Coding 101: The Basics. What precipitated this web seminar? Basics

Transcription

1 Coding 101: The Basics Debbie Abel, Au.D. Director of Reimbursement American Academy of Audiology What precipitated this web seminar? Questions that are posed to the Academy Concern about those questions Education of members Many new to the profession Many new to private practice Basics Need a CPT, ICD-9-CM and HCPCS manuals Can be purchased via: CategoryId=PhysicianOffices-Coding- Books(DecisionHealth08) 1

2 Other resources: The American Academy of Audiology Capturing Reimbursement Centers for Medicare and Medicaid (CMS) For Medicare Providers: Local Coverage Determination Policies (LCDs): Requirements from contractor May describe what is medically necessary CPT ICD-9 Your contractor may not have an LCD Not a negative, but look at others (by state, alphabetically or by contractor): Medicare Tenent: If you are a Medicare provider, cannot bill a Medicare patient more than you do another patient for the same procedure 2

3 Therefore You cannot perform free hearing evaluations Why would we want to de-value our own services? Retail vs medical? Impact on autonomy and recognition Medicare is going to do that Thoughts: These three coding systems support each other for filing claims Required: CPT (and/or HCPCS) AND ICD-9 If billing HCPCS codes May also be billing CPT Always have to have an ICD-9 code with each claim Coding Mantra: Need to code by signs and/or symptoms Why the patient presented to your office Code by patient complaints Tinnitus? Hearing loss? Dysequilibrium? 3

4 Need Outcome Measures! With MIPPA (Medicare Improvement for Patients and Providers Act of 2008): Audiologists now have access to Physician Quality Reporting Initiatives (PQRI) Need outcome measures Check Out: Audiology Clinical Practice Algorithms and Statements 4D06-A60A- C56DF888BAD3/0/ClinicalPracticeAlgorithms.pdf Thoughts: Case-building for differential diagnosis Differentiates us from non-audiology providers Provides our worth in the healthcare system Provides your worth to the facility that employs you Many are evolving into reimbursing you via relative value units (RVU) reimbursement Productivity 4

5 Considerations: CPT codes selected must be obvious to an insurance company as to why they were selected CPT codes must be ones typically performed by audiologists CPT codes must mesh in supporting the diagnosis code you have chosen Current Procedural Terminology (CPT) AND International Classification of Diseases (ICD-9) Have to support each other It needs to be apparent that what you performed would result in the disease code chosen What is being billed has to be appropriate to what you are licensed to perform Documentation has to reflect the above points Avert the denial: Do NOT use unspecified hearing loss codes Unless there is no other choice Likely to be denied 5

6 Thoughts: May utilize several ICD-9 s on the same claim: Example: Patient presents with a unilateral hearing loss and tinnitus: sensorineural hearing loss, asymmetrical subjective tinnitus Medicare may only allow one ICD-9 per CPT code ICD-9 Recommendations: When looking for diagnostic or disease codes, 5 digits are the most specific Less prone to denials Avoid those that are 3 and 4 digit and those than end in 0 Diagnostic V codes are also to be avoided Sometimes impossible ICD-9 vs ICD-10 ICD-9 has 17,000 codes ICD-10 has 68,000 codes Will need 5010 HIPAA standard for ICD- 10 Utilize 4010 HIPAA standard for ICD-9 Proposed deadlines April 1, 2010 for 5010 October 1, 2011 for ICD-10 6

7 Many opponents, implemention may be delayed: American Health Information Management Association (AHIMA) American Medical Association (AMA) American Academy of Professional Coders (AAPC) Extensive amount of professional health care organizations Large amount of hospital and medical offices ICD-10-CM Will be alphabetic and numeric: H900 Conductive hearing loss, bilateral H903 Sensorineural hearing loss, bilateral H910 Ototoxic hearing loss H912 Sudden idiopathic hearing loss H931 Tinnitus CPT Codes Procedures Examples: Basic comprehensive audiometry Currently the only audiology bundled code: (Pure tone air and bone conduction audiometry) (SRT) and (WRS) CPT TM five-digit codes, descriptions, and other data only are copyright 2007 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. TM CPT TM is a trademark of the American Medical Association. 7

8 CPT Codes (cont.) Vestibular codes: CPT Audiologic procedures: CPT Evoked potential codes: CPT OAE codes: CPT CPT Codes (cont.) Hearing aid related codes: CPT Cochlear implant codes: CPT Central auditory test codes: CPT Tinnitus code: CPT CPT Codes (cont.) Audiologic (aural) rehabilitation CPT code Nameless codes ----unlisted otorhinolaryngological service or procedure CPT Tinnitus treatment for example 8

9 Modifiers -22 Unusual Procedural Services Utilized when procedure is greater than what is typically required Involves increase in provider work, time and complexity of what is typically performed» Many insurance carriers state that if it is less than 25% more work, should not append» May yield a 20-50% increase of the allowable rate Example: Modifiers (cont.) Requires documentation to be submitted attesting to why additional time and/or work was necessary An audit and/or a delay in payment may occur Modifiers (cont.) -26 Professional component Utilized with: ENG (CPT ) ABR (CPT 92585) OAE (CPT 92587, 92588) Utilized: When someone else performed the procedure You do the interpretation and prepare the report Example:

10 Modifiers (cont.) TC Technical component Utilized with: ENG (CPT ) ABR (CPT 92585) OAE (CPT 92587, 92588) Utilized: When you only performed the test Bill TC Another provider does the interpretation They bill 26 This equals the same reimbursement as the global fee Example: TC Modifiers (cont.) -52 Reduced services Procedure is partially reduced or eliminated Discontinued at provider s discretion after the procedure commenced Can be used to indicate monaural vs binaural testing Not recognized by all carriers Example: Modifiers (cont.) -53 Discontinued procedure Procedure started, patient s well being becomes jeopardized during the procedure, provider discontinues Example: Patient having ototoxicity monitoring, becomes ill during procedure Reimbursed at 25% of the allowed amount Example:

11 Modifiers (cont.) -76 Procedure was performed more than one time on the same date of service Glycerol or urea test Ototoxicity monitoring Medicare Modifiers GY-Item or service is statutorily excluded or does not meet the definition of any Medicare benefit Often used when a secondary insurance has a hearing aid benefit On the Office of the Inspector General s list for 2009 GA-Waiver of liability on file To be used when a denial is expected and an ABN is on file No ABN, no billing the patient Medicare Modifier (cont.) GZ-Item or service expected to be denied as not reasonable and necessary To be used when a denial is expected and an ABN is not on file Can t bill the patient 11

12 Medicare Considerations: Medicare Participating Provider: Patient pays you their 20% co-insurance You bill Medicare Medicare pays you 80% of the allowable amount per the Medicare Physician Fee Schedule Medicare Non-Participating Non-participating categories: Non-participating 5% less than participating Limiting charge 10% higher than participating Medicare Non-participating Patient pays you their 80% allowable and difference in the limiting fee You bill Medicare Medicare pays the patient 80% of the allowable amount per the Medicare Physician Fee Schedule 12

13 Another category: Opting out Need a contract with Medicare Need a contract with the patient Cannot file any claims to Medicare Can t return to Medicare for 2 years Dying isn t hard. Getting paid by Medicare is. -Art Buchwald, 2006 Advanced Beneficiary Notice of Noncoverage (CMS-R-131) Released in March, 2008 Was to be a one-year phase-in Should be utilized now Required as of March 1, 2009 ABN and Notice of Exclusions of Medicare Benefits (NEMB) are now on the same form Patient directs how the claim is to be filed 13

14 Three options on the ABN: Three options: Bill Medicare Don t bill Medicare Patient declines procedure For those things that are statutorily excluded: Anything not medically necessary What is medical necessity? May be located in the LCD Needed for the diagnosis or treatment of a medical condition Provided for the diagnosis, direct care and treatment of the patient s medical condition Meets the standard of good health practice Is not for the convenience of the patient or health care practitioner -Williams, Burton and Abel, Audiology Today. Vol. 20 (6) 14

15 Incident to billing Does not pertain to diagnostic audiology procedures Has not been applicable since at least 2002 Audiologic procedures are classified as other diagnostic tests Other diagnostic tests cannot be billed incident to What IS Incident to? Furnished in a non-institutional setting to noninstitutional patients An integral, though incidental, part of the service of a physician in the course of diagnosis or treatment of an injury or illness Commonly furnished without charge or included in the physician s bill Of a type commonly furnished in the office or clinic of a physician Furnished under the direct supervision of the physician and furnished by a physician, other practitioner, or auxiliary personnel Incident to a professional issue CMS transmittals 84 and 1470 (issued on February 29, 2008) Specifies that audiologists are to utilize their own National Provider Identifier (NPI) when filing claims to Medicare Also need a Provider Identifier Number (PIN) - 15

16 Another transmittal CMS transmittal 1550: For claims with dates of service on or after October 1, 2008, audiologists should enroll in the Medicare program For claims with dates of service on or after October 1, 2008, the NPI of the enrolled audiologist shall be used on claims in the appropriate rendering and billing fields Addresses: Audiologists need to file: 855I 855R Clarification of SLP and audiologic services Also Otolaryngologists can no longer be (and should NOT have been) billing audiologic services with their own provider numbers Effective date was initially set for April 7, 2008 CMS extended the deadline until October 1,

17 If you are a contractor or employee of a physician, need to file an 855R to reassign the benefits to the physician /cms855r.pdf Reimbursed by way of the same physician fee schedule as the physician We are reimbursed at 80% of the allowable Medicare Physician Fee Schedule 17

18 Other components of CMS Transmittal 84: BP.pdf Contractors shall not pay for services provided using computer administered tests that do not require the skills of an audiologist CMS Transmittal 84 Contractors shall not pay for the technical component of audiologic diagnostic tests performed by a qualified technician unless the physician or nonphysician supervisor who provides the direct supervision documents clinical decision making and active participation in delivery of the service CMS Transmittal 84 Contractors shall not pay audiologists for treatment services

19 CMS Transmittal 84 Contractors shall pay for services that require the skills of an audiologist when furnished by an audiologist qualified according to section 1861 (II)(3) of the Act act/title18/1861.htm CMS Transmittal 84 Contractors shall not pay for services that require the skills of an audiologist when furnished by an AuD 4 th year student or others who are not qualified according to section 1861 (II)(3) of the Act

20 In the supporting information: Cannot deny payment if the diagnosis is sensorineural hearing loss Patient may have had a change in their hearing or other related concerns Needs to be vetted and the only way is an evaluation Supporting info (cont.) Computer administered tests or devices such as the device that produces an otogram do not require the skills of an audiologist (interpretation, comparison, consideration, or modification, during the tests) and can be administered by any staff. Such tests are screening and not audiological diagnostics tests Further With the exception of screening tests and tympanograms, audiologic function tests with medical diagnostic evaluation require the skills of an audiologist. For vestibular function tests, it may be appropriate for a physician or qualified nonphysician practitioner with the skills of an audiologist to directly supervise and provide the skills of an audiologist while the services are being furnished by a technician

21 And finally Although AuD 4 th year students and other audiology students do not meet the current requirements to statute to provide audiology services, they may meet standards equivalent to audiology technicians th Year AuD Students Can see Medicare patients IF: They are supervised 100% of the time Supervisor has to be in the booth with the student On-going decision making is discussed/directed Supervisor can bill Medicare for services if this condition is met Student may help write the report Evaluation and Management Codes (E/M) Time, complexity and review of systems are required Medicare will not reimburse audiologists at this point in time for E/M codes BE CAREFUL: Audiologists should not upcode-be realistic with what you are doing Personal thought: would not code beyond a level 3 so as not to trigger an audit 21

22 E/M New and established patient codes New: CPT Established: CPT Need to include Review of Systems (ROS): Head, including the face Neck Chest, including breasts and axilla Abdomen Genitalia, groin, buttocks Back Each extremity ROS (cont.) Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hemotologic/lymphatic/immunologic 22

23 E/M Codes CPT A problem focused history A problem focused examination Straightforward medical decision making Physicians typically spend 10 minutes face-to-face with the patient and/or family E/M Codes (cont.) CPT An expanded problem focused history An expanded problem focused examination Straightforward medical decision making Problems are of low-moderate severity Physicians typically spend 20 minutes face-to-face with the patient and/or family E/M Codes (cont.) CPT Adetailed history A detailed examination Medical decision making of low complexity Problems are of moderate severity Physicians typically spend 30 minutes face-to-face with the patient and/or family 23

24 E/M Codes (cont.) CPT A comprehensive history Acomprehensive examination Medical decision making of moderate complexity Problems are of moderate to high severity Physicians typically spend 45 minutes face-to-face with the patient and/or family E/M Codes (cont.) CPT A comprehensive history Acomprehensive examination Medical decision making of high complexity Problems are of moderate to high severity Physicians typically spend 60 minutes face-to-face with the patient and/or family E/M Codes (cont.) CPT code May not require a physician s presence Minimal problem Typical time spent: 5 minutes Performing or supervising 24

25 E/M Codes (cont.) CPT code A problem focused history A problem focused examination Straightforward medical decision making Problems are minor Physicians typically spend 10 minutes face-toface with the patient and/or family E/M Codes (cont.) CPT code An expanded problem focused history An expanded problem focused examination Problems are of low to moderate severity Medical decision making of low complexity Physicians typically spend 15 minutes face-toface with the patient and/or family E/M Codes (cont.) CPT code A detailed history A detailed examination Medical decision making of moderate complexity Physicians typically spend 25 minutes face-toface with the patient and/or family 25

26 E/M Codes (cont.) CPT Code A comprehensive history A comprehensive examination Medical decision making of high complexity Problems are of moderate to high severity Physicians spend 40 minutes face-to-face with the patient and/or family Cerumen Management Is in the scope of practice of audiology Unless cerumen is impacted, should not be billing for it separately as it is included in the CPT code Can be billed to the patient with the CMS- R-131, the new ABN/NEMB form and the appropriate modifier 26

27 CPT Code VRA According to the vignette, it is not a method code: The audiologist then proceeds to the control room and, through the diagnostic audiometer, presents speech stimuli and frequency specific sounds between 500 hertz and 4000 hertz. When and frequency specific minimum response levels between 500 hertz and 4000 hertz, the audiologist enters the patient side of the audiometric test booth and informs the mother of the results. CPT TM five-digit codes, descriptions, and other data only are copyright 2007 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. TM CPT TM is a trademark of the American Medical Association. CPT Code 92582: CPA the audiologist will hold one earphone to his own ear, listen for pulsed tones at a comfortable loudness level, say to the child, "Listen to this!", and hold just the earphone adjacent to the child's ear. This is repeated two or three times until the child demonstrates that he is no longer afraid of the presence of the earphone. The search for minimum response levels is repeated for each frequency from 250 hertz through 6000 hertz for the right and left ears, respectively. CPT TM five-digit codes, descriptions, and other data only are copyright 2007 by the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. TM CPT TM is a trademark of the American Medical Association. --Nothing noted about speech audiometry New CPT code for 2009! CPT code CANALITH REPOSITIONING PROCEDURE 27

28 HCPCS Codes Healthcare Common Procedure Coding System (HCPCS) Addresses what CPT did not with: Some services V5010 (Assessment for hearing aid) V5020 (Conformity evaluation) Supplies: Hearing aids Dispensing Earmolds (and earmold impression) Batteries Assistive Listening Devices Options: Unbundling vs bundling Gives the practitioner the option to unbundle Gives the insurance company the option to bundle Gives the patient and the applicable third party payor the mechanism to demonstrate professional value Standardized Billing Form: The CMS

29 Interactive CMS 1500: /cms1500.nsf/cms1500.html# forms/cms1500/instructions.html 29

30 ICD-9-CM International Classification of Diseases Conductive Hearing Loss Conductive Hearing Loss (CHL), unspecified CHL, external ear CHL, tympanic membrane CHL, middle ear CHL, inner ear CHL, unilateral CHL, bilateral Conductive HL of combined types Sensorineural Hearing Loss Sensorineural hearing loss, unspecified Sensory hearing loss, bilateral Neural hearing loss, bilateral Neural hearing loss, unilateral Central hearing loss Sensorineural hearing loss, unilateral Sensorineural hearing loss, asymmetrical Sensory hearing loss, unilateral Sensorineural hearing loss, bilateral 30

31 Mixed CHL and SNHL Hearing Loss Mixed hearing loss, unspecified Mixed hearing loss, unilateral Mixed hearing loss, bilateral Other Deaf, non-speaking, not elsewhere classifiable Other specified forms of hearing loss Unspecified hearing loss Diagnostic V codes V72.1 Examination of ears and hearing V72.11 Encounter for hearing examination following failed hearing screening V72.19 Other hearing examination of ears and hearing Last resort, likely to be denied Address specific events, not disease 31

32 Claim form: Lists the CPT(s), ICD-9(s) and HCPCS codes and demonstrates their interaction: What you performed (CPT) Diagnosis results (ICD) Resulting recommendations if product (HCPCS) Ties the coding systems together Questions? To ask a question, please type your question into the chat box in the lower left corner of the screen and click on the Send button located right below the box. Documentation A chart is a legal document Can be subpoenaed Provides continuity of care between health care professionals Third party payor requirement Quality Assessment/Peer Review 32

33 What should be included? Demographic information Patient s name Address Date of birth Contact information Insurance card Photocopy front and back (need address) Driver s license What else? Who is the referring professional if required by a third party payor Medicare physician referrals: On the physician s letterhead or prescription pad Not to have the appearance that it was solicited by you No referral pads with your practice name And? Reason for the visit Case history Surgeries Medications, past and present Herbals, over-the-counter meds Occupational noise exposure Recreational noise exposure 33

34 More HIPAA forms Notice of Privacy Practices (NPP) Case history Adult Familial hearing loss Age of onset, syndromes? Treatment plan» Surgeries? Amplification? May have to excavate for the history Pediatric: History: Prenatal Delivery Family More Chart Notes: If it isn t in the chart, it didn t happen Need to document all that patient relays to you SOAP outline 34

35 SOAP Subjective findings History Objective finding Physical exam Testing Assessment Puzzle piecing Plan Recommendations for patient based on the above Referrals to others Hard Copy Guidance If err, strike through with one single line No sticky notes! Everything needs to be secured with the patient s name and date 35

36 Further Initial with your three initials Do not use white out Do not scribble Do not shred Electronic Health Care Records EHR/EMR President Bush has requested this to be a reality by 2014 To reduce errors Portability Accessibility EMR Stumbling Blocks: The average cost of an EMR per physician or provider is $33,000! Implementation: $100 per hour for customization, training, and IT setup ($3,500) Accessibility: One tablet PC per provider =$2,500 One workstation for each member of your support staff =$1,000 Network server =$2,000 Maintenance contract: $2,000 to $3,000 per year 36

37 EMR Can enter all applicable information for that particular date of service Can utilize templates Audiograms Tympanometry Real ear measures Outcome measures EMR Once you hit the button to enter all information, cannot append for that date of service Can append with appendix or appendices Contracting-the new reality show?? Fear Factor? Everyone else will so I have to Survivor? Will I be paid enough to keep the doors open? Lost? In the legalese? The mole? Are we blindly walking into something that may not be beneficial to the practice? 37

38 Contracting Need to know if you can afford to be a provider: Overhead costs, practice expenses? Number of patients you can expect? Do you have to give something(s) away? Balance billing? Under what conditions? What may be a beneficial arrangement for the practice down the street may not be for you Contracting (cont.) Need to know what your monthly break even point is Need to know with each separate contract what you can (or can t afford) to loose Sacrifice diagnostics for product? If so, how much of a cost Personally Professionally Contracting tenets: As long as it is not contractually excluded, a patient should expect to pay for services, diagnostic or rehabilitative. 38

39 Insurance is a mechanism for reimbursement, not payment -Kadyn Williams, AuD Patients are expected to pay for their assigned health care costs -Supposed to deter fraud and abuse Final Questions? To ask a question, please type your question into the chat box in the lower left corner of the screen and click on the Send button located right below the box. 39

40 Thank You! Contact Info: Debbie Abel, Au.D. Director of Reimbursement American Academy of Audiology