12/4/2014. The Auditor s Role In The Appeals Process. Issues Leading to Denied Claims. Understanding How to Win

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1 The Auditor s Role In The Appeals Process Presented By: Sean M. Weiss, Partner Vice President & Chief Compliance Officer Issues Leading to Denied Claims Incident-to and Split/Shared Billing Locum and Reciprocal Arrangements Modifier 25 Utilization Medical Necessity and Medical Decision Making Cloning Aberrant Coding Patterns (One Coding, Over-coding, etc.) 12/4/ Understanding How to Win When it comes to appeals, the more you are in the face of the payors the less likely they are to bother with you in the future. Less than 25% of all medical practices in the US appeal their claims Medicare denies 6.85 percent of its claims, higher than any private insurer (Aetna was second, denying 6.80 percent of its claims), and more than double any private insurer s average. 12/4/

2 Carrier and Payor Denial Rates on Billed Claims for Services Percentages of claim lines denied 6.80% 4.62% Aetna Anthem BCBS CIGNA Coventry Humana UHC Medicare 12/4/ Hospitals Being Offered 68 Cents on the Dollar to Settle 2 Day Stays CMS issued a revision to the 2014 Inpatient Prospective Payment System (IPPS) Final Rule reimbursement criteria and instituted the two-midnight rule for Part A inpatient hospital claims, thus creating new guidelines for establishing the medical necessity of inpatient hospital admissions, as well as documentation requirements, inpatient admission orders, and certifications. The two-midnight rule clarifies that the decision to admit a patient should be based on an expectation that the patient will require a hospital stay with a duration of at least two midnights. The enforcement of the two-midnight rule will not begin until October However, CMS initiated a pre-payment medical review program, known as the probe-andeducate medical review program, designed to identify improperly billed claims and provide education to hospitals implementing the requirements of the 2014 IPPS Final Rule. There is a current backlog of claims in the Medicare appeal process as a result of the audits initiated by the probe-and-educate medical review program. Pending claim appeals are backlogged to 2009 and in some cases, further. 12/4/ Eligible Claims Eligible claims must satisfy all the following criteria to be considered for the settlement offer: The claim has a date of admission prior to October 1, The claim was denied due to a patient status audit conducted by a Medicare contractor on the basis that services may have been reasonable and necessary, but treatment on an inpatient basis was not. The hospital timely appealed the denial, and the appeal was still pending at the MAC, QIC, ALJ or DAB in which the provider has not exhausted its appeal rights. The claim was denied by an entity that conducted a review on behalf of CMS. The hospital did not receive payment for the service as a Part B claim. The claim was not for items/services provided to a Medicare Part C enrollee. The facility is an acute care hospital or critical access hospital. 12/4/

3 Settlement Process Hospitals that choose to accept the settlement must agree to settle all eligible claims and must complete and file with CMS an Administrative Agreement along with a spreadsheet containing all eligible claims by October 31, Once the Administrative Agreement and Eligible Claim Spreadsheet are reviewed and confirmed by CMS, a copy of the signed agreement will be returned to the provider; all claims identified will be dismissed from the appeal process; and, a payment in the amount of 68% of the net allowable will be issued. Payment will be made 60 days after the execution of the Administrative Agreement by CMS. The agreement states that hospitals are not allowed to collect the remaining balance from the patient for the services included in the settlement, including their coinsurance. Where there is a discrepancy between the claim information submitted by the hospital and CMS records, the hospital will have the opportunity to submit a revised spreadsheet and Administrative Agreement within two weeks of receiving notice of the discrepancy. 12/4/ Should You or Should You Not Settle? Hospitals should determine if they want to take advantage of this offer, as the deadline is quickly approaching. Providers may request an extension; however, if they take advantage of this settlement by the deadline, then they should be able to receive their settlement by the end of this year. Items to consider include: Do they have the resources to quickly apply for settlement and isolate all claims that are eligible for this settlement offer? If not, then do they want to consider requesting an extension? What is the current appeal success rate (net amount received less expenses compared to 100% payment for denied inpatient claims) for their organization relative to the 68% settlement being offered by CMS? Which is more advantageous waiting out the appeal process for the payment turnaround vs. receiving payment within 60 days of filing the settlement agreement to CMS? Is the reduction of the administrative cost and burden worth the reduction in payment--which amounts to the difference of collecting 0.68 per each dollar on the denied inpatient claims compared to expected net payments based on historical or projected success of pursuing the pending denials? Compliance-Programs/Medical-Review/InpatientHospitalReviews.html 12/4/ New Option in Medicare Appeals Settlement Conference Facilitation Pilot A request for hearing must appeal a Qualified Independent Contractor (QIC) reconsideration of a claim for Medicare Part B items or services; The appellant must be a Medicare provider or supplier; The beneficiary must not have been found liable after the initial determination or participated in the QIC reconsideration; All jurisdictional requirements for a hearing before an Administrative Law Judge must be met for the request for hearing and all appealed claims; The request for hearing must have been filed in 2013 and not be currently be assigned to an Administrative Law Judge; The amount of each individual claim must be less than $100,000. For the purposes of an extrapolated statistical sample, the extrapolated amount must be less than $100,000. At least 20 claims must be at issue, or at least $10,000 must be in controversy if fewer than 20 claims are involved; There cannot be an outstanding request for OMHA statistical sampling for the same claims; and The request must include all of the appellant s pending appeals for the same item or service at issue that meet the SCF criteria. 12/4/

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5 12/4/ United Healthcare, Inc Attn: 1355 S 4700 W Pacific Landing BLDG A Salt Lake City, UT United Payment Integrity Attn: Recovery Investigations Technology Drive MN Eden Prairie, MN DoctorsManagement, LLC Kingston Pike Knoxville, TN Re: Eye Clinic and Surgeons September 3, 2013 Dear: We are in receipt of your multiple letters dated August 27, 2013 whereby you indicate the Overpayment is valid against our client, Eye Clinic and Surgeons. I am at this time reiterating our adamant disagreement with the findings of your auditors. We request a copy of your auditor s working papers to substantiate their findings as they are 180 degrees from the findings from our firms, which by the way specializes in ophthalmology and surgical procedures of the eye. With that said, I am also requesting the credentials of your auditors, which demonstrate their competency in ophthalmology and eye surgery. Over the course of multiple letters we have watched United Healthcare Inc. change its position on the rationale for why monies are due back as well as decrease the amount of refund owed by our client. Your initial requests for refund demand was $87, which was then reduced to $69, then to $ based on the practice s appeal and now a revised request for $40, a decrease of more than $46, from the initial demand, which shows a lack of consistency within your staff and within the auditing department of United Healthcare, Inc. From letter to letter your department s findings changed and show a lack of consistency for your position, which further invalidates your claims against our client. Furthermore, we disagree with your department s assessment of an error rate, extrapolation methodology, claims of illegibility, lack of documentation to support specific line items, and up-coding of services. Based on the above information there will be no refund of requested monies to United Healthcare, inc. nor will United Healthcare Inc. offset future remunerations due our client. We respectfully request this case be closed against our client immediately without passion or prejudice. 12/4/ /4/

6 [Your letterhead] [Date] [Address for payer/claims appeal department] RE: Insured: Patient: ID #: Date of service: Claim #: To Whom It May Concern: This letter is being sent to appeal the denial of the above listed patient for payment of the attached claim. All services in question have been performed in accordance with generally accepted standards of medical practice and satisfy the overarching criteria used to determine Medical Necessity. The Explanation of Benefits your company has provided indicates the service we provided the patient was not medically necessary; we adamantly disagree., MD or PA/NP decided to perform the service based on the fact they are a qualified provider of healthcare services as well as their first-hand evaluation of the patient. Attached, please find a copy of the medical record, which provides sufficient evidence to support the medical necessity of the services provided this patient and why MD or PA, NP found the service to be medically necessary. I have also attached for your review, [articles from peer-reviewed journals, second opinions from other physicians, or other supporting material]. With the additional information and explanation for why we provided these services for your beneficiary and our patient, we expect payment in full for our claim. The total amount we are owed is. If you have any questions, please feel free to call me at. Thank you for your time and reconsideration of this claim. Respectfully, [Your name] [Title] [Practice name, city, state] 12/4/ J15 Part B Appeals Department PO Box Nashville, TN DoctorsManagement, LLC Attn: Sean M. Weiss Kingston Pike Knoxville, TN Re: Glenn R. Womack, MD August 26, 2013 Dear Auditing Supervisor: I am reaching out to you regarding a client I represent. The practice is Buffalo Trace Family Practice in Flemingsburg, KY and the physician is Glenn R. Womack. CGS has placed Dr. Womack on to a 100% prepayment review without proper cause. To date more than 500 dates of service have been placed into formal appeal and every day the list is growing causing undo financial burden on the practice and costing U.S. Tax Payers unnecessary costs. Thus far my client is out more than $20, due to either unethical business practices on the part of CGS or sheer negligence on the part of CGS auditors. The problem as we have determined based on our own investigation is the auditors are not actually reviewing the records they are requesting documentation for and down-coding. I say this because if they were actually reviewing the documentation there is no way they would reduce more than 500 dates of service from a (Moderate Complexity of Decision Making) to a (Straightforward Complexity of Decision Making) based on patients presenting with multiple chronic systemic illnesses (i.e. Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Coronary Artery Disease, etc.) Often these patients require medication management to adjust their Rx to ensure maximum efficacy and to control symptoms in addition to ordering of Medically Necessary tests. In addition, other patients being seen are presenting with acute medical conditions requiring ordering of clinical laboratory tests, diagnostic imaging, and other medically necessary tests which constitutes a Moderate Complexity of Decision Making. I can say with 100% certainty the auditors at CGS are failing to thoroughly review the provider s documentation, if they are reviewing it at all, and this is an egregious act of misrepresentation of the facts as they relate to patient care provided by Buffalo Trace Family Practice and Dr. Glenn R Womack. If your auditors are reviewing the documentation and are downcoding the services then they lack the requisite skills necessary to do an effective job. The DoctorsManagement team is comprised of clinical and non-clinical auditors all holding multiple credentials from AAPC (CPMA, CPC, CPC-P, CPC-I, CEMC) and AHIMA (CCS, CCS-P, ICD-10 AHIMA Ambassador) in addition to each having more than 15 years of physician documentation auditing within specific specialties in addition to their Bachelor, Masters and Advanced Clinical Degrees. My team also consists of former Senior CMS Auditors and former Senior Auditors from BCBS, CIGNA and United Healthcare. After reviewing more than 200 of the 500 dates of service reduced by CGS my team adamantly disagrees with 100% of the findings of the CGS auditors and requests CGS immediately cease and desist with further pre-bill activity against Buffalo Trace Family Practice and Dr. Glenn R. Womack in addition to refunding all monies recouped thus far from my client. 12/4/ Good Morning Madam Secretary Sebelius: I hope this finds you are doing well. I wanted to reach out to you regarding a client that I am representing. I am hopeful you will share in my concerns so you can open an investigation on behalf of my client against a CMS contracted carrier. The practice is Buffalo Trace Family Practice in Flemingsburg, KY. The carrier is CGS and they have decided to place my client on to a 100% pre-payment review without proper cause. To date more than 500 dates of service have been placed into formal appeal and every day the list is growing. Thus far my client is out more than $20, due to either unethical business practices on the part of CGS or sheer negligence on the part of CGS auditors. The problem as we have determined based on our own investigation is the auditors are not actually reviewing the records they are requesting documentation for and down-coding. I say this because if they were actually reviewing the documentation there is no way they would reduce more than 500 dates of service from a (Moderate Complexity of Decision Making) to a (Straightforward Complexity of Decision Making) based on patients presenting with multiple chronic systemic illnesses (i.e. Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Coronary Artery Disease, etc.) Often these patients require medication management to adjust their Rx to ensure maximum efficacy and to control symptoms in addition to ordering of Medically Necessary tests. In addition, patients being seen are also presenting with acute medical conditions requiring the ordering of clinical laboratory tests, diagnostic imaging, and other medically necessary tests which constitutes a Moderate Complexity of Decision Making. I can say with 100% certainty the auditors at CGS are failing to thoroughly review the provider s documentation if they are reviewing it at all and this is an egregious act of misrepresentation of the facts as they relate to patient care provided by Buffalo Trace Family Practice. The other concern is this; if they are reviewing the documentation and are down-coding the services then they lack the requisite skills necessary to do an effective job. As you know, The DoctorsManagement team is comprised of clinical and non-clinical auditors all holding multiple credentials from AAPC (CPMA, CPC, CPC-P, CPC-I, CEMC) and AHIMA (CCS, CCS-P, ICD-10 AHIMA Ambassador) in addition to each having more than 15 years of physician documentation auditing within specific specialties in addition to their Bachelor, Masters and Advanced Clinical Degrees. My team also consists of former Senior CMS Auditors and former Senior Auditors from BCBS, CIGNA and United Healthcare. After reviewing more than 200 of the 500 dates of service reduced by CGS my team adamantly disagrees with the findings of the CGS auditors and requests you intervene and demand CGS cease and desists with further pre-bill activity against Buffalo Trace Family Practice and refund monies recouped thus far from my client. 12/4/

7 12/4/ The Appeal Process There are five levels in the claims appeals process under Original Medicare: 1. Redetermination by a CMS contractor (carrier, fiscal intermediary or Medicare Administrative Contractor (MAC)) 2. Reconsideration by a Qualified Independent Contractor (QIC) 3. Hearings before an Administrative Law Judge (ALJ) within the Office of Medicare Hearings and Appeals in the Department of Health and Human Services 4. Review by the Appeals Council within the Departmental Appeals Board in the Department of Health and Human Services 5. Judicial review in federal district court 12/4/ Appealing Medicare Decisions Once an initial claim determination is made by a contractor, beneficiaries, providers, and participating physicians and suppliers have the right to appeal the determination Physicians and suppliers who do not take assignment on claims have limited appeal rights Beneficiaries may transfer their appeal rights to non-participating physicians or suppliers who provide the items or services and do not otherwise have appeal rights. All appeal requests must be made in writing 12/4/

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9 Redetermination Contractor staff not involved in making the initial claim determination perform the first level appeal, the redetermination. The appellant (the individual filing the appeal) must file the request for redetermination with the contractor as noted on the MSN and RA within 120 days from the date of receipt of the initial determination. The initial determination is the Medicare Summary Notice (MSN) issued to beneficiaries, and the remittance advice (RA) issued to providers and suppliers. The MSN and RA also include information about how to file a request for redetermination. A minimum monetary threshold is not required to request a redetermination. 12/4/ Requesting a Redetermination Physicians, suppliers and beneficiaries may follow the directions on their RA or MSN to request a redetermination. In addition, a request for a redetermination may be filed on Form CMS A written request not made on Form CMS must include: Beneficiary name Medicare Health Insurance Claim (HIC) number Specific service and/or item(s) for which a redetermination is being requested Specific date(s) of service Name and signature of the party or the representative of the party The appellant should attach any supporting documentation to their redetermination request. Contractors will generally issue a decision (either a letter, MSN or RA) within60 days of receipt of the redetermination request. Note: If a claim contains a minor error or omission, the claim may be corrected through the reopening process rather than the appeals process. 12/4/ /4/

10 Reconsideration A party to the redetermination may request a reconsideration if dissatisfied with the redetermination. A QIC will conduct the reconsideration. The QIC reconsideration process allows for an independent review of an initial determination, including the redetermination, which may include review of medical necessity issues by a panel of physicians or other health care professionals. A minimum monetary threshold is not required to request a reconsideration. 12/4/ Requesting a Reconsideration A written reconsideration request must be filed with the QIC within 180 days of receipt of the redetermination. A request for a reconsideration may be made on Form CMS If the form is not used, the written request must contain all of the following information: Beneficiary name Medicare Health Insurance Claim (HIC) number Specific service(s) and/or item(s) for which the reconsideration is requested Specific date(s) of service Name and signature of the party or the authorized or appointed representative of the party submitting the appeal Name of the contractor that made the redetermination 12/4/ Requesting the Reconsideration In the request for reconsideration, the appellant should clearly explain the reason for disputing the redetermination decision. A copy of the RA or MRN, and any other useful documentation should be sent with the reconsideration request. Documentation that is submitted after the reconsideration request has been filed may result in an extension of the timeframe a QIC has to complete its decision. Any evidence noted in the redetermination as missing and any other evidence relevant to the appeal must be submitted prior to the issuance of the reconsideration decision. Evidence not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless the appellant demonstrates good cause for submitting the evidence late. 12/4/

11 12/4/ /4/ Reconsideration Decision Notification Reconsiderations are conducted on the- record and, in most cases, the QIC will send its decision to all parties within 60 days of receipt of the request for reconsideration. The decision will contain information regarding further appeal rights. If the QIC cannot complete its decision in the applicable timeframe, it will inform the appellant of their right to escalate the case to an ALJ. 12/4/

12 Requesting an ALJ Hearing If at least $140* remains in controversy following the QIC s decision, a party to the reconsideration may request an ALJ hearing within 60 days of receipt of the reconsideration decision. (Refer to the reconsideration decision letter for details regarding the procedures for requesting an ALJ hearing.) Appellants must also send a copy of the ALJ hearing request to all other parties to the QIC reconsideration. ALJ hearings are generally held by video teleconference (VTC) or by telephone. If the appellant does not want a VTC or telephone hearing, the appellant may ask for an in-person hearing. An appellant must demonstrate good cause for requesting an in-person hearing. The ALJ will determine whether an in person hearing is warranted on a case-by- case basis. Appellants may also ask the ALJ to make a decision without a hearing (on-the-record). 12/4/ Requesting an ALJ Hearing preparation procedures are set by the ALJ. CMS or its contractors may become a party to, or participate in, an ALJ hearing after providing notice to the ALJ and the parties to the hearing. The ALJ will generally issue a decision within 90 days of receipt of the hearing request. This timeframe may be extended for a variety of reasons including, but not limited to, the case being escalated from the reconsideration level, the submission of additional evidence not included with the hearing request, the request for an inperson hearing, the appellant s failure to send notice of the hearing request to other parties, and the initiation of discovery if CMS is a party. If the ALJ does not issue a decision within the applicable timeframe, the appellant may ask the ALJ to escalate the case to the Appeals Council level. *Note: The amount in controversy required to request an ALJ hearing is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers. The amount in controversy threshold for 2014 is $ /4/ /4/

13 Appeal Council Review If a party to the ALJ hearing is dissatisfied with the ALJ s decision, the party may request a review by the Appeals Council. A minimum monetary threshold is not required to request Appeals Council review. The request for Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ s decision, and must specify the issues and findings that are being contested. (Refer to the ALJ decision for details regarding the procedures to follow when filing a request for Appeals Council review.) 12/4/ Appeal Council Review In general, the Appeals Council will issue a decision within 90 days of receipt of a request for review. That timeframe may be extended for various reasons, including but not limited to, the case being escalated from an ALJ hearing. If the Appeals Council does not issue a decision within the applicable timeframe, the appellant may ask the Appeals Council to escalate the case to the Judicial Review level. 12/4/ Judicial Review in US District Court If at least $1,400* or more is still in controversy following the Appeals Council s decision, a party to the decision may request judicial review in federal district court. The appellant must file the request for review within 60 days of receipt of the Appeals Council s decision. The Appeals Council s decision will contain information about the procedures for requesting judicial review. *Note: The amount in controversy required to request judicial review is increased annually by the percentage increase in the medical care component of the consumer price index for all urban consumers. The amount in controversy threshold for 2014 is $1, /4/

14 Original Medicare (Parts A & B Fee-for Service) Initial Determination / Appeals Process STANDARD PROCESS Parts A and B FI, Carrier, or MAC Initial Determination Initial Determination EXPEDITED PROCESS (Some Part A Only) Notice of Discharge or Service Termination 120 days to file Noon the next calendar day FI, Carrier, or MAC Redetermination 60 day time limit First Appeal Level Quality Improvement Organization Redetermination 72 hour time limit 180 days to file Noon the next calendar day Qualified Independent Contractor Reconsideration 60 day time limit Second Appeal Level 60 days to file Office of Medicare Hearings and Appeals ALJ Hearing AIC > $140* 90 day time limit 60 days to file Medicare Appeals Council 90 day time limit Qualified Independent Contractor Reconsideration 72 hour time limit Third Appeal Level Fourth Appeal Level days days to to file file AIC AIC = Amount = Amount in Controversy in Federal District Court ALJ ALJ = Administrative = Law Law Judge Judge Federal District Court AIC > $1,400* FI = FI Fiscal = Fiscal Intermediary AIC > $1,400* MAC MAC = Medicare = Administrative Contractor * The * The AIC AIC requirement for for an an ALJ ALJ Hearing Hearing and and Federal Federal District District Court Court is adjusted is adjusted annually annually in accordance in with with the the medical medical care care component of the of the consumer price price index. index. The The chart chart reflects reflects the the amounts amounts for for calendar calendar year year (CY) (CY) Judicial Review 40 Relevant Information to Getting It Right! 12/4/ Incident-to Vs. Split/Shared Visits 12/4/

15 Background As reimbursement from Medicare and other third party payers declined, physicians were faced with the task of using their time more productively and maximizing the resources of their practices. As such, the use of physician extenders such as nurse practitioners and physician assistants became increasingly common in the practices of many physicians. 12/4/ Background The question then was how to properly bill for extender services, and prior to the Final Rule, CMS (HCFA then) had no standardized policy. CMS recognized this trend and published a new rule in November 2001, permitting new reimbursement rules for Medicare patients. Since then, HHS has modified and tweaked when incident to billing is permitted, leading to some confusion among providers. 12/4/ Split/Shared Visits 12/4/

16 Split/Shared Visits A split/shared visit is defined as a medically necessary patient encounter in which the physician and a qualified NPP each personally perform a substantive portion of an E/M visit (all or some portion of the history, exam or medical decision making key components of an E/M) face to face with the same patient on the same date of service. The physician or qualified NPP who performed the E/M visit must personally document the service in the medical record, and the documentation should support the specific level of E/M visit to each individual patient. 12/4/ Split/Shared in Hospital When a hospital inpatient/hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP s UPIN/PIN number. If there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient s medical record) then the service may only be billed under the NPP s UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim. EXAMPLE: If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service. 12/4/ Split/Shared Visits Key: A consultation will not be performed as a split/shared E/M visit. 12/4/

17 Key Point The term incident to is a Medicare term ONLY (not even Medicaid). 12/4/ What is incident to? Medicare Benefit Policy Manual, Chapter 15, Section 60.1 Incident to a physician s professional services means that the services are furnished as an integral, although incidental, part of the physician s personal professional services in the course of diagnosis or treatment of an injury or illness. 12/4/ What is incident to? Incident to services include not only services typically performed by the physician s office staff, but also those performed by the physician himself, such as minor surgery, reading x-rays, setting casts or simple fractures and other activities that involve evaluation or treatment of a patient s condition. 12/4/

18 Question??? Can pharmacist services be billed as incident to a physician s services? Assuming that the services are medically necessary covered services and all other incident to requirements are met and documented, the services of pharmacists (and PharmDs) would be billable in the same manner as the services of any other nonadvanced auxiliary medical personnel employed and supervised by a physician. That is, their services may be billed under CPT code 99211, when appropriate. 12/4/ What is incident to? The services of many extenders, such as nurse practitioners and physician assistants may be billed by a physician practice using the name and Medicare billing number of these providers. However, when certain conditions are met, the services of nurse practitioners and physician assistants may instead be billed as an incident to service. 12/4/ What is incident to? Because incident to services are so integral to the physician s services, they can be submitted to Medicare as if the physician personally performed the service and the claim will be paid at 100 percent of the Medicare physician fee schedule even though the services were in fact furnished by auxiliary personnel. 12/4/

19 Reimbursement Compare incident to billing at 100 percent of the fee schedule to the reduced rate for non-physician practitioners (typically 85 percent). 12/4/ What is integral? Per the Medicare definition, incidental services must be part of the physician s personal services in the course of diagnosis or treatment of an injury or illness. This means the physician has to perform an initial visit on each new patient to establish the physician-patient relationship. 12/4/ What about an established patient with a new problem? Medicare Manual: the physician must be involved in subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment. National Medicare policy does not specify the frequency of physician involvement in the course of treatment. There may be other reasons to have the physician involved, including local carrier policy. 12/4/

20 Where is incident to permitted? CMS has specific guidelines: Office/clinic; Patient s home; Institution (such as a nursing or convalescent home); or Designated office area in a SNF/NF or hospital. 12/4/ Where is incident to permitted? These locations have specific place of service codes (POS), which means the correct POS must be inserted on the claim form (Box 24B), or the claim may be denied upon audit. 12/4/ Where is incident to permitted? It is also important to note what is NOT on the list of permitted locations for incident to billing: Hospital Inpatient/Outpatient Emergency Department Hospital Observation Hospital Discharge These are billed under split/shared service. Incident to does not exist in provider based entities 12/4/

21 Who are non-physician practitioners? Physician Assistant (PA) Advanced Practice Nurse Nurse Practitioner (NP) Clinical Nurse Specialist (CNS) Certified Nurse Midwife (CNM) Certified Registered Nurse Anesthetist (CRNA) Surgery Assistant Clinical Social Worker (CSW) Clinical Psychologist (Ph.D.) Non-clinical Psychologist Physical Therapist (PT) Occupational Therapist (OT) Speech Pathologist 12/4/ Who are non-physician practitioners? CMS terms this group auxiliary personnel. NOTE who is not on the list: physicians Let s discuss this one a bit 12/4/ Who are non-physician practitioners? Remember, NPPs are limited to what they are permitted to provide based on state laws. State practice act. State professional board rules/regulations. Generally this limits billing to Exception: Medicare permits certain non-physician providers (nurse practitioners, physician assistants, certified nurse midwives and clinical nurse specialists) to bill incident to a physician s services using the highest level of E/M code they are licensed to render under state law, even when no physician has been involved in the visit at all on that day. 12/4/

22 NPP Relationship NPP must be an employee of or independent contractor to the physician, physician s group, or physician s employer. W-2 employee or leased (1099) employee of the physician (or physician s employer), and The physician must be able to terminate the employee and direct how the Medicare services are provided by that employee. 12/4/ The service provided must be: General Requirements reasonable and medically necessary; within the NPP s scope of practice as defined in state law where (s)he practices; and performed in collaboration with a physician. This last one means supervision. Supervising physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. 12/4/ Supervision The Medicare term: direct personal supervision. Present in the office suite and immediately available to provide assistance and direction throughout the time the ancillary staff or NPP is performing the incident to services. 12/4/

23 Supervision Present essentially means nearby. CMS has made clear that the availability of the physician by telephone and the presence of the physician somewhere in the institution does not constitute direct supervision. Office suite means: A single structure that s usually under a single lease. It must have identifiable boundaries when part of another facility and services must be furnished within the identifiable boundary. Walkways, pathways and sky bridges between the office building and the hospital do not meet the on-premises supervision requirement. 12/4/ Supervision must be continuous. Supervision Lunch breaks, coffee breaks and even bathroom breaks that take the physician out of the office suite or otherwise render the physician unavailable to immediately respond if needed could potentially violate the rule. 12/4/ Supervision What about supervision in a group practice? CMS says that in a physician-directed clinic any physician in the clinic may serve as the supervising physician. (1) a physician (or a number of physicians) is present to perform medical, rather than administrative, services at all times while the clinic is open; (2) each patient is under the care of a clinic physician; and (3) the non-physician services are under medical supervision. Note: A court case in Hawaii found that any physician in a physiciandirected clinic may supervise incident to, and need not have specific knowledge that (s)he will be the supervising physician for billing purposes (U.S. vs Hawaii Pacific Health, etc.) 12/4/

24 General Requirements Physician has performed initial service and subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment. The professional identity of the staff furnishing the service must be documented and legible. Note: A counter signature alone is not sufficient to show that the incident to requirements are met. 12/4/ General Documentation Requirements The medical record should be complete and legible. The documentation of each patient encounter should include: The reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results; Current assessment, clinical impression or diagnosis; Medical plan of care; Date and legible identity of the person providing the service. 12/4/ General Documentation Requirements If not documented, the rationale for the ordering diagnostic and other ancillary services should be easily inferred. Past and present diagnosis should be accessible to the treating and/or consulting physician. Appropriate health risk factors should be identified. The patient s progress, response to and changes in treatment, and revision of diagnosis should be documented. CPT and ICD-9 codes reported on the health insurance claim form or billing statement should be supported in the documentation in the medical record. 12/4/

25 E/M Incident to : Not allowed : Notes from initial office visit and subsequent visits which will establish that the physician performed the initial exam and is still actively participating in the patient s care), or Notation by supervising MD that (s)he did perform the initial exam and is still actively participating in the patient s care. NOTE: If E/M service is furnished incident to a physician s service, but not as part of a physician s service, the physician bills code for the service. 12/4/ What about SNF/NF (POS 32)? E/M Incident to Notation by supervising MD that he/she did perform the initial exam and is still actively participating in the patient s care. The POS on the claim form must be POS 11 to indicate the designated office area. What about home visit (POS 12)? Same as SNF/NF. It must also be obvious in the notes for the date of service under review that the physician is physically present in the patient s home at the time of the service. 12/4/ Procedures Incident to Can NPPs perform procedures incident to? CMS says yes, as long as: The NPP is permitted under state law to perform a specific medical procedure; It must be performed under the direct supervision of the physician as an integral part of the physician s personal in-office service. There must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment, and there must be subsequent services by the physician of a frequency that reflects the physician s continuing active participation in and management of the course of treatment. Example: wound debridement. 12/4/

26 Procedures Incident to Key: Some state practice acts or board regulations allow NPPs to perform procedures without physician supervision. But if this occurs, incident to is not permitted. 12/4/ Other Incident to Rules Can extenders bill incident to an NPP? Yes. What about psychotherapy services? Psychotherapy services are considered stand-alone services and are not an incidental part of the patient s care. 12/4/ Incident to Thoughts Whether to bill NPPs incident to is an important question to consider. Appropriateness Capability Reimbursement Supervision 12/4/

27 Thoughts The default E/M code for billing incident to is /4/ Thoughts Supervision is a sticky issue. State guidelines CMS guidelines Sometimes they do not neatly mesh. 12/4/ Thoughts If someone (perhaps a patient who notices that his bill is from a physician when his visit was with an NPP) reports an irregularity to a Medicare carrier, CMS may initiate an investigation that includes a review of the office schedules. When a physician is not scheduled to work and an NPP bills for services incident to, then CMS will be able to prove that bills were submitted fraudulently. 12/4/

28 Thoughts The incident to rules, when used properly, can quite literally give physicians an extra set of hands around the office, increasing efficiency and the bottom line. However, if even one of the requirements is not met, the services are simply not billable to Medicare, and the potential consequences could be risky. 12/4/ Locum Tenens 12/4/ Objectives Quickly determine whether a doctor is locum or reciprocating Bill for reciprocal arrangements when doctors are from the same practice Enter the appropriate modifiers and provider identifiers on your claims Avoid the three common errors practices make when they bill in either situation Track and retain the appropriate information on substitute doctors Determine when and how you should pay a substitute for his services Stay within Medicare s 60-day limit for substitute arrangements Show you re entitled to exceed the 60-day limit because a doctor is on active duty 12/4/

29 Definitions Locum Tenens short for the Latin phrase locum tenens (lit. "place-holder," akin to lieutenant), is a person who temporarily fulfills the duties of another. For example, a Locum doctor is a doctor who works in the place of the regular doctor when that doctor is absent. These professionals are still governed by their respective regulatory bodies, despite the transient nature of their positions 12/4/ Definitions Reciprocal Billing arrangement is typically an agreement among physicians that one will cover the other's practice when the regular physician is absent. Reciprocal billing arrangements are often informal, and Medicare does not require them to be in writing. No money changes hands, and the regular physician compensates the covering physician by reciprocating in the future under similar circumstances. Physicians can have reciprocal billing arrangements with more than one physician. 12/4/ History It is a longstanding and widespread practice for physicians to retain substitute physicians to take over their professional practices when the regular physicians are absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for the regular physician to bill and receive payment for the substitute physician s services as though he/she performed them. The substitute physician generally has no practice of his/her own and moves from area to area as needed. The regular physician generally pays the substitute physician a fixed amount per diem, with the substitute physician having the status of an independent contractor rather than of an employee. These substitute physicians are generally called locum tenens physicians. Section 125(b) of the Social Security Act Amendments of 1994 makes this procedure available on a permanent basis. Thus, beginning January 1, 1995, a regular physician may bill for the services of a locum tenens physicians. A regular physician is the physician that is normally scheduled to see a patient. Thus, a regular physician may include physician specialists (such as a cardiologist, oncologist, urologist, etc.). 12/4/

30 How do I get paid for reciprocal billing? It depends on how the billing is done. Reciprocal billing is where the doctor who did not treat the patient but "owns" the patient, bills for the services provided by the covering doctor. The concept is that the two doctors cover for each other equally, so if they each bill for their own patients, even if they did not provide the service during the coverage period, it will even out in the end. 12/4/ Ways to Get Paid for Substitute Physicians 1. Remember that reciprocal billing allows a physician to submit claims and receive Medicare payments for services that he has arranged for a substitute physician to provide on an occasional, reciprocal basis. 2. To appropriately report services a physician performs under a reciprocal billing agreement, use modifier Q5 (Service furnished by a substitute physician under a reciprocal billing arrangement). 3. Locum tenens also allows your radiologist to receive payment for services another physician performs. But a locum tenens physician cannot work for another practice, and your physician cannot restrict the locum s services to your office. 4. The regular physician pays a locum tenens physician on a per-diem or fee-for-time basis. 5. When reporting locum tenens physician services, always use modifier Q6 (Service furnished by a locum tenens physician). 12/4/ Ways to Get Paid for Substitute Physicians 6. Medicare will not pay for reciprocal billing or locum tenens services for more than 60 continuous days. 7. To use modifiers Q5 and Q6, your physician must be unavailable to provide services. This means that your physician should be out of the office while the substitute physician provides services. 8. The Medicare patient must have arranged or seeks to receive your physician s services. 9. You cannot report either Q5 or Q6 if your physician bills for services under a group practice number. You can, however, use the modifiers if your physician works for a group practice but bills as an independent physician. 10. The patient s regular physician must maintain all of the substitute physician s service on record, along with the substitute physician s physician ID number. 11. Locum tenens applies only to Medicare. Most other payers (such as TRICARE, managed care, traditional indemnity insurance, etc.) do not recognize the locum tenens guidelines or reimburse for substitute physicians, so you must bill these insurers using the name of the physician who rendered the service. 12/4/

31 How to bill locum tenens- Private Carriers Even doctors get sick. So if your physician is out on leave for vacation, illness or another reason, you should have your private payer rules at the ready to bill locum tenens. While many private payers follow Medicare rules, more often than not credentialing, coding and billing issues can hold up locum tenens reimbursement from private payers if you aren t vigilant. Credentialing can be a primary reason for denied locum cases; many payers won t reimburse claims sent by non-credentialed providers. Some payers moderate this restriction, though. For example, Blue Cross/Blue Shield of Michigan allows payment for locum services from the date the credentialing application is received by the payer. Payers generally defer to Medicare guidelines on locum tenens billing. While Medicare limits locum billing to 60 days, some payers extend that to 90 or even 180 days. Here are some factors you need to keep in mind when billing locum tenens physicians to private payers: 12/4/ How to bill locum tenens- Private Carriers Ask your payer whether it accepts the Q6 and Q5 modifiers. These are the two modifiers used in locum situations. The Q6 modifier is for when a temporary physician performs services for the patients of a credentialed provider. The Q5 modifier is for when a substitute physician performs a service, but the regular provider submits the claim. Regardless of what your payer wants, if you don t include one of the two modifiers on locum claims, you may be submitting a false claim Find out which provider ID number you should use. In most cases, you would bill the locum physician under the absent provider s ID number. But in some cases, payers may have other rules. For instance, Blue Cross/Blue Shield of Montana has specific ID numbers for locum physicians for longer than 180 days. Try pushing for delegated credentialing, in which your practice or hospital credentials the temporary physician. This method often results in speedier credentialing, meaning you can start billing the payer quicker. 12/4/ Medicare Although Medicare typically only pays physicians who actually furnish a service, it does make exceptions for "covering physician" arrangements. Medicare will pay you for services provided by a covering physician under the following circumstances: You enter into an arrangement with other physicians to cover each other's practice on an occasional, as-needed basis. This is known as a "reciprocal billing" arrangement. You have an agreement with a substitute physician to cover your practice as an independent contractor when you are away from the practice. This is known as a locum tenens arrangement. 12/4/

32 Reciprocal Billing Medicare will honor reciprocal billing arrangements only if the following conditions are met: The regular physician is unavailable to provide the services; The beneficiary has arranged or seeks to receive the services from the regular physician; The substitute physician does not provide the services to the beneficiary over a continuous period of longer than 60 days; and The regular physician identifies the services as substitute physician services. 12/4/ Example As an example, suppose you plan to go on vacation from July 28 until Aug. 6 and you have arranged for a substitute physician to see your patients in your absence. You can bill for the services that the substitute physician provides to your patients while you are on vacation since the continuous coverage period of 10 days is well under the 60-day limit. Note: Reciprocal billing arrangement rules do not apply to substitution arrangements among physicians in the same medical group where claims are submitted in the name of the group. As a result, physicians in medical practices that bill as groups do not need to maintain reciprocal billing arrangements with other members of their group. 12/4/ Locum Tenens Medicare recognizes that physicians often retain a substitute physician to take over their professional practices while they are absent for reasons such as illness, vacation, continuing medical education and pregnancy. Medicare further recognizes locum tenens arrangements and pays the regular physician for services provided by the substitute physician if: The regular physician is unavailable to provide the services; The beneficiary has arranged or seeks to receive the services from the regular physician; The regular physician pays the locum tenens physician on a per diem or a feefor-service basis; The locum tenens physician does not provide services to beneficiaries over a continuous period of longer than 60 days; and The regular physician identifies the locum tenens physician on claims submitted for the services provided by the locum tenens physician 12/4/

33 Group billing Generally, reciprocal billing arrangements do not apply to the substitution arrangements among physicians in the same medical group where claims are submitted in the name of the group. On claims submitted by the group, the group physician who actually performed the service must be identified with one exception: When a group member provides services on behalf of another group member who is the designated attending physician for a hospice patient, the Q5 modifier may be used by the designated attending physician to bill for services related to a hospice patient s terminal illness that were performed by another group member. 12/4/ Group billing For a medical group to submit claims for a substitute physician who is not a member of the group, and for an independent physician to submit claims for the substitution services of a physician who is a member of a medical group, the following requirements must be met: The regular physician is unavailable to provide the visit services; The Medicare patient has arranged or seeks to receive the visit services from the regular physician; and The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days. 12/4/ Keys to Billing Physicians who are members of a group but who bill in their own names are treated as independent physicians for purposes of applying the requirements of this section. References for this material can be located in the Internet-Only Manual (IOM) available on the CMS website: IOM Chapter 1, (Payment Under Reciprocal Billing Arrangements - Claims Submitted to Carriers) and IOM Chapter 1, (Physician Payment Under Locum Tenens Arrangements - Claims Submitted to Carriers). 12/4/

34 Post Operative Coverage As with the locum tenens billing arrangement, if the only substitution services a physician performs in connection with an operation are postoperative services during the covered global period, these services do not need to be identified on the claim as substitution services. 12/4/ Keys to Billing A continuous period of covered visit services begins with the first day on which the substitute physician provides covered visit services to Medicare Part B patients of the regular physician, and ends with the last day the substitute physician provides services to these patients before the regular physician returns to work. This period continues without interruption on days on which no covered visit services are provided to patients on behalf of the regular physician or are furnished by some other substitute physician on behalf of the regular physician. A new period of covered visit services can begin after the regular physician has returned to work. 12/4/ EXAMPLE: The regular physician goes on vacation on June 30, and returns to work on September 4. A substitute physician provides services to Medicare Part B patients of the regular physician on July 2, and at various times thereafter, including August 30 and September 2. The continuous period of covered visit services begins on July 2 and runs through September 2, a period of 63 days. Since the September 2 services are furnished after the expiration of 60 days of the period, the regular physician is not entitled to bill and receive direct payment for them. 12/4/

35 EXAMPLE (con t) The substitute physician must bill for these services in his or her own name. The regular physician may, however, bill and receive payment for the services that the substitute physician provides on his or her behalf in the period July 2 through August 30. The requirements for the submission of claims under reciprocal billing arrangements are the same for assigned and unassigned claims. 12/4/ Modifier 25 12/4/ /4/

36 Modifier 25 Facts Definition- Significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure *Same physician - Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician." The same physician concept also applies when the exact same physician performs services. All E/M services provided on the same day as a procedure are part of the procedure and Medicare only makes separate payment if an exception applies. Appropriate Usage Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and postoperative care associated with the procedure or service performed. Use Modifier 25 with the appropriate level of E/M service. The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File. An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation supports the 25 modifier and the 24 modifier (unrelated E/M during a post-operative period.) Use Modifier 25 in the rare circumstance of an E/M service the day before a major surgery that is not the decision for surgery and represents a significant, separately identifiable service. 12/4/ Modifier 25 Facts Cont d Inappropriate Usage A physician other than the physician* performing the procedure. Documentation shows the amount of work performed is consistent with that normally performed with the procedure. The following statements are false I can always use this modifier for a new patient. I can always use this modifier when I did not plan the procedure. I can always use this modifier when the diagnoses are different. I can never use this modifier when the diagnoses are the same. Special situations Occasionally two physicians in the same group with the same specialty (but different subspecialties) see the patient on the same day. Medicare does not recognize subspecialties on front-end claims processing. The physician may use Modifier 25 if the documentation meets the definition above. Please submit the documentation when requesting a redetermination. 12/4/ Example: The physician sees the patient for a condition requiring a significant and separately identifiable E/M service prior to removing a wart. 12/4/

37 The physician appended modifier 25 to the wrong code. 12/4/ General items most do know about the 25 modifier: It has been on the Office of Inspector General (OIG) watch list for some time It is applied only to the Evaluation and Management Service codes for significant and separately identifiable services by the same physician on the same day of a procedure or other services Services provided must be documented appropriately in the note for that specific date of service It is not used to report a decision to perform surgery 12/4/ Modifier 25 CMS Specifics It should only be appended to E/M service codes within the ranges of (Eye Exams), (E/M service codes) and HCPCS G0101 and G0175 The use of modifier 25 would be reported on an E/M service when reported with a procedure code with a status indicator of S or T when the procedure meets the definition of significant and separately identifiable from the E/M service (Note: 25 modifier claims will still be excepted for procedure codes that do not have a S or T indicator) The documentation must be supported in the patient s note for the specific DOS to support services provided What if you have two CPT codes that are within the E/M code service range that is significant and separately identifiable? What s the status indicator for the E/M code services? How would this issue be handled appropriately? 12/4/

38 Adding to The Confusion Codes do not have an indicator of S or T, some have a status indicator of A or are services not even covered by Medicare. for example the preventive medicine series For CMS, this means that when you have two codes with a status indicator of A, modifier 25 would not be indicated. For example, if you have a (initial hospital day) and (critical care) billed on the same day, by the same provider, CMS does not require a modifier 25 on the 99221, as both the and the have status indicators of A. Noridian, instruct providers to bill the above scenario as follows: Modifier 25 should be placed on the It is not necessary on the critical care code. From this MAC response one can see that they give further local policy on the subject, so in turn, it is always good as a course of action to check with the MAC in addition to CMS when billing for Medicare patients. When encountering the status indicator A, remember the carriers have discretion for coverage decisions when national policy is lacking. 12/4/ Exceptions to the rule When billing a medically necessary E/M service ( ) that takes place at the same visit as and Welcome to Medicare Exam (IPPE) or Annual Wellness Exam (AVW). Medicare CPM Chapter 12, Section indicates, CPT Modifier 25 shall be appended to the medically necessary E/M service identifying this service as significant, separately identifiable service from the IPPE or AWV code reported. This guideline also instructs not to use any components that were used as part of the IPPE or the AVW toward the components of medically necessary E/M to determine the appropriate level of service for the E/M code /4/ Clarification of Modifier25 Evaluation and Management Services Coding On May 10, 2012, CGS Administrators, LLC, the Medicare Administrative Contractor for Medicare Parts A and B in Ohio and Kentucky, announced that providers must perform and document all three elements of an Evaluation and Management (E&M) service in order to bill for any code higher than CPT 99211, the lowest subsequent office visit. The final coding level should still be assigned based on the highest two of the three elements. The healthcare community is well aware that documentation of E&M services includes three elements: patient history, physical exam, and medical decision-making. Before CGS May 10 update, providers could code and bill E&M services based on the performance and documentation of any two of the three E&M elements. For example, at a follow-up E&M visit for a prescription refill, a physician could perform and document only the patient history and medical decision-making components commensurate with a level 3 visit and then bill for a CPT Historically, the physician did not need to perform or document the third E&M component (e.g., physical exam). This is no longer acceptable. Now providers must perform and document all three elements of an E&M service to justify their coding and billing. This means that providers must perform and document at least a minimal third E&M element at every follow-up visit. CGS will downgrade any claim that is not supported by documentation of all three E&M elements to CPT and its accompanying lower reimbursement. Make certain that your EMR templates and other billing policies are revised to meet this new requirement. 12/4/

39 Modifier 25 Change cont d Modifier-25 On May 14, CGS clarified proper use of Modifier-25 with respect to the global surgery indicator XXX. CGS states that a Modifier-25 should ONLY be used to designate a significant and separately identifiable E&M service that was performed by the same physician on the same day as another procedure or other service. The E&M service may be related to the same diagnosis as the XXX procedure but cannot include any work inherent in the performance, supervision, or interpretation of the XXX procedure. A Modifier-25 cannot be used when the E&M visit is an inherent and necessary part of the surgical procedure. For example, a physician cannot use a Modifier-25 when performing an infusion procedure at an office visit because such an E&M visit is a necessary part of the infusion. In this example, the infusion procedure and E&M visit are bundled and reimbursed as one service. CGS warns against any attempts to circumvent the rules by conducting an E&M visit on a different day than the underlying XXX surgical procedure just so the provider can bill for the E&M service in addition to the XXX surgery. CGS considers this type of unbundling inappropriate and will deny payment for the delayed E&M visit upon any subsequent audit of the documentation. 12/4/ Medical Necessity 12/4/ Is There a Difference in Medical Necessity and Medical Decision Making? Medical necessity is the overall analysis of the complexity of the full episode Medical decision making is merely a documentation audit process --- a bean counting process 12/4/

40 Medical Necessity Defined Medically Necessary or Medical Necessity shall mean healthcare services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: a. In accordance with the generally accepted standards of medical practice: b. Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient s illness, injury or disease; and c. Not primarily for the convenience of the patient or Physician, or other Physician, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient s illness, injury or disease. 12/4/ Medical Necessity Defined Medical necessity can be described with the following terms. Medically Appropriate Complexity of care The reason why 12/4/ Assumption of Medical Complexity Complications with medical necessity arrive when providers insist that it should be assumed that a test should have been ordered DO NOT ASSUME OR INTERPRET!! The provider of the medical care is responsible for connecting the dots CMS states the provider should paint a portrait 12/4/

41 PATIENT LEVELS OF SERVICE* Chronic Problems Release From Care Stable Mild Exacerbatio n Severe Exacerbatio n Level 2 Minimal Follow up Level 3 Level 4 Level 5 Acute Problems Self Management Problem Uncomplicated Complicating Factor Present Complication Posing Threat to Life/Bodily Function Level 2 Minor problem patient could have treated themselves Level 3 Level 4 Level 5 12/4/ Putting the Puzzle of Medical Necessity Together 12/4/ Scoring the Medical Necessity 12/4/

42 Minimal Scoring the Medical Necessity O One self-limited or minor problem, e.g. cold, insect bite, Tinea Corporis Low O Two or more self-limited or minor problems O One stable chronic illness, e.g. well controlled hypertension or non-insulin dependent diabetes, cataract, BPH O Acute uncomplicated illness or injury, e.g. cystitis, allergic rhinitis, simple sprain Moderate O One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment O Two or more stable chronic illnesses O Undiagnosed new problem with uncertain prognosis, e.g., lump in breast O Acute illness with systematic symptoms, e.g.pyelonephritis, pneumonitis, colitis. O Acute complicated injury, e.g., head injury with brief loss of consciousness High O One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment O Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g. multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure O An abrupt change in neurologic status, e.g., seizure, TIA, weakness or sensory loss 12/4/ Determining Medical Necessity Components most needed for assessing the appropriate medical necessity History Plan of care 12/4/ Medical Necessity of the Plan of Care The plan of care documents the providers analysis of the severity of the patient s problem. Plan of Care elements Diagnosis Scripts/Tests/Labs/Procedures Follow up 1 & 2 are pretty straight forward Complexity comes in #3 12/4/

43 Diagnosis Diagnosis will account for the patient s current condition. Symptoms could support complexity Co-Morbidities could complicate the problem Personal/Family histories aide in severity 12/4/ Diagnosis Orders help to interpret the severity of the patient Continue medications or therapies More complex test/studies Consult to a specialist 12/4/ Follow Up The follow up usually is the tell all summary for the plan of care To Follow Re-evaluate condition 12/4/

44 Medical Necessity of the Plan of Care Example: Continue Rx as prescribed and RTC in two months 12/4/ Medical Necessity of the Plan of Care Example Revised: Continue Naproxen 250 mg QD and re-evaluate the patients condition in two months with repeat x-rays. At that time if no improvement will consider MRI. 12/4/ Scoring the Medical Necessity Compiling the problems: Does it Help? Does it increase the medical necessity 2 diagnoses or 20 diagnoses 12/4/

45 Services affected by Medical Necessity How do you interpret medical necessity for services Summary Paragraph? Diagnosis only? 12/4/ Interpretation for physician Physician buy-in to medical necessity Help them understand Remember how they process information Can you tell them where to find information Medical Necessity 12/4/ Interpretation for physician Explain the difference between documentation guidelines and medical necessity Who trumps who Why Why templates limit medical necessity flow 12/4/