Optimizing Coding in Primary Care, Part 1

Transcription

1 Learning Objectives Optimizing Coding in Primary Care, Part 1 Understand the financial impact of poor coding Correct common primary care coding errors Bill Dacey, MHA, MBA, CPC The Dacey Group, Inc. Palm Harbor, FL 2 Today s Agenda Urban Coding Myth #1 The Role of Coding in Reimbursement Errors Bundling (Light) Modifiers General Considerations Correct coding equals reimbursement =NOT Reimbursement is a function of your understanding and response to third-party payer reimbursement policies You are far more likely to get paid based on what you know rather than simply by what you do 3 4 Federally Identified Risk Areas Coding and Billing Per the Final OIG Compliance Guidance the Specific Risk areas outlined are: - Coding and Billing - Reasonable and Necessary Services - Documentation - Improper Inducements, Kickbacks, and Referrals Within each category further detail is provided. The elements specified in the plan are: Billing for items or services not rendered Reasonable and necessary service Double billing duplicate payments Non-covered services Incorrect provider ID numbers Unbundling Modifiers Clustering Upcoding (under-documentation?) 5 6 1

2 What Are Your Risk Areas? Current Risk Areas/Opportunities In the absence of fraud, all of the areas addressed are likely process or education issues with the exception of unbundling, clustering, and upcoding Many of these can be addressed via data audits and attendant process reviews, typically with good result Unbundling is a coding error, and the solution depends on who creates it EHR/EMR cloning/over-use (more next session) The trend towards technological solutions versus medical necessity Quality reporting Category II codes Clustering and upcoding are E/M issues (next session) 7 8 Top 6 Errors (payer perspective) You May Get Paid for What Is Payable Duplicate claims Claims not covered by this payer Bundled services Beneficiary eligibility Medical necessity Non-covered services It is your obligation to know how each payer processes claims and covers services It is highly likely that each contract you sign assigns this responsibility to you In Health Care Claims submission and processing what you don t know will likely hurt you financially 9 10 Submitting the Claim CPT Coding You may submit a claim for services, but that does not necessarily mean you will be paid (i.e. preventive/cosmetic) Just plain NOT COVERED Professional MD services are reported on the CMS-1500 (some still call it the HCFA ) 11 New CMS-1500 (Went into effect June 2007) This change is primarily to allow for the 10-digit NPI #s 12 YOU NEED TO OWN THIS You need to KNOW this Codes range from head to toe in each coding section of CPT Learn the subsection guidance that applies to what you do 2

3 Category II Codes Surgical Coding These are tracking codes; they are designed to facilitate data collection for performance measurement. These codes are released in January and again in July each year. They are optional BUT now are part of Medicare s Quality Reporting Initiative no individual payment but part of the quality reporting system. When can one report procedures and visits on the same date? When does a coder need to utilize a modifier to obtain accurate payment? What impact does the National Correct Coding Initiative have on coding? What role does the RBRVS play? The Surgical Package Items NOT Included in the Surgical Package Preop Intraoperative Postop Minor day of surgery (Modifier 25 is applicable) Major day of and day before surgery (Modifier 57 is applicable) Minor 0 or 10 Major 90 day post-op +1 day pre-op 91 global days Global Period determined by payer [Not CMS] Intra OP Bundling determined by payer Initial decision for surgery Other MD services (diff. spec./diff. group) Visits unrelated to surgical diagnosis (24) Treatment for underlying conditions Complications following surgery (78) Unrelated surgical procedures (79) Unrelated critical care services (24/25) Staged/related/distinct procedures (58/59) National Correct Coding Initiative (CCI) CCI Status Indicators Commonly referred to as bundling Created under CMS contract with Adm. Federal early in 1996 Saved $96 million in the 1st 6 months. Updated quarterly 0 This code is ALWAYS included in the Comprehensive code. Knowing this fact will reduce denial rates and lower aged insurance receivables. 1 There may be a chance to unbundle. Only add modifiers on this component code if appropriate. Use caution, reviews are possible are you certain you should be paid? Previously bundled in error. This component code is invisible. It is no longer on the list; therefore, should be allowed for claim submission. 3

4 Bundling Selecting E/M Codes Two main types of bundling: 19 - Incidental: The relationship between one service and another, and - Integral Component: One of the services is generally considered an integral part of a larger more comprehensive service - This is payer-specific you need to find out how each one does it E/M is far and away the most important group of codes for regulatory liability concerns Depending on specialty potential high revenue impact as well Coding correctly requires documenting it correctly there is no other safe harbor 20 Chart Audit or Pattern Monitoring Documentation Issues Scope is all payers look ahead Triage by risk payer mix, profile Focus chart intensive reviews on High Risk Pattern monitor low-risk areas or reduce audit size or frequency Coding By Time: Document Counseling and Coordination of care versus Prolonged Services coding If 50% or more of an encounter is c/c, time can be used as a driving factor to support a higher level of service of the original code Just state the time and the purpose For prolonged just state the nature of the extra time Critical Care requires total time that day Customize reviews to performance Improve Processes Effective Tools Establish Compliance and Correct Coding rates for providers: CPT and ICD-9 Develop thresholds of compliance geared to specific educational activities Verify all no bill determinations Establish correct coding/reviewing rates for coders and reviewers 23 One set of rules: Don t forget about the other 55% of private payers The Template bridge to electronic record Real time and the prospective review: The best opportunity for MD education use their own work product Reward high performers all staff levels 24 4

5 Templates and Forms The E/M Modifiers CMS allows but is concerned about cloning and repetitive documentation They don t want stamps but rather that the MDs will write what they did Don t over-rely on these they support documentation they don t replace it If forms are used avoid total repetition mix it up they should reflect your patients! Use rarely if ever prefer prolonged CPT codes -24 Unrelated E/M in a global (that you performed) -25 Separate, Significant, Identifiable, etc. -32 (sometimes) Mandated -57 Initial decision to perform surgery (+10 global) 26 The Surgical Modifier Own the Work, the Codes, and the Payment Process For most providers the big issues here are: Modifier 51 Same site, same incision Modifier 59 separate site, separate incision Modifier 58, 76, and 78 Know your codes Work the denials feedback to the coders Learn the rules by payer painful but true