Cracking The Code: Clinical Case Management & Medical Record Compliance Ohio Optometric Association 2015

Transcription

1 1 Cracking The Code The Power Of The Pen American Optometric Association 2015 John Rumpakis, OD, MBA Practice Resource Management, Inc. 1 John Rumpakis, OD, MBA Named the Chief Medical Coding Editor for Review of Optometry & Optometric Management, he has been extensively published on the topics of third party coding & billing, strategy development Dr. Rumpakis is currently President & CEO of Practice Resource Management, Inc., a firm that specializes in providing a full array of consulting, appraisal, and management services for healthcare professionals and industry partners. He has developed some of the leading Internet based software applications for the medical/eye care field such as CodeSAFEPLUS.com ( the industry leading cloud based CPT & ICD Code Data and Information Service, and offers personal medical coding consultation through JustAskJohn ( He is also the founder of Opt ED Professional Continuing Education ( ED.com) which creates and delivers top tier continuing education around the country as well as Opt IN which provides optometric marketing and promotional services. and execution, practice management, team building, maximizing effectiveness and profitability, including the textbook Business Aspects of Optometry. Dr. Rumpakis is a popular lecturer both nationally and internationally. In addition to having had a successful solo practice, Dr. Rumpakis developed the practice management curriculum at Pacific University College of Optometry and taught optometric & medical economics there for over a decade. A 1984 graduate of Pacific University College of Optometry, he served as a volunteer for the AOA for near 17 years and sits on numerous advisory boards, and board of directors for companies both in and out of the ophthalmic industry. 2 Financial Disclosures John Rumpakis, OD, MBA I Am A Project Based Consultant & Have Received Honoraria From: (Partial Listing) Alcon Laboratories Carl Zeiss Meditec Optos Vistakon CooperVision Maculogix EMRLogic TearLab Freedom Meditech Allergan Beaver Visitec OfficeMate Maximeyes Luxottica MacuRisk Paragon RevolutionEHR VisionWeb Opticare United Health Care Vision Source Bio Tissue ECRVault Eye Tel Imaging Bausch & Lomb Essilor of America Wal Mart Macuscope Topcon CyclopsEMR Chief Medical Clinical Coding Editor Review Of Optometry & Optometric Management JustAskJohn Personalized Medical Coding Consultation ( CodeSAFEPLUS ( Founder Opt ED, Professional Optometric Continuing Education Founder Opt IN, Optometric Marketing & Promotions WhatsMyPracticeWorth.com Online Practice Appraisals ArcticDX Modernizing Medicine Annidis Kowa Optimed HeartSmart Diopsys Nicox 3

2 2 Disclosures All fees represented within this presentation are the 2015 Medicare Maximum Allowable Reimbursements for each procedure listed as of June 5th, 2015 for this zip code. All information regarding policies, procedures, guidelines and definitions is current as of June 5th, Each viewer is responsible to be current in their own geographical jurisdiction interpretation of policies, procedures, guidelines and definitions prior to implementation within their own practice. The coding examples contained this presentation are examples only and each practitioner should apply these coding guidelines to what is actually recorded in the patients medical record before submitting any claim to a third party carrier. 4 Learning Objectives Clinical Grand Rounds Understanding That Your Medical Record Is Nothing More Than An EXTENSION OF YOUR CLINICAL CARE The Medical Practice Environment Audit Triggers & Prevention Definitions o Medical Necessity & The Chief Complaint The Resource Based Relative Value System (RBRVS) o Relative Value Units & Geographic Practice Cost Index The ICD 10 o ICD Changes The Move From ICD 9 to ICD 10 Examination Services o The Routine Eye Exam S Codes vs. 920XX codes vs. E/M codes o The Ophthalmic Coding Guidelines 920XX codes Compliance Issues and the medical record o Demystifying E/M Coding Guidelines 992XX codes 1995 E/M Guidelines 1997 E/M Guidelines Compliance issues and the medical record How To Translate The Exam Performed Into Coding Language o o Scoring The E/M Encounter Audit triggers and prevention Special Ophthalmic Testing 2015 Update Interpretive Report requirements The ABN & NEMB The Official Method of Notification o Understanding the GX, GA, GZ and GY modifiers The Rules Surrounding Ocular Surgical Procedures o Appropriate Use of Modifiers Local Coverage Determinations o What is an LCD o Implications of LCD s o What LCD s mean for coding compliance Medical necessity Documentation Issues/Proof Covered diagnoses Recording requirements CMS s Correct Coding Initiative o What are the CCI Edits o Column 1/Column 2 Codes o Mutually Exclusive Codes o Appropriate use of modifiers with the CCI Edits Factors For Success John s Top Twelve o Implementation & Integration Guidelines Identifying Obstacles & How To Overcome Them (16) Coding Requires 2015(16) Rules Get Your Resource Material o By Book CPT 2015 ICD /ICD HCPCS Level II 2015 Or Get Everything Updated AUTOMATICALLY o Online Cloud Based Resources & 6

3 3 Three Essential Resources So I know how to do it, but HOW DO I MAXIMIZE THE RETURN ON MY INTELLECTUAL PROPERTY? If I Don t Understand IT & Practice IT IT May Be Taken Away 8 Your Practice Is Like A Bucket Refractive & Contact Lens Revenue Medical Eye Care Revenue Contact Lens Drop Outs Patients Going Elsewhere For Medical Eye Care 9

4 4 Avoiding The Race To Zero Reimbursement (Income) Patient Volume (Exams per hour) Practice Profit 10 How Patient Value Is Calculated 11 John s Medical Eye Care Pledge I, say your name, hereby pledge the following: It s not my fault that, My prescriptive authority allows me to treat disease. It s not my fault that, My patient has sought me out for eye care. It s not my fault that, I have the ability to diagnose and treat my patient. It s not my fault that, My patient may not have medical insurance that covers my services. It s not my fault that, Providing the best care to my patient s costs money. It s not my fault that, I cannot fix everything wrong with my patient in one visit. And, It s not my fault that, I can be successful and profitable providing primary eye care. 12

5 5 It is your fault if you don t exercise your prescriptive authority and take care of your patients the way that they expect you to! 13 The trend is clear that we are shifting to a benefit structure that is borne by the recipient of the care, rather than a third party provider. 14 The Optometric Frame Of Mind Guilt 15

6 6 There Are Different Levels of Guilt Catholic Guilt Jewish Guilt Optometric Guilt 16 But John, I m So Confused EVERYBODY S AN EXPERT??? THERE ARE SO MANY DIFFERENT PEOPLE THAT SAY SO MANY DIFFERENT THINGS 17 TRANSPARENCY 18

7 7 It s Not Complicated At All The patient s condition determines everything that you do. History that was required understand the patient s complaint Exam that was required to properly diagnose the condition Assessment of the condition(s) Plan to provide the best outcome in the most efficient way that is concurrent with local standard of care What you do with the patient determines what you write down in the medical record. What you have written down determines the codes you use to describe the care required. 19 Bottom Line The individual patient presentation or what you have them returning for determines everything that you do with them, and therefore determines the services performed and the subsequent coding of those services. 20 Provider Relationships The Basics of Professional Ethics Other than the doctor/patient relationship (the most important relationship), ethical behavior of providers is organized around: o Relationships with payers o Relationships with fellow providers o Relationships with vendors 21

8 8 Relationships With Payers Relationships with patients is increasingly dominated by a third party the payer Components of the provider/payer relationship include: o Accurate coding and billing o Accurate medical records documentation o Prescription authority o Assignment within the Medicare system 22 Relationship With Payers Accurate Billing and Coding The main issues involved in billing for rendered services include: Billing only: o medical necessity care o services actually performed Billing for: o services with no benefit or beneficial outcome o services provided by improperly trained or improperly supervised care o services provided by a provider included in the Exclusion Statute 23 Special Note! The OIG is VERY serious about worthless services patient services that provide no real diagnostic or therapeutic benefit to the patient. The last three convictions in 2014 all resulted in CRIMINAL convictions with federal prison sentences up to 10 years 24

9 9 Worthless Services Per CMS is not accepted as safe and effective by the medical community is not supported in peer reviewed medical literature is experimental or investigational is not medically necessary in a specific case or specific medical Dx is furnished at a level, duration, dosage or frequency not appropriate for a specific patient or clinical condition is not furnished in a manner consistent with standards of care is not furnished in a setting (place of service) consistent with the patient's medical needs and condition is furnished in a manner for patient or provider convenience is a device is not approved by the FDA is a test or service now considered obsolete 25 Relationship With Payers Medical Records Documentation By contract with the payer, providers attest that the patient s medical records are: Accurate Complete Show justification of medical necessity Have you ever read the back of your HCFA1500 form? It is a LEGAL CONTRACT assuring the necessity and truthfulness of your services. 26 The Contract You Sign 20x Per Day (and have never read ) In submitting this claim for payment from Federal Funds, I certify that: 1. The information on this form is true, accurate and complete 2. I have familiarized myself with all laws, regulations and program instructions available from the Medicare contractor 3. I have provided or can provide sufficient information required to allow the government to make an informed eligibility and payment decision 4. This claim complies with all Medicare program instructions 27

10 10 And The Icing On The Cake My signature is to certify that the foregoing information is true and accurate. I understand that any false claims or statements or concealment of a material fact may be prosecuted under applicable Federal and Stark laws. 28 Important Definitions FRAUD When someone intentionally falsifies information or deceives Medicare. The Only Difference Between Fraud & Abuse Is Intent. ABUSE When health care providers or suppliers don t follow good medical practices, resulting in unnecessary costs, improper payments, or services that aren t medically necessary. 29 CMS Fraud Detection Past & Present PAST Providers suspected of fraudulent activity were put on prepay review, sometimes indefinitely CMS initiated overpayment recovery Law enforcement determined if an arrest is appropriate PRESENT Denies individual claims Its contractors use prepay review as an investigative technique Revokes providers for improper practices Collaborates with law enforcement before, during and after case development Addresses the root cause of identified vulnerabilities and Education/Training/CMSNationalTrainingProgram/Downloads/2013 Fraud and Abuse Prevention Workbook.pdf and Education/Training/CMSNationalTrainingProgram/Downloads/2013 Fraud and Abuse Prevention Workbook.pdf 30

11 11 This Frightens Me More Than Anything UPCOMING WEBINAR Turning Wellness Exams Into Medical Exams for Increased Reimbursement This provides the doctor with an excellent tool for converting a very low reimbursing Wellness exam into an excellent reimbursing medical exam. About the Speaker: Robert E. Rebello is the CEO of Nteon Software, the makers of EyeCOR medical coding & reimbursement software. He is a nationally known expert on all issues relating to billing and coding. Sponsored by Oculus Discuss this webinar 31 The Government Recovery Is Hitting Records! 32 33

12 12 Obama Administration Announces Ground Breaking Public Private Partnership to Prevent Health Care Fraud July 26, 2012 For Immediate Release HHS Secretary Kathleen Sebelius and Attorney General Eric Holder announced the launch of a ground breaking partnership among the federal government, State officials, several leading private health insurance organizations, and other health care anti fraud groups to prevent health care fraud. This voluntary, collaborative arrangement uniting public and private organizations is the next step in the Obama administration s efforts to combat health care fraud and safeguard health care dollars to better protect taxpayers and consumers. The new partnership is designed to share information and best practices in order to improve detection and prevent payment of fraudulent health care billings. Its goal is to reveal and halt scams that cut across a number of public and private payers. The partnership will enable those on the front lines of industry anti fraud efforts to share their insights more easily with investigators, prosecutors, policymakers and other stakeholders. It will help law enforcement officials to more effectively identify and prevent suspicious activities, better protect patients confidential information and use the full range of tools and authorities provided by the Affordable Care Act and other essential statutes to combat and prosecute illegal actions. One innovative objective of the partnership is to share information on specific schemes, utilized billing codes and geographical fraud hotspots so that action can be taken to prevent losses to both government and private health plans before they occur. Another potential goal of the partnership is the ability to spot and stop payments billed to different insurers for care delivered to the same patient on the same day in two different cities. A potential longrange goal of the partnership is to use sophisticated technology and analytics on industry wide healthcare data to predict and detect health care fraud schemes. 34 Former Optometrist Sentenced in Medicaid Fraud Case FOR IMMEDIATE Seventh RELEASE Circuit Court : Wednesday, Judge Janine M. December Kern ordered 5, him 2012 to pay a total of $363, in CONTACT: Sara restitution Rabern to (605) Medicaid and Medicare. Feldman allowed the South Dakota Board of PIERRE, S.D.- Optometry Attorney General to revoke Marty his Jackley license announced in October. today that Cary Stephen Feldman, 60, Spearfish, was sentenced to serve 15 years in prison for committing Medicaid fraud. Feldman entered a plea of guilty on October 11, 2012, to grand theft by deception, a Seventh Circuit Court Judge Janine M. Kern suspended the execution of sentence on several conditions. Judge Kern class 4 felony, and making false claims, a class 5 felony, pursuant to a plea agreement ordered Feldman to serve 180 days in jail and ordered him to pay a total of $363, in restitution to Medicaid and Medicare. Feldman reached turned with the over State. a coin Feldman collection admitted with an estimated that he knowingly value of $157,000, and intentionally and paid an additional $80,000 to the government, submitted so his remaining false claims restitution to the balance South Dakota is $126, Medicaid Feldman program was and also to ordered Medicare. to serve 300 hours of community service, Feldman pay began costs submitting of $ to the the false State claims and court in late costs 2008, of $208. and Feldman continued allowed until early the South Dakota Board of Optometry to revoke his license in October. Feldman entered The case a plea was of investigated guilty on October and prosecuted 11, 2012, to grand by the theft South by Dakota deception, Medicaid a class Fraud 4 felony, Control and making false claims, a class Unit, 5 felony, with assistance pursuant to from a plea the agreement South Dakota reached Department with the State. of Social Feldman Services, admitted the federal that he knowingly and intentionally submitted false claims to the South Dakota Medicaid program and to Medicare. Feldman admitted that he Department of Health and Human Services Office of Inspector General, the South submitted claims to Medicaid and to Medicare for consultation services, even though he had not provided such services. Feldman began Dakota submitting Division the of false Criminal claims Investigation, in late 2008, and the continued Spearfish until Police early Department, the Rapid City Police Department, the Pennington County Sheriff s Office, the Pennington County The case was Office investigated of State s and Attorney, prosecuted the by Minnehaha the South Dakota County Medicaid Sheriff s Office, Fraud Control and the Unit, South with Dakota assistance from the South Dakota Department of Social Services, the federal Department of Health and Human Services Office of Inspector General, the Office South of Dakota United Division States of Attorney. Criminal Investigation, the Spearfish Police Department, the Rapid City Police Department, the Pennington County Sheriff s Office, the Pennington County Office of State s Attorney, the Minnehaha County Sheriff s Office, and the South Dakota Office of United States Attorney. 35 June 6, 2013 Press Release Medicare Urges Seniors To Join The Fight Against Fraud In mailboxes across the country, people with Medicare will soon see a redesigned statement of their claims for services and benefits that will help them better spot potential fraud, waste and abuse. Because of actions like these and new tools under the Affordable Care Act, the number of suspect providers and suppliers thrown out of the Medicare program has more than doubled in 35 states. Update on CMS Anti Fraud Efforts The Affordable Care Act has enabled CMS to expand efforts to prevent and fight fraud, waste and abuse. Over the last four years, the Obama administration has recovered over $14.9 billion in healthcare fraud judgments, settlements, and administrative impositions, including record recoveries in 2011 and Since the Affordable Care Act, CMS has revoked 14,663 providers and suppliers ability to bill in the Medicare program since March These providers were removed from the program because they had felony convictions, were not operational at the address CMS had on file, or were not in compliance with CMS rules. In 18 states, the number of revocations has quadrupled since CMS put the Affordable Care Act screening and review requirements in place, as well as the implementation of proactive data analysis to identify potential license discrepancies of enrolled individuals and entities. These efforts are ensuring that only qualified and legitimate providers and suppliers can provide health care products and services to Medicare beneficiaries. 36

13 13 Ripped From The Headlines CMS Proposes New Safeguards and Incentives to Reduce Medicare Fraud On April 24, 2015 CMS issued a proposed rule that would increase rewards paid to Medicare beneficiaries and others whose tips about suspected fraud The lead proposed to the successful rule would recovery also of strengthen funds to as certain high as $9.9 million. In addition, On a April new 24, funding 2014 opportunity CMS issued released a proposed this rule month that supports would increase the expansion of Senior Medicare Patrol activities rewards to educate paid to Medicare Medicare beneficiaries beneficiaries provider on and how enrollment others to prevent, whose provisions detect, tips and including report Medicare allowing fraud, CMS waste, and abuse. The proposed rule would also strengthen certain provider enrollment provisions including allowing CMS to about deny enrollment suspected fraud of providers lead to to who the deny successful enrollment are affiliated recovery of with an of providers entity funds that to who are affiliated with has unpaid Medicare debt, deny, or revoke as high billing as privileges $9.9 million. for individuals In addition, an entity with a new felony that funding convictions, has opportunity unpaid and Medicare revoke privileges debt, deny, for providers or and suppliers released who are this abusing month their supports billing revoke the privileges. expansion billing of privileges Senior Medicare for individuals with felony These proposed Patrol activities changes to will educate support Medicare the administration s beneficiaries on comprehensive how to approach to program integrity, including the work being done with the convictions, Health Care and Fraud revoke Prevention privileges and Enforcement providers Action and Team, a joint effort between prevent, detect, HHS and and the report Department Medicare of Justice fraud, waste, to fight and health abuse. suppliers who are abusing care their fraud. billing This joint privileges. effort recovered a record $4.2 billion in taxpayer dollars in fiscal year And It s Not Just CMS We Need To Worry About! 38 What Is A Red Flag That Triggers An Audit? Using codes under review by the OIG Not reviewing your submitted claims against recovery audit issues Abusing codes Aberrant or inconsistent billing patterns Maximizing revenue without sufficient documentation Cloning of documentation Not understanding definitions of modifiers and inappropriate use of modifiers 39

14 14 How You Create Your Medical Record Matters! THERE ARE LEGAL IMPLICATIONS OF HOW YOU RECORD YOUR ENCOUNTER 40 Successful Medical Coding Is Not A Contest In Creativity 41 Creativity Isn t Always Rewarded 42

15 15 Creativity Isn t Always Rewarded 43 Creativity Isn t Always Rewarded 44 Creativity Isn t Always Rewarded 45

16 16 Creativity Isn t Always Rewarded 46 Creativity Isn t Always Rewarded 47 Creativity Isn t Always Rewarded 48

17 17 Creativity Isn t Always Rewarded 49 Creativity Isn t Always Rewarded 50 Creativity Isn t Always Rewarded 51

18 18 Creativity Isn t Always Rewarded 52 Creativity Isn t Always Rewarded 53 Fundamental Principles Are IMPORTANT! What do you do? (hint think evidence based medicine) What does this patient need? (hint not what do you want to do) What is in the patient s best interest? 54

19 19 Medical Necessity Is Services or supplies that are proper and needed for the diagnosis or treatment of the patient s medical conditions, are provided for the diagnosis, direct care and treatment of the patient s medical condition, meet the standards of good medical practice in the local area and aren t mainly for the convenience of the patient or the physician. Source: 55 So What Exactly Does That Mean? The medical record must clearly demonstrate that the service, procedure, or test ordered & performed was absolutely necessary in order to diagnose, treat, or monitor the treatment of the patient s condition. 56 E&M Medical Necessity Medical Necessity of E&M Services Section 1862(a)(1)(A) of the SSA, Exclusions From Coverage and Medicare as Secondary Payer does not include expenses acquired for items and services which are not deemed necessary for the diagnosis or treatment of illness or injury. This applies to all services. CMS IOS Publication , Chapter 12, Section states: Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record. 57

20 20 SERVICE-SPECIFIC PREPAYMENT REVIEWS OF EVALUATION AND MANAGEMENT SERVICES National Government Services will be conducting service-specific prepayment reviews on the following CPT codes targeting E&M services for JK Part B providers: A prepayment review consists of a medical review of claims prior to payment. Request for records are most frequently electronically generated and referred to as ADS letters. Please note that when medical records are requested for chiropractic services, it is necessary to submit all the specific documentation as notated in the ADS, which would include but is not limited to: Physician/nonphysician practitioner s progress notes, Orders, Medication records, Procedure/operative reports, Relevant diagnostic/operative reports or documentation of time that would assist in supporting the service(s) submitted The primary focus of the audits will be to better identify common billing errors, develop educational efforts, and prevent improper payments. Providers will be receiving ADSs asking for documentation to support the service billed. Medical Review encourages providers to respond with the requested documentation in a timely manner to expedite adjudication of these claims. Providers can assist in this process by: Reviewing all contractor publications and LCDs Understanding Medicare coverage requirements Ensuring office staff and billing vendors are familiar with claim filing requirements Performing self-audits of medical records against billed claims using coverage criteria, LCD, and coding guidelines Responding to request(s) for records in a timely manner (CMS requires that providers respond to an ADS within 30 days of the request) Ensuring documentation is legible and demonstrates that the patient s condition warrants the services being reported and billed Reports from June 2013 through March 2014 show the following CPT code error rates CPT CODE ERROR RATE (PERCENT) % % % % Posted 05/07/ Office Of Inspector General 2014 Interim Report OIG Report: Documentation Coding Errors Costing Medicare Billions Posted on May 29,2014 According to a new OIG report, documentation coding errors related to routine patient evaluation and management (E/M) visits are costing Medicare billions of dollars in improper payments a year. The investigation found that nearly $7 billion dollars in improper payments were made in 2010 alone. Most of the losses were the due to bills that were incorrectly coded and/or lacking documentation; 42% of claims for E/M services in 2010 were incorrectly coded and 19% lacked proper documentation. 60

21 21 How Can You Fight Big Data & Technology? LET S FIGHT BACK WITH REAL TIME DATA & INFORMATION THAT IS SPECIFIC TO YOUR ZIP CODE & ALWAYS ACCURATE! 61 CodeSAFEPLUS.com THE INDUSTRY LEADER IN CLOUD BASED CPT & ICD DATA SERVICES 62 And When A More Personal Solution Is Needed ONE ON ONE PERSONAL CODING CONSULTATION SERVICES 63

22 22 Medical Carriers & Medical Necessity CARRIERS GENERALLY DEFINE IT FOR US! 64 What Happens If The Carrier Doesn t Have A Policy? But, sometime carriers will not have a specific policy regarding the indications of medical necessity, nor a list of covered diagnoses or utilization guidelines that you can refer to. When this is the case, then the prevailing CPT definition and guidelines in combination WITH YOUR MEDICAL EXPERTISE become the defensible rule. 65 Or What Happens If The Patient Is Paying? If the patient is paying out of pocket and it is a separate distinct financial transaction where the carrier is NOT involved (i.e. balance billing), then you are free to do what you and the patient agree to. 66

23 23 Medical Plans Vs. Refractive Plans WHAT S THE DIFFERENCE? 67 Refractive Plans Do patients need a reason to see you? o Do they need to have something wrong with them? What conditions have to be met? o Policy in force o Coverage eligibility o Participating provider What about duplicative coverage? o Who s choice is it?? My doctor always wants to bill medical if they find something 68 Answer: A Chief Complaint Rule Number One QUESTION: WHAT IS THE FIRST THING THAT MUST BE PART OF EVERY MEDICAL VISIT? 69

24 24 So What Can Possibly Be New With A Chief Complaint? 70 Cloned Documentation The word 'cloning' refers to documentation that is worded exactly like previous entries. This may also be referred to as 'cut and paste' or 'carried forward.' Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter. Palmetto GBA Last updated on 11/06/ Cloned Documentation Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made. Palmetto GBA Last updated on 11/06/

25 25 The OIG said that the ability to "clone" chart notes from a previous patient encounter to help document the next one can help physicians work more efficiently, but also invite fraud, especially if no one edits the cloned information to make sure it's accurate and up to date. Government officials are worried that many physicians bill for higher levels of evaluation and management (E/M) services than warranted by cloning dense blocks of old patient information. Cloning Update A Renewed Interest By The OIG 73 Patients Are Not Expected To Be The Expert WE ARE! WHY? THINK OF THE THREE E S EDUCATION, EXPERTISE, & EXPERIENCE 74 Why Is The Patient In Your Office? There are only THREE ways that the patient ends up in your practice. 1. They initiate the appointment by phone call, , online booking. 2. You initiate the appointment by telling them to return to the office for a specific reason. 3. Other Physician initiates the appointment by telling them to make an appointment for a specific reason. Once we know who initiated the encounter we can now properly determine the Chief Complaint. 75

26 26 There Are TWO Ways A Chief Complaint Requirement Is Met Physician Directed (reason for visit) Patient Directed 76 The Chief Complaint The Medicare Carriers Manual, Part reads: "The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient's condition. When a beneficiary goes to a physician with a complaint or symptoms of an eye disease or injury, the physician's services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition." 77 The Chief Complaint The Medicare Carriers Manual, Part reads: "The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient's condition. When a beneficiary goes to a physician with a complaint or symptoms of an eye disease or injury, the physician's services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition." 78

27 27 The Chief Complaint The Medicare Carriers Manual, Part reads: "The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient's condition. When a beneficiary goes to a physician with a complaint or symptoms of an eye disease or injury, the physician's services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition." 79 The Chief Complaint The Medicare Carriers Manual, Part reads: "The coverage of services rendered by a physician is dependent on the purpose of the examination rather than on the ultimate diagnosis of the patient's condition. When a beneficiary goes to a physician with a complaint or symptoms of an eye disease or injury, the physician's services (except for eye refractions) are covered regardless of the fact that only eyeglasses were prescribed. However, when a beneficiary goes to his/her physician for an eye examination with no specific complaint, the expenses for the examination are not covered even though as a result of such examination the doctor discovered a pathologic condition." 80 Your Contact Lens Patient With Ocular Allergy 81

28 28 The Process Yikes! Patient calls for exam Obtain demographics Contact info Marketing Insurance Build chart Welcome form HPI HIPAA Recall Exam form Superbill File chart Check insurance eligibility & authorization Appt reminder TC Exam Chart to technician OPTOS discussion Schedule appt Inquire about family member Find chart Make/send patient packet Transcribe information to chart Patient check in Copy insurance cards Patient paperwork HPI Recall HIPAA Welcome sheet 82 The Process Yikes! Greet/escort patient History & VA CL check Overrefraction Fit check Remove contacts Pretest OPTOS Autorefractor History Visual acuity EOMs Confrontations Pupils Topography Dr. exam Review chart Refraction Slit lamp DFE Review optical choices Finalize contacts Rx Review treatment plan Patient education Recall Superbill Notify Dr. Dilate (prn) Tonometry Checkout Collect balance Optical CL I & R Transcribe referral letter Thank you card/call 83 Differential Diagnosis Dry eye presents with grittiness, burning and signs of surface disease Infection shows discharge Allergy itches + family history Urban allergy vasomotor conjunctivitis varies with environmental triggers 84

29 29 Ocular Allergy Patient Presentation Coding Concepts New Patient New vs. Established 43 y/o AAF Chief Complaint o VSP (refractive insurance) o Blue Cross (medical insurance) Medical vs. Refractive Presents with Contractual Obligations o Ran out of CL s New Insurance o Dx Blur O.D. > O.S. (refractive in nature) o Seasonal allergies discovered during case history, but not primary reason for visit Claritin OTC, QD, Visine AC per PI Additional Services Covered 85 Coding The Comprehensive Exam 86 Initiating A Treatment Plan What would be the Standard of Care? Communicate with patient Complete the medical record Prescribe a medication Set follow up visit 87

30 30 Ocular Allergy 1 week later Billed To VSP, But On Claim For Educational Purposes 88 The ICD 10 Era PROCEDURES 9921X DIAGNOSES H10.45 Other Chronic Allergic Conjunctivitis H Chronic Giant Papillary Conjunctivitis, Right Eye H Chronic Giant Papillary Conjunctivitis, Left Eye H Chronic Giant Papillary Conjunctivitis, Bilateral H Chronic Giant Papillary Conjunctivitis, Unspecified Eye 89 Why 99213? History Exam Decision Making

31 31 What about the code? Use of the code could be perfectly acceptable if & when the medical carrier accepts them as medical in nature vs. refractive and if the code definition is met. o You Often Want To Choose It Because Less documentation requirements Increased reimbursement o BUT CPT 2015 Definition: describes an evaluation of a new (condition) or an existing condition complicated with a new diagnostic or management problem not necessarily related to the primary diagnosis. 91 Ocular Allergy 6 months later 92 The ICD 10 Era PROCEDURES 9921X DIAGNOSES H10.45 Other Chronic Allergic Conjunctivitis H Chronic Giant Papillary Conjunctivitis, Right Eye H Chronic Giant Papillary Conjunctivitis, Left Eye H Chronic Giant Papillary Conjunctivitis, Bilateral H Chronic Giant Papillary Conjunctivitis, Unspecified Eye 93

32 32 Ocular Allergy Profitability Per Hour 94 Lost Opportunity Costs? Did the one week allergy follow up cannibalize another annual eye exam opportunity? NO! Why? o Allergy visit 5 minutes o Can be double booked with an annual examination o Maximizes revenue per Dr. hour 95 Key Concepts Allergy encounter was driven by annual exam Easy to diagnose Easy to treat Not a drag on schedule Builds other areas of business 96

33 33 Just What IS The Value Of Your Intellectual Property? 97 John s Golden Rule You have to follow the rules Even if they economically benefit you! 98 Does Medical Coding Seem Like A Foreign Language? IT DOESN T HAVE TO BE WE JUST HAVE TO SPEAK THE LANGUAGE 99

34 34 Understanding Code Differences WITHIN THE HCPCS SYSTEM EACH CODE SUBSET HAS IT S OWN IMPLICIT PURPOSE AND IT S OWN FORMAT 100 Key Concepts Term Definition Code Format Ownership HCPCS I CPT 4; Current Procedural Terminology, 4th Edition (HCPCS Level I Codes) Always Five Digits AMA 1 HCPCS II Healthcare Procedural Coding System Level II Codes A V1234 Always Alphanumeric AMA 1 HCPCS III Healthcare Procedural Coding System Level III Codes (Emerging Technology) 1234T Always Alphanumeric AMA 1 ICD 9 CM International Classification of Disease, 9 th Edition Generally Five Digits WHO 2 1: assn.org/ama/pub/category/3884.html 2: Health Care Procedural Coding System (HCPCS) Level One HCPCS CPT Procedural Codes Level Two HCPCS Level Three HCPCS Non CPT Codes for Materials, Services & PQRS Emerging Technology & Temporary Use Codes 102

35 35 Health Care Procedural Coding System (HCPCS) Level One HCPCS Are The CPT 4 o Current Procedural Terminology 4th Edition CPT Codes Are Always o One Five Digit Code Plus Up To Four, 2 Digit Modifiers Initial Procedure 1st Modifier 2nd Modifier AB CD EF GH 103 Health Care Procedural Coding System (HCPCS) Level Two National Codes for Materials, Services & PQRS Level Two Codes: 5 Digit Alpha Numeric Level II Designation A V Health Care Procedural Coding System (HCPCS) Level Three Emerging Technology & Temporary Use Codes Level Three Codes: Category III codes are temporary codes for emerging technology, services, and procedures. Category III codes consist of four numbers followed by the letter "T." Category III Designation 1234T 105

36 36 Key Concepts To Reimbursement Term Definition Resource RBRVS Resource Based Relative Value System CMS* RVU Relative Value Unit CMS* GPCI Conversion Factor Maximum Allowable Reimbursement * Geographic Practice Cost Index A Dollar Multiplier In The Reimbursement Calculation Geographically Adjusted RVU s X The Conversion Factor CMS* CMS* CMS* 106 Reimbursement Fundamentals RBRVS Determines the Maximum Allowable Fee o For Every Procedure o For Every Carrier Relative Value Units Are Based On: o Amount Of Work Associated With Procedure o Practice Overhead Expenses Associated With Procedure o Malpractice & Professional Liability Costs Associated With Procedure o Geographic Location Adjustments GPCI Geographic Practice Cost Indices 107 Calculating Reimbursements IT S NOT ROCKET SCIENCE JUST MATH 108

37 37 Procedure Relative Value Units CPT Code Descriptions Work Practice Expense Malpractice Eye exam & treatment Refraction Special eye evaluation Fitting of contact lens Visual field examination (s) Geographic Practice Cost Index (GPCI s) Locality Name Work GPCI PE GPCI MP GPCI Alabama Alaska Arizona Arkansas San Francisco, CA Oakland/Berkley, CA Santa Clara, CA Los Angeles, CA Anaheim/Santa Ana, CA The Conversion Factor A conversion factor is nothing more than a Dollar Multiplier in determining the Maximum Allowable Reimbursement for each CPT code Total Geographically Adjusted RVU s X The Conversion Factor = The Maximum Allowable Reimbursement 111

38 38 Medicare Conversion Factors $40 $38 $36 $34 $32 $30 Proposed Final $28 $26 $24 $ Just One Question Are You Ready? 113 Saying It Once Again The patient s condition determines everything that you do. History that was required understand the patient s complaint Exam that was required to properly diagnose the condition Assessment of the condition(s) Plan to provide the best outcome in the most efficient way that is concurrent with local standard of care What you do with the patient determines what you write down in the medical record. What you have written down determines the codes you use to describe the care required. 114

39 39 Bottom Line The individual patient presentation or what you have them returning for determines everything that you do with them, and therefore determines the services performed and the subsequent coding of those services. 115 So Which Code Do I Use? ONCE AGAIN, SIMPLY FOLLOW THE RULES 116 Identifying The Appropriate Category Of Service To Perform Based upon patient s presenting status Category For Code Selection What is their chief complaint? Do they have coverage where there exists a contractual obligation? Ophthalmological 1 E/M Service 2 S Code 3 117

40 Special Ophthalmological Services 119 The CMS 1500 Form Your LEGAL document submission o You are attesting under penalties of perjury that everything is true and accurate Standard format accepted by all carriers for submitting claims Understanding this form is essential to getting properly reimbursed and for following rules in claims submissions. Effective 1/1/2014, Grace Period 1/1 3/31, must use 4/1/2014 Let s Take A Look 120

41 41 What Are They? Definition: Describes services in which a special evaluation of the part of the visual system is made, which goes beyond the services included under general ophthalmological services or in which special treatment is given. Special ophthalmological services may be reported in addition to the general ophthalmological service or evaluation and management services. CPT: Professional Edition, Pg Some Frequent Questions! When can I do a special ophthalmic test? o You can perform a special ophthalmic test on the same day as any office visit. o They are a distinct and separate procedure and are not bundled into any examination services Can I do the tests when the doctor is not in the office? o Yes but you do have to pay attention to Supervision Status Can I bill the test on the same day? o May have to use a modifier for some carriers Do I have to collect two co pays? Can I order tests way ahead of time? 122 Key Learning Point Interpretation and report by the physician is an integral part of the special ophthalmological services where indicated. Technical procedures (which may or may not be performed personally) are often part of the service, but should not be mistaken to constitute the service itself. New Rule For 2013 Maintained In 2015 o Self Referral For Special Ophthalmic Testing o C0 16 EOB Claim Designator Requires Physician Name & NPI in Box 17 of CMS 1500 CPT: Professional Edition, Pg

42 42 Performing Additional Tests Routine Procedures VS. Ordered Procedures The chronology of your medical record is imperative Routine testing = standing orders o Never billable Ordered testing o Based upon medical necessity o Bill with office visit Use modifier when appropriate o Be aware of specific code requirements & definitions o Generally require an Interpretive Report How Do We Code Something That Is Different Than Its Defined Value? 124 Example Fundus Photography (92250) Active Code Bilateral By Definition Global Period Definition (XXX) Traditional Bilateral Use Unilateral Use (RT or LT) Base Code Reduced Services Laterality Indicator 125 Patient Notification WHAT IT IS AND WHY WE NEED IT 126

43 43 Patient Notification of Services Two Types Of Patient Notification Specific Use For Each The ABN and NEMB o ABN Advance Beneficiary Notice Financial Informed Consent Patient May Pay Patient Signature Required o NEMB Notice Of Exclusion From Medicare Benefits Patient Must Pay excluded benefits Patient Signature NOT Required 127 Modifiers For Patient Notification GA Waiver of Liability Statement Issued as Required by Payer Policy GX Notice of Liability Issued, Voluntary Under Payer Policy GY Statutory exclusions GZ Expected Denial, No ABN on file 128 Using The Right Modifier Is Critical GA indicates that the ABN is required by the payer policy. It is appended to a CPT code to report that a required ABN was issued for a service and is on file. If the service is denied, CMS will assign financial liability to the beneficiary. Because an ABN was properly obtained, the financial liability is legally transferred to the patient and the physician can bill the patient for this service. GX When modifier GX is appended to a CPT code, it used to report that a voluntary ABN was issued for a service that is statutorily excluded from Medicare reimbursement. Medicare rejects noncovered services appended with GX and assigns liability to the beneficiary. Because this is a voluntary ABN, the patient always has financial responsibility for the procedure or test being conducted. 129

44 44 Using The Right Modifier Is Critical GZ indicates that a service or item is expected to be denied as unreasonable or unnecessary. It is appended to a CPT code to report that an ABN was not issued for this service. CMS will automatically deny these services and indicate that the beneficiary is not responsible for payment. Because the doctor did not obtain an ABN prior to performing the service, he cannot bill the patient. GY When modifier GY is appended to a CPT code to report when a service is specifically excluded by Medicare and an ABN was not issued to the beneficiary. This indicates that the service is statutorily excluded or does not meet the definition of any Medicare benefit. CMS will deny these claims and the beneficiary will be totally responsible for all financial liability. 130 The Interpretation & Report Should Contain Indications for testing Whether the test was ordered Test reliability Test results o Comparative findings o Plan Initiation of diagnostic/treatment plan Doctors signature 131 My Action Plan WHAT DO I DO NOW?

45 45 Intent vs. Impact We ALL have great intentions! There is often a clear difference that occurs between what you had intended to do and what you actually did Just Do It vs. Just Think About It 133 The Power Of I to the 4th Power Intent Impact Integrate Implement 134 You Can t Teach An Old Dog New Tricks OR CAN YOU? 135

46 John s 12 Step Program HI, MY NAME IS <BLANK > I AM A REFORMED CODER 137 John s 12 Step Program Identify carriers with whom you want to be on their plan it s a business decision! Establish Needs Assessment for your situation Obtain resource material that you need Create disease protocols for your office Review the findings regarding the health and vision of each patient Correspond with the patients PCP regarding your care and the patients condition Develop system for appointing the patients next visit before they leave the office Put the process in flow chart format 138

47 47 John s 12 Step Program Everyone in the office must be educated about the protocol and the process o All staff must be onboard with providing the highest level of care Diagnosis Treatment Selection of Medication Market your ability to provide primary care to your patient base Set Goals, Objectives, Strategies, and Tactics for what you want to achieve 139 John s 12 Step Program Always perform the standard of care as your baseline Document the medical record with your thoughts and impressions Be vigilant about proper coding Perform internal audits on a regular basis Use a grading sheet on a regular basis Keep up with change in coding protocols Develop office strategy for change mgmt 140 John s 12 Step Program Develop office strategy for change management Rules & requirements change frequently Be audit proof a perfect medical record that accurately reflects the care provided and outcomes attained is priceless Never be complacent! Keep up on your continuing education and remember that your medical record and subsequent coding of your services is a legal requirement it s not an option! 141

48 48 Cracking The Code Clinical Case Management & Medical Record Compliance Ohio Optometric Association 2015 John Rumpakis, OD, MBA Practice Resource Management, Inc. 142