Best Practices: Physician Billing/Coding for Hospice & Palliative Care

Transcription

1 Best Practices: Physician Billing/Coding for Hospice & Palliative Care Presented by: Christopher P. Acevedo, CHC, CPC Objectives Describe the circumstances that allow physician visits to be separately billable List common pitfalls made by providers in hospice and palliative care Differentiate the hospice benefit from billable physician services Discuss how to substantiate the medical necessity of physician visits through thorough documentation You may pause now to download the handouts Billable Physician Visits

2 What Physician Services Are NOT/Are Billable? Are NOT: Medical director General supervisory services Physician member of IDG (team physician) Participation is establishing or revising plan of care Supervision of care and services Establishment of governing policies CFR (a) Visits to Hospice patients performed by a Nurse Practitioner (NP), if the specific NP has not been formally elected as the Hospice Attending E/M Services Billable encounters/visits Medically necessary Face-to-face Code sets by type of service and/or place of service New patient vs. established patient Home visits ALF, domiciliary, rest home visits Initial care vs. subsequent care Inpatient hospital SNF/NF Medically Necessary Defined* MEDICALLY NECESSARY Services or supplies that are needed for the diagnosis or treatment of your medical condition, meet the standards of good medical practice in the local area, and aren t mainly for the convenience of you or your doctor.

3 CMS FAQ Q: For hospice services, why are rounds not considered a patient care visit? A: Rounds are an administrative activity rather than a patient care activity. A visit provided during rounds would not be considered a patient care visit unless a patient required a physician s assessment and/or intervention during the visit. Rounds performed in a facility for the purposes of writing orders or any other non-patient care required services, do not count as visits. (Revised) Reference: Medical Necessity Reason for visit May/May Not Mirror Subjective Complaint May/May Not be Related to Terminal Dx May/May Not be Related to Level of Care Medical Necessity

4 Reason for Today s Visit Medical Necessity Medical Necessity & E/M Documentation software may facilitate carry-overs and repetitive fill-ins of stored information. Even when a complete note is generated, only medically necessary services for condition of patient at time of encounter as documented can be considered when selecting appropriate level of E/M service. Information not pertinent to patient s condition at time of encounter cannot be counted.

5 Medical Necessity & E/M, cont. However, providers are entitled to appropriate level of reimbursement for medically necessary services that are supported by documentation. Should not down code or code middle of the road when a higher level of service has been rendered. Remember: down coding is as much of a billing error as up coding! E/M Services Once the right type is identified Location of the patient New vs. Established Initial vs. Subsequent Must choose right level of service 3, 4 or 5 levels; Based on documentation of history, exam, and medical decision making; or Time and counseling/coordination of care Pitfalls

6 Common Pitfalls Documentation An Incomplete Hx Can Easily Sabotage an Encounter Example: Upon admission to your IPU, a medically necessary physician visit takes place and an H&P is documented. The physician bills The documentation consists of a comprehensive Physical Exam and MDM is high, however the Hx lacks a documented Social Hx & Family Hx. How does this effect what should be billed? Common Pitfalls Documentation Even a requires these be documented With the minimum documentation requirements not met for even a 99221, all that s left is 99499: an unlisted E/M service. Good luck getting paid! Common Pitfalls Documentation An Incomplete PE Can Also Easily Sabotage an Encounter Example: A medically necessary MD visit takes place in a patient s home. The physician bills The documentation consists of a comprehensive Hx and MDM is high, however the documented PE only consists of 7 OS. How does this effect what should be billed?

7 Common Pitfalls Documentation With both a & requiring a comprehensive PE, the highest level new-pt. home visit supported by the documentation is Common Pitfalls Type of Patient Established patient billed as New patients Common occurrence as a pt may be new to me Common Pitfalls Respite The million dollar question Would I be seeing this patient if they were not under our care for Respite? If yes, it becomes even more essential to document a clear reason for TODAY s visit.

8 Common Pitfalls Assumptions Most Common Pitfall! Physicians Know How to Document They run their own private practice, they must know how to do it Documentation from a coding/documentation compliance perspective is not inherent to Physicians! WHO IS LOOKING AT US? XYZ Hospice The Fight Against Fraud & Abuse CMS MACs Probe Audits Prepayment Review Statistical Valid Random Sampling (SVRS) ZPICs Formerly Program Safeguard Contractors (PSCs) Recovery Audit Contractors (RACs) Comprehensive Error Rate Testing (CERT) contractor Medicaid Integrity Program (MIP) Don t forget the Private Payers! Special Investigative Units (SIU) Contracted audit companies

9 2010 OIG Work Plan PHYSICIAN BILLING FOR Medicare HOSPICE BENEFICIARIES We will review the extent of Part B billing for physician services provided to Medicare hospice beneficiaries. Physicians may receive reimbursement for hospice services under Medicare Part A or Part B. This study is a follow-up to recent OIG studies on hospice care. We will determine the frequency of and total expenditures for physician services under Part A and Part B for hospice beneficiaries. We will identify whether physicians double-billed hospice services to Part A and Part B OIG Work Plan TRENDS IN Medicare HOSPICE UTLIZATION When the hospice benefit was created in 1982, Medicare did not cover more than 210 days of hospice care per beneficiary. Congress changed the benefit to eliminate the limit on the number of days covered by Medicare. Since then, the number and types of diagnoses associated with hospice utilization have increased and longer stays have become more common. We will examine the characteristics of hospice beneficiaries, geographical variations in utilization, and differences between for-profit and not-for-profit providers. OEI ; expected issue date: FY 2011; new start Some Numbers 2006 Presidential Review Hospice Services Trends from FY 1995 FY 2005 Most dramatic annual increases between 21% to 26% occurred from FY The greatest increases by provider: Freestanding hospices 28% in FY 01 and 31% in FY 03 and 04 Skilled nursing facility (SNF) based hospices 25% in FY 03 The greatest increases by care type: Physician services - exceeded all other care types 43% in FY 02 and 30% in FY 03 Continuous home care (CHC) 33% FY 03 and 31% in FY 04

10 Cause for Concern? The average length of stay: Continues to rise National average of 64 days in FY 05 vs. 53 in FY 02 Freestanding facilities - 69 days in FY 05 vs. 57 in FY 02 Expenditures continue to rise at double digits each year Number of beneficiaries/amount of outlay per beneficiary has been increasing at a much more modest rate. Staggering Numbers 491% increase in total outlays for freestanding hospices Outlays for physician services have risen 641%! Decrease in Cancer Related Dx Source CMS Hospice Data

11 Some Additional Numbers Source CMS Hospice Data Internal Controls Best Practices in Billing/Coding Identify the Internal Experts (you may be surprised) Identify Physician Champions of Compliance Your Best Ally Education For Providers (you will be surprised!) Include Appropriate Billing Staff For Leadership Team Documentation is the Key Provide Cheat Sheets (trying to teach new tricks!) QAPI Consider Outside Audit Mock Payer Review

12 Auditing/Monitoring What type of quality checks do you have in place? Assessing physician/npp documentation Assessing contract physician documentation YOU are billing for these services? Are they being documented appropriately? Annual Code Changes Changes to coding rules Annual Rule Changes Are we in compliance today? Compliance Guidance What codes do we look at? a random sample of claims/services? all claims/services from a particular payer? Identify risk areas Use these risk areas as the universe of claims/services from which to select the sample OIG recommends an evaluation to determine if the codes billed and reimbursed were accurately ordered, performed, and reasonable and necessary for the treatment of the patient What are you looking for? Evaluation & Management Consultation vs. Referral Levels of E/M service Can you read it? Can you tell who provided the service? Can you tell in what setting service was provided?

13 Compliance Guidance Must make appropriate response when problem identified Timely Specific action depends on circumstances May be straight forward repayment with appropriate explanation to payer May need to involve a Qualified Health Care Attorney to determine the next best course of action Post Audit Follow-Up Education Physicians, NPPs, nurses Staff (registration, coding/billing, administrative) Processes to prevent identified errors from reoccurring Monitoring techniques Correspondence from the carriers and insurers challenging the medical necessity or validity of claims Check productivity reports for illogical patterns or unusual changes the pattern of CPT, HCPCS or ICD.9 code utilization Review monthly A/R reports for high volumes of unusual charge or payment adjustment transactions. Follow-up Focused review Targeted area of coding, documentation W/in days of education New physician, new service Progressive action One CPT code on 100% prospective review All coding on 100% prospective review Comparisons Rewards! Start all over again

14 Auditing/Monitoring At what point do we hire a coder? What credentials should he/she have? Experience? Where do we look? How do we monitor the coder? How do we know what we don t know??? Education Needs Recognize the importance of continued education Educate physicians/npps as new hires! Regulations change frequently have a plan to keep up with changes Develop templates that incorporate coding requirements Use billing/coding Cheat sheets Assessing Providers Who are your outliers What are the most frequent E/M codes Keep track w/ benchmarks

15 Education Needs Provider Meetings Case studies Selective review of random charts Time allotted each quarter to billing/coding teaching Focus on basics Agency Education Needs Assign someone to own Knowledgeable about provider billing Become familiar w/ nuances Review transmittals from Medicare Benchmark your provider billing/coding CME yearly Christopher P. Acevedo, CPC, CHC Acevedo Consulting Incorporated