Essential Vocabulary Common Procedural Terminology Relative Value Update Committee Relative Value Units

Transcription

1 Billing and Coding Prepared for the AAOS: Business, Policy and Practice Management in Orthopaedics William Beach, MD Orthopaedic Research of Virginia Julie Balch Samora, MD, PhD, MPH The Ohio State University

2 Objectives Gain a basic understanding of the various terms, concepts, and abbreviations involved in coding and billing Develop an educated approach to coding and billing with particular emphasis on office and surgical coding and billing Provide real examples of appropriate coding and billing

3 Essential Vocabulary Common Procedural Terminology (CPT)- alphanumeric system that represents all physician services Relative Value Update Committee (RUC)- composed of physicians and other coding experts from medical specialty societies and CMS Relative Value Units (RVU)- Unit used as the basis for measuring the economic value of medical procedures. The units are relative are applied across all of medicine

4 Governmental Programs Center for Medicare and Medicaid Services (CMS)- the largest purchaser of healthcare services in the world Recovery Audit Contractors (RAC) Medicare Administrative Contractors (MAC) Zone Program Integrity Contractors (ZPIC) Comprehensive Error Rate Testing (CERT) Reported 9:1 return on investment for CMS on all programs!

5 Modifiers When a bill for physician services is prepared, often more than one CPT code number is listed in descending order of RVU s After the first CPT code, known as the index code, the physician/biller must assist the payor by providing rationale for why more than one code is being listed There are many instances when a bill or service will have CPTs with modifiers, which are 2- digit numbers, identifying a special situation

6 Modifiers Used when multiple procedures are performed or same procedure performed more than once Used when service(s)/procedure provided within the global services period of another service/ procedure Used to indicate occurrence of unusual events Format: Two digit appendage to a CPT code Example ; arthroscopic rotator cuff repair, a massive cuff tear. 22 modifier for increased procedural services when the work required to provide a service is substantially greater than typically required (e.g. massive rotator cuff tear)

7 Correct Coding is imperative Medicare Fraud intentional or unintentional, doesn t matter Based on what you should know, not what you may know 5 years in prison and a $10,000 fine For every occurrence Plus interest Disqualified from participation in Medicare You cannot abdicate this responsibility to an assistant or EMR!!!!

8 Surgical Coding CMS uses a third party bundling package known as the National Correct Coding Initiative A bundling package defines which surgical CPT codes can be reimbursed either separately or in combination AAOS has an excellent bundling package, the Global Services Data Book which is the definitive package for orthopedic surgical billing The bundling package lists every surgical procedure/cpt code as well as which codes can and cannot be listed for reimbursement with that code

9 Example When more than one procedure on a single date of service (ie during one case) is performed, the procedure with the highest number of RVUs (index code or index procedure) must be listed first The reimbursement is based on the number of RVUs a procedure is given is based on the RUC The RUC uses time and intensity to determine the RVUs Example: is the CPT code for a medial AND lateral meniscectomy. Several codes would therefore be bundled together and billing for multiple other procedures would be disallowed by the bundling package (medial OR lateral meniscectomy) would therefore be prohibited.

10 Evaluation and Management E&M services are the non-surgical services such as office, emergency room and hospital patient visits. The basics of outpatient coding are the 1995 or 1997 Documentation Guidelines for Evaluation and Management Service.

11 Key Components Chief Compliant and History (CC and Hx) Every medical record must have a chief compliant. The history includes HPI, ROS, PMH, social history and family history Physical Examination (PE) Medical Decision Making (MDM) Every medical record must have each of these documented or referenced for audit purposes Reimbursement is based on the Lowest Level of service for these required key components

12 Templates Whether using electronic medical records or paper charting, templates greatly facilitate data acquisition and documentation Intake data sheets (which ask patients to provide all the information required by CMS and insurers for each level of service) are very helpful In general, templates: Aid in efficiency INCREASE patient work time STANDARDIZE team encounter time DECREASE physician encounter time!

13 EXAMPLE

14 New Patient Visits

15 6/12/2015 History of Present Illness Chief Complaint Template CLODIER + associated items (4 bullets) Character Location of pain and injury Onset Duration Intensity Exacerbation Remission

16 New Patient History

17 Physical Exam Rules There are only six recognized body parts (2 upper extremities, 2 lower extremities, back and neck) There are a maximum of 30 available data points TRIM (Tenderness, Range of motion, Instability or stability and Muscle strength) pneumonic coined by Jack Ritchie, MD to remind him of the necessary exam points for each body part

18 New Patient Physical Exam body part 1 body part 2 body parts 4 body parts 4 body parts 6/12/2015

19 PE Data Points Well developed/well nourished = 1 Stands with? weight bearing line = 1 Alert and oriented X 3 = 1 Normal mood and affect = 1 TRIM & skin X 2 body areas = 10 Sensation X 2 = 2 Pulses X 2 = 2 Total available = 18 (only need 12)

20 Physical Exam continued Use the normal extremity to determine the expectation of the abnormal extremity. The goal for every new patient visit should be a level 3 physical exam! Key point -- a level 4 or 5 new patient visit requires 30 bullets which includes all the data points available from vitals signs to lymph node exam!

21 MDM Documentation Medical decision making is the most complicated part of the medical record There are three sections in MDM Data Diagnosis Risk The rules require (from an audit/documentation rules standpoint) that the medical record must qualify in only 2 of the 3 areas of MDM

22 MDM nitty gritty If the goal is to document a new level 3 visit, then must attain the required number of bullets in 2 of 3 areas in MDM (data, diagnosis and/or plan/risk) That goal is easily attainable for the normal new patient visit Data interpretation of an image = 2 points or reviewing a report/summary = 2 points requires a total of 2 points from this area. Diagnosis an established problem which is worse Patient presents for an evaluation = 2 points. If problem is new and does not require a work-up = 3 points. If it does require a work-up = 4 points requires 2 points from this area. Risk/plan components of this section are divided into plan elements and risk elements. Only one item is required in this area. Over-the-counter medications plan Physical therapy - plan A radiograph risk Arterial puncture risk and plan The standardized risk required to meet is an ankle sprain

23 MDM Documentation (example) Interpret radiographs = 2 pts. (need 2) Review outside image or information = 2 pts. Diagnosis (worsening) = 2 pts. (need 2) New problem no W/U = 3 pts New problem with W/U = 4 pts Plan/risk = 1 pt. (need 1) OTC meds PT Obtain an x-ray 2 of 3 sections

24 In conclusion, the medical record will be reimbursed at the lowest level of the three key components and is 100% dependent on documentation There should always be a level 5 history (utilize templates) There should always be a level 3 physical exam (12 bullets/two body areas), which is the rate limiting key component for a new patient visit And lastly if you take a radiograph or interpret an image, have a worsening problem that is new or requires a work-up, and suggest an OTC med, recommend PT or have a problem equal or greater than an ankle sprain, then the level of documentation has met the requirements of 99203

25 Established Patient Visits

26 Established Patient History Bullets (Can copy and paste, but be careful!) /12/2015

27 Physical Exam If audited, pass on this section

28 E&M Expectation Level 3 New patient visit History = 5, PE* (2 body parts) = 3, MDM = 3 Level 4 Established patient requires: Level 4 or higher history Pass on the PE Level 4 MDM* Data = 3 points OR 2 Diagnoses Level 4 Plan/Risk = Prescription Injection Surgery * Rate limiting key component

29 Dr. Beach s Approach to E&M Coding Develop/acquire all the necessary paper tools to facilitate data collection and documentation Define the expected/anticipated level of service (N3 (99203) and E3 (99213) or E4 (99214)) Understand the variations of the expected level of service Count bullets Document the E&M service Code the service Develop Define Document (D³) & KEEP IT SIMPLE

30 Audit Red Flags! New level 4 and 5 visits = or Physical Exam requires 30 physical exam bullets including a lymph exam of at least one body area Medical Decision Making Level 4 prescription, aspiration/injection or surgery Level 5 surgery with risk, emergent, fracture with dislocation, neurologic loss, discogram, myelogram, arthrogram = risk to life or limb! Established level 5 visits = 99215

31 KEYS to Success and Safety Be as educated a coder as you are an educated physician and surgeon Work backwards if you wrote a prescription/inject/schedule surgery document the remainder of the requirements and charge an E4. Attend AANA/AOSSM Coding ICL!!!

32 Thank You