructions often apply May be easier to set up a rental cabinet and have local DME supplier (supplier with most contracts in your area) stock on consignment Can consider using cast and splint application charges for certain splints and cast boots (reimbursement usually higher than cost) Are various codes (HCPCS book), common listed: L0120 Cervical, flexible, non-adj (foam collar) L0140 Cervical semi-rigid, adj (plastic collar) L0450-L0490 TLSO s, Flexible L1000L1520 Scoliosis Orthotic Devices (including Milwaukee) L3650 Shoulder orthosis, figure of eight prefabricated L3651 Shoulder orthosis, single shoulder, elastic prefabricated, includes fitting and adjustment L3907 Wrist hand finger orthosis, elastic, prefabricated (may include thumb spica) L3908 Wrist hand orthosis, wrist extension control cock-up, nonmolded, prefabricated L3917 Hand Orthosis, metacarpal fracture orthosis, prefabricated (e.g., Galveston splint), includes fitting L3956 Addition to joint upper extremity orthosis, any material; per joint L4350 Ankle control orthosis, stirrup style, rigid, includes any type of interface (e.g., pneumatic, gel), prefabricated, includes fitting L4360 Walking boot, pneumatic, with or w/o joints, prefabricated, includes fitting L3486 Walking boot, non-pneumatic, with or w/o joints prefabricated, includes fitting L4398 Foot drop splint, prefabricated (dorsiflexion night splint?) L1800 Knee orthosis, elastic with stays, prefabricated, includes fitting L1830 Knee orthosis, immobilizer, canvas longitudinal prefabricated, includes fitting K-codes: various DME such as wheelchair devices, etc. (not frequently used in sports medicine) Compartment Pressure Measurement: specify RT or LT Accompanying letter of explanation of procedure can be helpful to limit denials Modifier -50 for both sides (bilateral procedure) Modifier -51 for multiple compartments (multiple procedures) CECS or nontraumatic compartment syndrome ICD-9:

17 Leg or thigh: , upper extremity: , abdomen: change makes codes distinct from 958.9x code used for acute, traumatic compartment syndrome Exercise Treadmill global cv stress test (covers supervision, tracing, interpretation, report) phys superv cv stress test tracing cv stress test test interp & report cv stress test J1250-inj dobut per 250 mg J1245-inj dipyridamole per 10 mg Use appropr ICD-9 codes to docum med necess for tm KT 1000 Athrometer : 97750; PT code Osteopathic Mobilization (1-2 areas), (3-4), (5-6) Areas: head, cervical region, lumbar region, sacral region, pelvic region, lower ext, upper ext, rib cage region, abdomen/viscera region Use 25 modifier to protect more expensive visit fee Plan reimbursement variable Some don t pay at all Some don t pay if you are not a DO Warts Destr Lesion, benign (2006: omitted and 17003) Splinter/Foreign Body Removal remov for body-foot-subcut (splinter) Supply codes (know contracts/eob) Supplies above and beyond those normally included in visit (Theraband, Ace wraps, slings, etc.) Injection Supplies: J1100 Dexamethasone, J2920 Depo Medrol, J3301 Kenalog, J2001 Xylocaine/Marcaine, Hyalgan, Synvisc Must assign $ amount to code Bill for number of units (ml) of inj substance (e.g., J1100 x 1 unit & J2001 x 5 units) Telephone Calls

18 telephone calls by physician to patient or for consult or med management (can't bill with same day E/M service) XIV. Supplementary Codes V-codes: used when circumstance arises (reported as Dx) other than disease or injury classifiable to ICD Pertinent in sports medicine: V65.3: dietary counseling V65.4: health counseling nos V65.41: exercise counseling V65.42 counseling substance abuse/use V65.43 counseling injury prevention V70.0 general medical exam V70.3 school/sports exam V70.5 occupational or pre-employment exam V (preop exam, list appropriate #, also individual dx) EOB beware: insurance may not pay for these services and patient may be responsible for bill E-codes: used to classify environmental events, circumstances and conditions as the cause of injury, poisoning, and other adverse effects Used in addition to ICD-9 code Pertinent in sports medicine: E-codes for motor vehicle (various types), motorcycle, machinery or watercraft accidents XV. Billing, Collection, and Practice Economics Billing Front Desk: starts here Demographic & insurance info current Deductibles & co-payments Review co-pays and outstanding balances day prior to appointments Get them now! Up front before visit. Avoid cost of re-billing for small fees ($10-15) Cash, check, credit card Take-home statements (avoid cost of mailing and facilitate memory) Managed care referral specialist Plan details, co-payments, prior auth Billing and Collections Complex & sensitive

19 Have clearly defined policies and procedures Billing and Collections Expert Knowledgeable with coding fundamentals CPT, CPT modifiers, RBRVS, global surgery package Team approach: the doc should be involved! (lose this in larger settings) evolution Proactive approach: tracking a/r (practice software), adjustments, outstanding accounts (60-90d), filing deadlines (90d), claims checks and review (monthly) Regularly reviews fee schedule (annually) Collections! (bug, bug, bug.) Billing & Collections Expert: the Guru Knows contracts/eob s Files claims daily Electronic billing when possible Claims checks: monthly Call about unpaid claims: 60 days Document name of customer service rep & details of conversation Makes sure secondary insurance is billed Oversees front desk Co-payments now, review insurance info each visit, verify prn (red flags) Trouble in Paradise: Bundling & Denial FP s 3 top insurance complaints: Denial of modifier (-25 most common) Track those procedure codes! Bundling of services Late payment Bundling: combining two or more CPT codes and substituting one overarching code, includes ignoring modifiers: naughty, naughty Software beware: don t get mad at the machine, appeal Most insurance companies have software programs that have pattern recognition capabilities: they speak the language deny and bundle Many low $ appeals are automatically paid, time costs the insurance company $ too Bundling & Denial: Red Flags Payment for this service is included in the fee for the procedure Submitted charges were redistributed for a more accurate benefit The procedure submitted on your claim has been changed to one that better represents the service performed by your physician The service is a component of a primary procedure. Payment for the primary procedure includes reimbursement for the related procedure Payment for one or more billed procedure codes has been denied because it is considered a component of this billed procedure code Medical visit not allowed for separate reimbursement Related changes rolled up into primary procedure per HIPPA regulations

20 Appeals Process Be efficient, time will cost you $ Don t be a victim of assumptions Insurance companies bank on the fact that physicians do not have time to track billing/coding or to appeal; they make $ on physicians based on this assumption No tracking, no appeals; no appeals, no problems (for insurance company) Most appeals (estimated as high as 90%) are won by physician (if appropriate - appeal does not violate EOB), but most physicians don t appeal Appeals Log (see Appendix) Date refused/unpaid (60-90d) Reason claim refused (red flags): Call insurance company or IPA/review EOB knowledge is power Complete Claim Correction Form (AAFP) Call Claims Manager Escalate (30d) Report (45d) Local state or county medical society Appropriate legal authorities Practice Economics: Caution Be aware that higher charges, more procedures, and more modifiers will likely decrease collection rate (a mirage) Bill the highest (some would argue higher) RBRVS $ amount reimbursed by area insurance company (e.g., United Health Care pays 140% RBRVS, but you charge 130% b/c that is what Cigna pays should charge 140% to all) You are leaving money on the table Regularly review and update fee schedules Don t let the numbers fool you Collection rate lower, but revenue higher! Today s Top 10 List: Top 10 ways to lose money Lost productivity Inadequate and inaccurate coding Bad billing practices Poorly reimbursing insurance plans Infrequently and improperly updated fee schedules Lack of a budget Excessive overtime and overstaffing Insufficient supply purchasing Petty theft and embezzlement Unmanaged risk

21 (Lack mid-level provider) Helpful Tools Templates Don t lose the art! Coding charts/cheat sheets (hang in front of desk or dictation area) Software PDA, desktop (coding or office software), AAFP Brain (memory) Seminars/Courses Putting It All Together Coding is no harder than biochemistry, but biochem won t likely lose you money 99214: two roads diverged in a wood Only TIME will tell Consultations, consultations Did somebody call? Proceed and modify, and anything else? What else can I do for you?: Ancillary services Practice economics: up close & personnel, but protect your bubble (indexing) Be efficient, timely, have fun, and enjoy the potential extra income privy to a diversified sports medicine physician!

22 References American Medical Association: Current Procedural Terminology cpt 2007 Standard Edition CPT, American Medical Association Press, Chicago, American Medical Association: International Classification of Diseases ICD-9-CM, American Medical Association Press, Chicago, Borglum K: 10 ways family practices lose money. Fam Pract Manag 10(6)51-6, Chao J, Gillanders WG, Flocke SA, et al: Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation. J Fam Pract 47(1):28-32, Cimino JJ: Review paper: coding systems in healthcare. Methods Inf Med 35(4-5):273-84, Costa AJ: CPT coding by family physicians. J Am Board Fam Pract. 14(5):400, Elevitch FR: Prospecting for gold in the data mine. Clin Lab Med 19(2):373-84,1999. Herbst MR: CPT and HCPCS coding: the modifier fiasco. Health Manag Technol. 19(11):74, Hill E: How to get all the s you deserve. Fam Pract Manag 10(9):31-6, Hull S: Changes abundant for CPT J AHIMA 75(1):79-82, Kemp S: Clinical coding in sports medicine--it s good to talk. Br J Sports Med 33(1):4-5, King MS, Lipsky MS, Sharp L: E/M coding problems plague physicians, coders. J AHIMA 73(7):62-3, King MS, Lipsky MS, Sharp L: Expert agreement in Current Procedural Terminology evaluation and management coding. Arch Intern Med 162(3):316-20, King MS, Sharp L, Lipsky MS: Accuracy of CPT evaluation and management coding by family physicians. J Am Board Fam Pract 14(3):184-92, Lamothe HL: Clinical insights for office practice management. Orthop Nurs 17(1):23-6, Madden C: Establishing a Sports Medicine Network. In McKeag D: Primary Care Sports Medicine, 2 nd ed. Lippincott Williams & Wilkins, in press. Madden C, Macintyre J, Joy L: Sports Medicine Practice Economics; Part 1: Coding Basics. Physician and Sportsmedicine 33(5), Madden C, Macintyre J, Joy L: Sports Medicine Practice Economics; Part 2: Consultations, Modifiers and Other Codes. Physician and Sportsmedicine 33(6), Madden C, Macintyre J, Joy L: Sports Medicine Practice Economics; Part 3: Billing, Collecting, Appeals and Related Tasks. Physician and Sportsmedicine 33(7), Medical Management Institute: HCPCS Healthcare Common Procedural Coding System, Level II Codes, 11 th ed., Alpharetta, Medical Management Institute, Medical Management Institute: Professional ICD-9-CM, Volumes 1&2 Professional Coding Manual, 4 th ed. Alpharetta, Medical Management Institute, Moore KJ: CPT: What s in store for 2004? Fam Pract Manag 11(1):18, Moore KJ: Coding& documentation: answers to your questions. Fam Pract Manag 10(8), Moore KJ: Coding& documentation: answers to your questions. Fam Pract Manag 10(7), Moore KJ: CPT coding update for Fam Pract Manag 10(1):14, Morrison KM: Coding and billing software for palm-top computers. Fam Pract Manag 9(5):33-7, O Hara K: Pleanty of CPT changes for Latest on additions, revisions, and deletions. J AHIMA 74(1):80-2, Pennachio DL: How to fight bundling. Med Econ 80(17):65-8,73, Plunkett C: CPT (current procedural terminology) coding and patient accounting: controlling the process and improving billing efficiency. Patient Acc 16(5):2-3, Rheinisch D: Improving office operations and maximizing reimbursement for the orthopedic practice. Clin Sports Med 21(2):223-9, Scichilone RA: Clarifying CPT modifiers. J AHIMA 71(4):69-73, Trouble at the money/medicine interface. Fam Pract Manag 10(6):8, Walker AM: Pattern recognition in health insurance claims databases. Pharmacoepidemiol Drug Saf 10(5):393-7, Weinman H: Coding & documentation: no harder then biochemistry (letter to ed). Fam Pract Manag 9(1):14, Yoder L: Using CPT modifier 25 for professional billing. J AHIMA 71(1):21, 2000.

23 Case Scenarios ACL Tear New (99203), f/u (99213) Anterior knee pain with rehab (99214 or ) F/U MCL sprain (not doing well) and URI (99214) Asthma exacerbation and URI (99214) Multiple plantar warts Initial (99213 & ), f/u (17110), f/u with other problem (approp. level [99213] & ) Fx right radius, LT sprain left wrist both need casts (using global fracture care code: or plus & & A4590[$25]) Fx f/u and mentions high cholesterol (99213 or & & A4590[$25]) Preoperative exam for meniscal tear (99242,3, or 4 depending on complexity) Partner asks you to evaluate a knee (appropriate consult code: or 99243) Physical therapist refers you an elbow problem (appropriate consult code: or 99243) New chronic back pain w/o neuro sx, reviewed old record, independently reviewed films (99204) New Acute back pain with radiculopathy and sensory loss, reviewed old record, independently reviewed films (99205) Eating disorder est. pt. (took 10 min b/c pt wanted to leave) (99124) Eating disorder and depression est. pt, takes 75 minutes ( & 99358) TFCC/sprain wrist est. pt., needs cast, put on NSAID (99214 & & A4590[$25]) Thumb UCL sprain, requires cast, put on NSAID, and plantar warts (99214 & & A4590[$25] & 17110) Bilateral trochanteric bursitis and management est. pt., wants 2 steroid injections (99214 & & ) Orthotic Not in EOB: May charge insurance company for initial problem (eg, plantar fasciitis) & management, measure or cast this visit: (no charge for measuring orthotic) Suggest arranging f/u visit for problem (plantar fasciitis), charging approp. f/u problem code and separately billing pt for orthotic (99213 plus appropriate L-code for orthotic; insurance pays for f/u visit, pt. pays for orthotic) In EOB:

24 Visit code (eg, 99213)-25 & appropriate L-code (pt cannot be charged) Appendix 1: Appeals Log Claim Appeal Process/Log 1. Date claim refused: 2. Reason claim refused (red flags): Check(s) Ot Reason (often bundled, downcoded, or denied inappropriately by claims software) Payment for this service is included in the fee for the procedure. Submitted charges were redistributed for a more accurate benefit. The procedure submitted on your claim has been changed to one that better represents the service performed by your physician. The service is a component of a primary procedure. Payment for the primary procedure includes reimbursement for the related procedure. Payment for one or more billed procedure codes has been denied because it is considered a component of this billed procedure code. Medical visit not allowed for separate reimbursement. Related changes rolled up into primary procedure per HIPPA regulations. her: 3. Call insurance company or IPA/review EOB (explanation of benefits) 4. Complete Claim Correction Form (AAFP) if claim inaccurate 5. Call insurance company and speak with claims manager. State: Physician performed service in good faith and claim should be paid in 3-45 days, will track and call if not appropriately addressed (second communication could state: Will escalate, contact employer, and report or register with appropriate agency (e.g., Colorado Medical Society, insurance board). Document: Name of case manager: Title: P hone: ext: F ax: D etails of conversation: 6. Tickler & track: 30d re-contact case manager; 60d: further measures (escalate, report, contact employer: employee-benefits representative, IPA) Re port: 1. or 2. Local state or county medical society 3. Appropriate legal authorities

25 Appendix 2: Claim Correction Form Adapted from a form developed by the Plan-Provider Claims Workgroup convened by the American Association of Health Plans and the Healthcare Financial Management Association in cooperation with the Specialty Society Insurance Coalition. Physicians may adapt or photocopy for use in their own practices. Best Practices in Claims Processing. Backer LA. Family Practice Management. July/August 2003:19-22; CLAIM CORRECTION FORM Submitted to: Plan/Payer name: Date submitted: / / Plan/Payer address: STREET SUITE CITY STATE ZIP Telephone: ( ) Fax: ( ) Patient name: Birth date: / / FIRST M.I. LAST Subscriber name: Date of service: / / Policy #: Group #: Original claim #: Submitted by: Provider: Contact: Telephone: ( ) Ext: Fax: ( ) The following corrections were made on this claim: _ Patient s policy number/group number was incorrect. The correct number(s) are shown above. _ Date of service was incorrect. Correct date is: / /. _ CPT code was incorrect. Correct CPT code is instead of. _ Diagnosis code was incorrect. Correct diagnosis code is instead of. _ Visit was denied as over carrier s utilization limits. Please see attached letter to justify extensions of these limits. _ Procedure was denied as over carrier s utilization limits. Please see attached letter to justify extensions of these limits. _ Carrier indicated that the patient is covered by another plan that is primary. Patient indicates our practice is primary. _ Secondary carrier is. _ There is no secondary carrier. _ Procedure was denied as not medically necessary. Supporting documentation is attached. _ Carrier s clerk failed to enter correct number of times (units) procedure was performed. Correct units are as follows: DOS: / / Code: Units: Charge total: $ We failed to enter correct number of times (units) procedure was performed. Correct units are as follows: DOS: / / Code: Units: Charge total: $ Multiple surgical procedures: _ Carrier failed to approve any procedure at 100%. _ Carrier approved incorrect procedure at 100%. Carrier should have approved 100%/50% (circle one). Carrier should have approved 100%/50% (circle one). Carrier should have approved 100%/50% (circle one). _ Modifiers were omitted. Please reconsider as follows: Code Code Code Code GA _ E/M service was denied as included in the global surgical fee. Please reconsider with attached supporting documentation: Code: Modifier(s): _ -24 _ -25 Charge: $ UPIN information was omitted. Code: Physician name: UPIN: Plan-specific provider ID#:. _ CLIA number:. _ Place of service:. _ Service was rendered at the physician s physical location listed in Box 32 of the original claim form. _ EOB from primary carrier is attached. _ Incorrect information was entered on claim form. Line #: Correct information: Other reason for correction: Comment:

26 Appendix 3: Appeals Letter Letterhead Date: Re: Unpaid claim To whom it may concern: You have not appropriately addressed the attached claim. We expect to receive an appropriate settlement within 30 days. This is your last chance to address this claim. We have kept a careful log of this claim up to this point, and we will accurately track this final request. If no settlement has been received in 30 days, we will submit complaints in writing to the American Medical Association, the Colorado Medical Society, and appropriate legal authorities (e.g., attorneys involved in class action lawsuits against insurance companies). We will also file a complaint and establish a case with the employee-benefits representative at the patient s employer, who will likely contact you. Finally, we will log the unsettled or inappropriately settled claim, and if a pattern of inappropriate denials or bundling is noted, we will pursue legal action, and we will take time to carefully recruit area colleagues before doing so. We are aware of various class action lawsuits against major payers regarding inappropriate reimbursement and bundling. Sincerely,