Osteopathic Coding & Billing: An Overview
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1 Osteopathic Coding & Billing: An Overview Douglas J. Jorgensen, DO, CPC, FAAO, FACOFP, CAQ Pain Medicine
2 Agenda Intro HCPCS (CPT) Review ICD-10 Charge Setting & Analysis Practice KPI Medicare Par, Non-par, or Opt-out E&M/OMT Coding Summary
3
4 HCPCS Review: OMT CPT Codes OMT CPT Codes are M99.00-M99.09 for ICD 10 Other manual therapy codes (i.e., Chiropractic CPT Codes ( )
5 HCPCS Review: OMT CPT Codes DC use Treatment Plan of defined number of treatments prior to re-evaluation. Not so for OMT -25 Modifier
6 OMT CPT Codes CPT Codes for OMT Number of Regions Treated Regions Regions Regions Regions Regions Current Procedural Terminology 2015
7 ICD-10 Your EMR, won t show you: ICD-10 s two volumes the Alphabetic Index the Tabular List Procedural Code System not used at CHCs
8 ICD-10 Thoughts Duality of ICD-9 & ICD-10 How long Unique terminology Excludes 1 vs. Excludes 2 X Space holders Laterality Acute & Chronic Sequala(ae) EMR & PM Updated Test, test, test Start summer not Oct 1 Get house in order
9 ICD-10 X EXAMPLE
10 1. Ingrown toenail, right great toe Answer: L60.0
11 2. Mild intermittent asthma, status asthmaticus Answer: J45.22
12 3. Pneumonia, bacterial, left upper lobe (1 of 2)
13 3. Pneumonia, bacterial, left upper lobe (2 of 2) Answer: J15.9
14 4. Perforation of tympanic membrane due to chronic suppurative otitis media, right ear (1 of 3) Answer, Part 1: H72.91
15 4. Perforation of tympanic membrane due to chronic suppurative otitis media, right ear (2 of 3)
16 4. Perforation of tympanic membrane due to chronic suppurative otitis media, right ear (3 of 3) Answer, Part 2: H66.3X1 Final Answer: H66.3X1, H72.91
17 5. Type 1 diabetes with diabetic nephrosis (1 of 2)
18 5. Type 1 diabetes with diabetic nephrosis (1 of 2) Answer: E10.21
19 6. Well baby exam, without abnormal findings, aged 3 months Answer: Z00.129
20 Charge Setting (1 of 2) Payers pay your charge or there fee schedule whichever is less Desired Adjustment 30%+ Medicare fees = charge floor Underpayment management Within 10%, too low Prompt payment discount Unilateral application Time value to money Afforded to all entities
21 Charge Setting (2 of 2) CPT Codes Item Name Fee in Dollars Medicare Fee 150% of Medicare 200% of Medicare 250% of Medicare E/M Svc New Pt Level 1 $ $43.98 $66 $88 $ E/M Svc New Pt Level 2 $ $75.08 $113 $150 $ E/M Svc New Pt Level 3 $ $ $164 $218 $ E/M Svc New Pt Level 4 $ $ $249 $332 $ E/M Svc New Pt Level 5 $ $ $313 $417 $ E/M Svc Est Pt Level 1 $ $20.02 $30 $40 $ E/M Svc Est Pt Level 2 $ $43.98 $66 $88 $ E/M Svc Est Pt Level 3 $ $72.94 $109 $146 $ E/M Svc Est Pt Level 4 $ $ $163 $217 $ E/M Svc Est Pt Level 5 $ $ $219 $292 $512
22 Charge Analysis (1 of 2) CPT Item Name Fee in Medicare Percentage of Codes Dollars Fee Medicare E/M Svc New Pt Level 1 $ $ % E/M Svc New Pt Level 2 $ $ % E/M Svc New Pt Level 3 $ $ % E/M Svc New Pt Level 4 $ $ % E/M Svc New Pt Level 5 $ $ % E/M Svc Est Pt Level 1 $ $ % E/M Svc Est Pt Level 2 $ $ % E/M Svc Est Pt Level 3 $ $ % E/M Svc Est Pt Level 4 $ $ % E/M Svc Est Pt Level 5 $ $ %
23 Charge Analysis (2 of 2) CPT Codes Item Name Fee in Dollars Medicare Fee Percentage of Medicare ERCP w/sphincterotomy $ 2, $ % ERCP w/removal stones $ 2, $ % EGD ENDOSCOPIC STENT PLACE $ 2, $ % EGD LESION ABLATION $ 1, $ % ERCP DUCT STENT PLACEMENT $ 2, $ % ERCP REMOVE FORGN BODY DUCT $ 1, $ % ERCP STENT EXCHANGE W/DILATE $ 2, $ % ERCP EA DUCT/AMPULLA DILATE $ 1, $ % Change Gastrostomy Tube $ $ % SMALL BOWEL ENTEROSCOPY $ $ %
24 Key Performance Indicators- KPI DAR/DSO Net AR Encounter Rate Payment Percentage
25 KPI- DAR/DSO This conversation needs to stay between us -CFO of $10M health center What is Days of Accounts Receivable (DAR)? Example in a year (365 days) $1,000 in charges per day $365,000 in annual charges If AR = $47,000, DAR = 47 days Example Jan to June Charges = $1,500,000 Total days (365 divide by 2 (half a year)) = days Average Daily Charge ($1.5M divided by 182.5) = $8, If AR = $723,723 then DAR = this # divided by $8, DAR = days
26 Data Elements KPI- Net AR Total Charges: $ 12,345, Total Payments: $ 5,016, Total Adjustments: $ 3,764, Time Period (months): 12 Payments + Adjustments = $ 8,781, Net AR: $ 3,563, Total Charges produced less Payments + Adjustments = Net AR True value of Net AR = Payment Percentage Net AR
27 Data Elements KPI- Encounter Rate Average Monthly Charges: $ 1,028, Average Monthly Payments: $ 418, Average Montly Adjustments: $ 313, Annual Visits 27, Monthly Average: 2, Encounter Rate = $ Payments over a fixed fiscal period divided by the number of visits (patients seen) to achieve those patients = Encounter Rate
28 KPI- Payment Percentage Payer Charges Payments Adjustments Payment Percentage Anthem BCBS $ 3,086, $ 1,555, $ 941, % Cigna $ 1,481, $ 802, $ 451, % United Health $ 3,333, $ 1,003, $ 828, % Self Pay $ 1,357, $ 752, $ 752, % Medicare $ 1,851, $ 702, $ 414, % Medicaid $ 1,234, $ 200, $ 376, % $ 12,345, $ 5,016, $ 3,764, % Payments (Numerator) as a Percentage of Payments plus Adjustments (Denominator) = Payment Percentage Average Daily Charge: $33, Average Daily Payment: $13,744.48
29 The Goal
30 Covered and Noncovered Services
31 ABNs Advanced Beneficiary Notices CMS-R General-Information/BNI/ABN.html
32 ABNs Advanced Beneficiary Notices Private Payers too Why? Every time you perform a non-covered service Accepted assignment/contracted Cash Practice (Opt out vs. Non Par)
33 A Cash Market Obamacare: High Deductibles What s applied vs. not? Again covered vs. not covered
34 CMS Form 1490S Patients Can Submit Claims Forms/CMS-Forms/downloads/cms1490senglish-instructions-partb.pdf
35 The Cash Conundrum Cash only practice Cash for noncovered services Blended option &/OR
36 Deductibles Deductibles are applied for covered services PRP/Prolo non-covered Arithmetic: $5,000 Deductible
37 Deductibles Total Deductible $5, PRP w/ US Guidance 2 $1, $2, Diagnostic US 3 $ $ $ $ $ $ $ $ $91.00 $ $86.00 $ Perceived Amount Met: $3, Actual Amount Met: $1, Amount to Meet Deductible: $3,611.00
38 Covered Elements Consults, New and Established Office Visits Osteopathic Manipulation Non-Prolo/Non-PRP Injections (ASU/ASC & CON) AKA Diagnostic the rationale Diagnostic Imaging Diagnostics DME
39
40 Worth of Covered Services NON-FACILITY FACILITY CONVERSION Non-Facility Facility HCPCS/CPT DESCRIPTION TOTAL RVU TOTAL RVU FACTOR Fee Fee New Pt E&M $ $ $ Established Pt E&M $ $72.94 $ Inj tendon sheath/ligament $ $60.07 $ Inj tendon origin/insertion $ $61.50 $ Inj trigger point 1/2 muscl $ $55.78 $ Inject trigger points 3/> $ $64.72 $ US Guidance for Injection $ $60.78 $ US Extr non-vasc complete $ $ $ US Extr non-vasc lmtd $ $36.47 $ OMT 1-2 regions $ $31.46 $ OMT 3-4 regions $ $45.77 $ OMT 5-6 regions $ $59.71 $ OMT 7-8 regions $ $73.30 $ OMT 9-10 regions $ $87.60 $ Drain/inj joint/bursa w/o us $ $48.27 $ Drain/inj joint/bursa w/us $ $73.30 $ Drain/inj joint/bursa w/o us $ $50.41 $ Drain/inj joint/bursa w/us $ $81.16 $ Drain/inj joint/bursa w/o us $ $61.14 $ Drain/inj joint/bursa w/us $ $93.68 $63.64
41 Worth of Covered Service New Patient/Consult Example New Patient with Diagnostic US and US Guided Diagnostic Injections with OMT New Pt E&M $ US Extr non-vasc complete $ Inj tendon sheath/ligament $ Inj tendon origin/insertion $ US Guidance for Injection $ OMT 7-8 Areas $60.43 Intitial Total: $374.80
42 Worth of Covered and Noncovered Follow Up Visit for Reevaluation Established Patient Level 3 $ Limited US MSK Extremity $ OMT 7-8 Areas $60.43 F/U Subotal: $ PLUS Prolo: $ F/U Total: $401.61
43 Worth of Covered Follow Up without Prolotherapy Established Patient Level 3 $ Limited US MSK Extremity $ OMT 7-8 Areas $ Inj tendon sheath/ligament $ Inj tendon origin/insertion $ US Guidance for Injection $60.78 F/U Subotal: $222.22
44 Modifiers -25 Significantly Separately Identifiable E&M Service; same provider, same DOS in addition to another service/procedure -59 Distinct Procedural Service -X(EPSU)
45 -59 SubModifiers January 1, 2015 XE: Separate Encounter; therefore distinct XP: Separate Practitioner; therefore distinct XS: Separate Structure; therefore distinct XU: Unusual, nonoverlapping Distinct since it does not overlap usual components of main service (-22) (Dx & Tx procedure) SUSPENDED until further notice
46 Medicare Participation National Provider Identifier (NPI) Provider Enrollment Chain & Ownership System 855-I & 855-R (type of corporate entity?) Participation Agreement (CMS 460) Annually EDI (MAC) & EFT (CMS 588) ABN (GA Modifier) File 2Q if able Co-pay: 20% of PFS not charges Accept Assignment no mas Source: MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN pdf
47 Medicare Non-Participation Your choice don t sign CMS-460 Open enrollment mid-nov through 31-Dec Assignment accepted case by case 5% reduction in PFS 95% if accepting assignment Limiting Charge = 115% of 95% of PFS Source: MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN pdf Source:
48 Medicare Opt Out BBA 1997 Afforded option Opt out 30 days prior to end of any quarter In writing to MAC specific language A.K.A., Private Contracting Must have contracts seek legal counsel Allowed to order/refer for covered services SSA Sections 1128, 1156, 1892 Emergency service exception X Source: MLN/MLNProducts/downloads/MedicareClaimSubmissionGuidelines-ICN pdf Source:
49 2015 Bundled Joint Injection and Ultrasound Codes
50 "It is not the strongest of the species that survives, nor the most intelligent, but the ones most responsive to change." Charles Darwin ( )
51 2015 OIG Report Medicare payments for E/M services increased by 50% from 2001 to 2014 Spending went from $22.7B to $35B/qtr Expected to double by 2021 However, over $70B per annum for Part B Reduced by $16B since 2012 CBO Feb 2014 Pew Research.org Kaiser Foundation Payment/SustainableGRatesConFact/downloads/sgr2015f.pdf
52 2015 OIG FOCI Modifier 25 Under Scrutiny New Patient Hospital CPT Codes ( consult ) Correct Coding Initiative (CCI Edits) Obamacare and criminalization of civil offenses
53 2015 OIG Foci EMR Upcoding Cloned Notes Proving Medical Necessity
54 Summary You protect yourself and your family even if you are employed Know the rules The rules change Stay up to date Be methodical in your business practices
55 Thank You! What you get by achieving your goals is not as important as what you become by achieving them. -Henry David Thoreau
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