E/M coding workshop. The risk of not getting it right. PAMELA PULLY CPC, CPMA BILLING/CLAIMS SUPERVISOR GENESEE HEALTH SYSTEM

Transcription

1 E/M coding workshop. The risk of not getting it right. PAMELA PULLY CPC, CPMA BILLING/CLAIMS SUPERVISOR GENESEE HEALTH SYSTEM

2 Disclaimer This information is accurate as of December 1, 2014 and is designed to offer basic information for coding and billing. All information is based on experience, training and has been researched, interpreted and carefully reviewed by this trainer. Medical compliance/coding and billing information changes quickly. This can become outdated. This is intended to be an educational guide and should not be considered as legal or consulting opinion.

3 Disclaimer cont. I use CPT, HCPCS and ICD-9 books for coding information. Rules come from AMA, ICD-9, CMS and other carriers. HIPAA and PPACA laws. Any questions on information I am presenting please ask. I will give you the source document used. It is important to me to give the best and most up to date information I can.

4 Presenter Pamela Pully 8 years at Genesee Health System 30+ years billing/coding/auditing most specialties. Two national certifications from the American Academy of Professional Coders (AAPC) CPC - Certified Professional Coder CPMA Certified Professional Medical Auditor Member of (AAPC), Past officer of local chapter. Member of the National Alliance of Medical Auditing Specialist (NAMAS) Current officer of Michigan Association of Reimbursement Officers (MARO)

5 Goals for Training Understand the over all risk of not coding evaluation and management correctly. Bell curves and the important role they play in assessing risk. Have a better understanding of Evaluation and Management (E/M) codes. Understand the components and elements of an E/M code. Understand where to find rules and information related to E/M codes.

6 How to achieve the goals 1. Risk--% of claims coded incorrectly. 2. Bell curves How they help you find the outliers. 3. Evaluation and Management (E/M) codes. 4. The 7 Components of E/M. 5. Documentation requirements for each level of E/M /1997 Exam Rules. 7. What makes someone a New patient vs Established patient. 8. Different E/M codes for different places of services.

7 The perfect storm Medical Economics April 09-4 practices audited after implementing EHR s and using them as instructed and intended -Audit failures ranged from 20% to 95% of charts -Fines ranged from $50,000 to $175,000+ per physician -Non-compliant documentation also called a canary in the coal mine showed problems with usability, data integrity, and quality of care & liability protection.

8 Interesting facts about recovery audits How would you like an investment that returns $7.20 for every dollar you invest? Our government has found just such an investment healthcare providers E&M coding, is a potential target; the and office codes were the top two CPT codes in terms of both charges and unit volume. See more at:

9 Recovery audits no longer if but when Medicare Administrative Contractors (MAC) Recovery Audit Contractors (RAC/RA) Comprehensive Error Rate Testing (CERT) Zone Program Integrity Contractor (ZPIC) Health Care Fraud Prevention and Enforcement Action Team (HEAT). Office of Inspector General (OIG) Payment Error Rate Measurement (PERM) 3 rd party payer audits With all these audits you can see it really is only a matter of time before you have one or more reviewing your records.

10 Interesting fact about PERM

11 WPS Medicare e-news Are You Billing these Evaluation and Management (E/M) Services Correctly? Review of recent Comprehensive Error Rate Testing (CERT) findings for WPS Medicare providers in J8 reveals the three CPT codes used to report E/M services listed below were incorrectly coded at a rate of at least 44% Office or other outpatient visit for the evaluation and management of an established patient Initial hospital care, per day, for the evaluation and management of a patient Initial hospital care, per day, for the evaluation and management of a patient If you bill E/M services to Medicare, we highly recommend performing a selfaudit of your billing and documentation processes to determine if the medical records support the level of service billed and the medically necessity of the level.

12 Timeliness requirement Late Entries in Medical Documentation (Rev. 377, Issued: , Effective: , Implementation: ) The MACs, CERT, Recovery Auditors, and ZPICs shall give less weight when making review determinations to documentation, including a provider s internal query responses, created more than 30 calendar days following the date of service. If the MACs, CERT, or Recovery Auditors identify providers with patterns of making late (more than 30 calendar days past the date of service) entries in the medical documentation, including the query responses, the reviewers shall refer the cases to ZPIC and may consider referring to the RO(regional office) and State Agency.

13 What can we do to minimize risk? Do not cross walk codes Do not use time as the only factor for E/M coding Do not treat all places or carriers the same Do not use only one set of rules Do not rule out getting a certified coder. Mental health is new to E/M. E/M is not new to coding.

14 Risk of doing things wrong If you cross walk, the old medication review to one E/M code you run the risk for not meeting the documentation requirements. You will also be an outlier. (review on bell curve slide) Using only time its wrong. You must have a time statement to use time. You might not have documented to that level. You may have up coded. Using the same code for easy and difficult cases. Doing this can lead to rejections and flags for audit. Only following one carriers rules. They are different, you run the risk of rejection and monetary take backs.

15 Risk of doing things wrong, continued You can only use new patient codes when the client is new to your group or has not been seen by a provider of that specialty for more than 3 years. Every carrier has there own set of rules. Many are similar however you need to review and stay familiar if you want to make the most or your coding and billing revenue. Watch your codes and your documentation. Monthly peer reviews with staff can prove to be enlightening for all. You can easily spot and outlier. Don t give them an easy target. Hire a certified coder. Keep in mind 1% error is 100% wrong.

16 Review of documentation requirements Must include the condition for which the medication is needed, type of medication, dosage, directions for use, any frequent side effects and the effect the medication is having on the patients symptoms/condition 2 of 3 key elements for established patient Expanded problem focus history Expanded problem focus exam Low Medical Decision Making (MDM)

17 Evaluation and Management There are 7 components to E/M 3 key elements and 3 contributory factors and time. 1. History 2. Exam 3. Medical Decision Making 4. Counseling 5. Coordination of care 6. Nature of Presenting Problem 7. Time

18 Evaluation and Management Chief Complaint (CC) sets the medical necessity. (CC) and Medical Decision Making (MDM) are the most important part of an E/M code Your E/M code can never be a higher level then your MDM. Time factor: You can only use time if more than 50% of the visit is spent counseling and it is documented. You can have a higher level of E/M codes with less time.

19 Chief Complaint The Chief Complaint also known as CC, is part of the medical history taking, and is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factors that are the reason for a medical encounter. (the medical necessity of this visit) The patient's initial comments to a physician, nurse, or other health care professional help form the chief complaint.

20 Understanding History Element of E/M ] CMS required history elements Type of history CC HPI ROS Past, family, and/or social Problem focused Required Brief N/A N/A Expanded problem focused Required Brief Problem pertinent N/A Detailed Required Extended Extended Pertinent Comprehensive Required Extended Complete Complete

21 Billing Provider Must Document the HPI Per CMS rules: E/M services guide. 1. The Review of Systems and the Past, Family and/or Social History may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, the physician must add a notation supplementing or confirming the information recorded by others. 2. Only the physician or NPP that is conducting the E/M service can perform the HPI. This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff.

22 Understanding the Exam element 1995 rules are simplistic. Usually not best rule to use for specialty physicians and NPP. Limited to affected body or organ system (1 body area or system related to problem) Problem Focused Affective body area or organ system and other symptomatic or related organ system (additional systems up to 7) Expanded Problem Focused Extended exam of affected area (up to total of 7 or more in depth then above) Detailed General Multi-system exam (8 or more systems) Comprehensive

23 1995/1997 Exam rules Best advise decide what works best for your practiced and use it. You can use 1995 for one claim and 1997 for another. Eliminate the potential risk from an audit. Make decision to use 1995 or Write in policies and/or procedures. We use 1997 exam rules for E/M or 1995 rules.

24 1995/1997 Lets look at the 1997 exam for psych. Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/eval_mgmt_serv_gui de-icn pdf

25 Understanding MDM Element of E/M A-number of diagnosis or treatment options B-Risk of Complications and/or Morbidity or Mortality C-amount and/or complexity of data reviewed

26 A. number of diagnosis or treatment options A Number of Diagnoses or Treatment Options A B x C = D Problem(s) Status Number Points Result Self-limited or minor (stable, improved, or worsening) Max = 2 1 Est. problem (to examiner); stable, improved 1 Est. problem (to examiner); worsening 2 New problem (to examiner); no additional Max = 1 3 workup planned New problem (to examiner); add. Workup planned 4

27 Risk of complications and/or morbidity or mortality There is much information in this area. Let review CMS.gov site again. Important factor in using the high level of toxic medicine. You need to identify this either by machining it and the fact it can be toxic or using wording, phrases like: checked for toxicity none found

28 Amount and/or complexity data reviewed C Amount and/or Complexity of Data Reviewed Reviewed Data Points Review and/or order of clinical lab tests 1 Review and/or order of tests in the radiology section of CPT 1 Review and/or order of tests in the medicine section of CPT 1 Discussion of test results with performing physician 1 Decision to obtain old records and/or obtain history from someone other than patient 1 point 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. Independent visualization of image, tracing or specimen itself (not simply review of report) 2 2

29 AIMS test adds to E/M Aims tests are not individually billable. Usually done by non-physician provider. If you review test positive or negative and document you reviewed this is, an additional point is added to review of test data. The is in the MDM section of the E/M code. This test falls under the Amount of data reviewed and adds one point. The only way to get points for reviewing old history is if you summarize this information.

30 Time for counseling/coordination of care You must spend more than 50% of the visit on counseling or coordinating care. It must be documented: Total time and the amount of time spent on counseling or coordinating care. You do not have to use start stop time of counseling. You can think of the process as time spent as part of the entire visit.

31 N.A.M.A.S. 5/9/2014 Documentation of Time with Evaluation and Management Services: Time is built into the E/M codes. Providers are told to base their E/M selection on the 3 key elements : History, Exam and Medical Decision Making. Times are listed in the CPT manual with each level of service as a guideline only. If a provider spends more than 50% of a face-to-face visit counseling and/or coordinating patient's care, the provider can code the visit based on time spent even if the History, Exam and MDM elements are lacking.

32 N.A.M.A.S. 5/9/2014 Time must be documented as well as the detailed description of the circumstance (counseling patient or coordinating care). For example: 55 minutes spent with patient, 30 minutes was spent in discussion with patient and family regarding care. Prolonged service codes can be reported in addition to an E/M code when the length of time a provider spends with a patient in an outpatient setting exceeds greater than 30 minutes beyond the typical for the level of service selected.

33 Bell curves/understand outliers

34 99211 This code is for the office setting only. If there is a nurse visit done in the home you have to follow the rule: CPT code first HCPCS codes second. There is no CPT code for nurse visit in the home so you look to HCPCS. The best HCPCS code for a nurse visit in the home is T1002. Do not use T1002 for nurse visit in the office.

35 99211 This is the most basic service done in the office. Usually done by nurse when patients is not being seen by doctor. Can be billed same day as doctor visit when it is a separately, identifiably different service by using a 25 modifier.

36 Difference in New patient and Established patient A new patient for a group practice is one that has not been seen by anyone in the group with the same discipline in the last 3 years. A new patient E/M code must meet 3 of 3 to be coded at that level. An established patient only requires 2 of 3 to be coded at that level.

37 E/M codes for different place of service AFC/Group home. There are two groups of codes. New and Established. New Established Residential home POS 12 New Established

38 Documentation Documentation Guidelines a) They are in place and you need to familiarize yourself with them. b) Medical necessity is the most weighted elements in a E/M. c) There needs to be a reason for the visit the Chief Complaint. d) There are different guidelines for different carriers when it come to billing.

39 Documentation rules for E/M We now know the parts of E/M. We need to be reminded that documentation must be complete in these areas. You can lose or increase revenue with your documentation. You must put down what you are doing and the calculations in your head must be documented. One doctor I worked with put it like this. Document what you did do and why did you do it. Explain your thought process.

40 Fiscal Year 2015 HHS OIG Work Plan Outpatient evaluation and management services billed at the new-patient rate. Questionable billing patterns for Part B services during nursing home stays. Physicians Place-of-service coding errors Physical therapists High use of outpatient physical therapy services. Need to follow all the rules around scripts, dx and certification of the plan.

41 Reduce risk, get it right Understand there are areas of risk. Identify by looking for your outliers. Create bell curves, compare to national standards. Learn rules and bill CPT (especially your E/M codes) properly insuring Medicaid funds are used as payer of last resort. Review your policies on coding and billing. Add language to help reduce risk. Have ongoing internal audits for proper documentation. Have external audits and trainings. This is a moving target ever changing and we need to keep up.

42 Good News This is not rocket science---you can do it. Many doctors have embraced the fact you have to documents all you do. You can start getting it right today. Start a self audit plan. Review what you have done right and fix what is wrong. Keep up to date ALWAYS. There are many in the industry that can help.

43 Any questions?

44 Thank you Pamela Pully CPC, CPMA