EHR and Scribes in the ED

Advanced Procedure Coding for Emergency Medicine Lightning Rounds: Don t Get Struck Scribes, EHRs, MDM Controversies, and Other Hot Topics Identify the most common controversies in emergency medicine coding, including EHR documentation issues Review scribe use and coding implications Discuss coding controversies related to MDM scoring 1/15/2015 1:45:00 PM-3:15:00 PM TH-07 Las Vegas Ballroom January 15-16, 2015 Las Vegas, NV DISCLOSURES: (+) No significant financial relationships to disclose (*) Ownership Interest: President Logix (**) Ownership Interest: Team Parker (***)Consulting Fees : ERcoder, Inc (+) David A. McKenzie, CAE (Moderator) David A. McKenzie, CAE (Moderator) Reimbursement Director, ACEP, Irving, Texas; Staff Contact, AMA RVS Update Committee, the CPT Editorial Panel, and the CPT Advisory Committee; Liaison to Reimbursement and Coding and Nomenclature Advisory Committees, ACEP (*) Michael A. Granovsky, MD, CPC, FACEP Michael A. Granovsky, MD, CPC, FACEP President, LogixHealth; Editor ED Coding Alert, Subject Matter Expert AAPC ED Subspecialty Certification Exam; Member Reimbursement Committee, Course Director National ACEP Coding and Reimbursement Conference, Professor George Washington University, Department of Emergency Medicine Subject Matter Expert ACEP Panel for quality measure development. (+) Stacie Norris, MBA, CPC, CCS-P Stacie Norris, MBA, CPC, CCS-P Director of Coding Quality Assurance, Emergency Medicine services, Zotec MMP; Member, American Health Information Management Association (AHIMA), AHIMA ICD-10 Certified Trainer; Certified Professional Coder (CPC); Member, CNAC (Coding Nomenclature and Advisory Committee) for National ACEP; serves on the EDPMA Coding and Documentation Committee and the Quality Committee; articles published for ED Coding Alert (**)Rebecca B. Parker, MD, FACEP Chair, ACEP Board of Directors; Executive Vice President, EmCare North Division; President, Team Parker LLC; Clinical Assistant Professor, Texas Tech-El Paso, Dept. of Emergency Medicine (***)Todd Thomas, CCS-P President, ERcoder, Inc; Oklahoma City, Oklahoma; Past-President, Oklahoma City Chapter, American Academy of Professional Coders; Member, ED Coding Alert Editorial Advisory Panel; Member, Coding and Nomenclature Advisory Committee, ACEP; 2009-10 Outstanding Speaker of the Year Award, ACEP

EHR and Scribes in the ED Electronic Medical Records There are many positive aspects of using an EMR: Improved Legibility Faster chart completion Prebuilt Templates for common presenting complaints Real time access to record for previous encounters and diagnostic studies 1

Electronic Medical Records There are many positive aspects of using an EMR: Copy and paste functions allow for inserting past history and previous ROS. Ease of sending records to other providers for continuity of care Helps optimize reimbursement Electronic Medical Records However, some positives are also on the list of negatives: Faster chart completion Speed is not the same as efficiency, nor should it be achieved by sacrificing accuracy. The EMR should help physicians work quickly while maintaining optimal care and compliant documentation. 2

Electronic Medical Records Prebuilt Templates for common presenting complaints History and physical exam documentation content should be determined by the clinical circumstances of the patient as it relates to the presenting problem and not be driven by the template. History or exam components that are not performed should not be documented simply to complete the template. Electronic Medical Records Copy and paste functions allow for inserting past history and previous ROS. Inappropriate use of the copy and paste function can cause the physician to inadvertently falsify the medical record or create an ED chart that appears to have been cloned. Helps optimize reimbursement More documentation does not equal more money. Over documented charts make it very easy to upcode the E&M service. Prompts to add more documentation for higher codes do not recognize medical necessity. 3

OIG on EHRs Experts in health information technology caution that EHR technology can make it easier to commit fraud. Certain EHR documentation features, if poorly designed or used inappropriately, can result in poor data quality or fraud. Ways EHRs May Facilitate Fraud Copy-Pasting Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location. When doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient s medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims. 4

Ways EHRs May Facilitate Fraud Overdocumentation Overdocumentation is the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services. Some EHR technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider may be inaccurate. Such features can produce information suggesting the practitioner performed more comprehensive services than were actually rendered. EHR Oops From the physician s exam: patient ambulates well From the nurses notes: patient arrives in a wheelchair HPI documented by the EDMD Patient presents with chest pain and shortness of breath. ROS documented by the EDMD Cardiovascular - no chest pain. Respiratory - no SOB". 5

EHR Oops EHR Oops 6

MAC Concerns Default documentation is a problem because it is difficult to tell what work was actually provided for the current visit. Medical necessity documentation is a cognitive process that is difficult to document with templates and macros. Mac Concerns Information that has no pertinence to the patient s situation at that specific time cannot be counted. - cignagovernmentservices.com - "Due to excessive documentation for minor presenting problems, I have been forced to make a judgment call to identify which E&M elements to score as reasonable and necessary for many of the visits." 7

OIG on EHRs OIG is currently determining the extent to which documentation errors were facilitated by using EHR technology. CMS did issue guidance to the contractors that states that medical record keeping within an EHR deserves special considerations and that the original content, the modified content, and the date and authorship must be identifiable. CMS response to OIG report CMS has been actively considering the issue of preventing fraud, waste. and abuse in EHRs. In May 2013, CMS and ONC held a public listening session with stakeholders about a number of issues pertaining to billing and coding for EHRs, including the impact of EHRs on clinical documentation. Given its potential for use in fraud. CMS intends to develop appropriate guidelines to ensure appropriate use of the copy paste feature in EHRs. CMS will also consider whether additional guidance and tools are needed to help detect fraud associated with EHRs. 8

Scribes in the ED A scribe accompanies the doctor into each patient encounter to transcribe the doctor s dictation into the medical record. A scribe must document verbatim what is being said by the physician. The scribe cannot document any of their own findings. The scribe s documentation should identify the scribe and the physician. 9

Scribes in the ED When using an electronic medical record, the scribe must have their own username and password to access the system. Entries in the EMR must be identified has having been made by the scribe. The physician must review and verify the scribe documentation and attest to its accuracy in addition to also signing the chart. Per CMS The scribe functions as a recorder of facts and events which occur between the physician and the patient during the encounter. There must be evidence that the physician reviewed and confirmed what is stated by the scribe. 10

CMS on Scribes Joe Kuchler, Spokesman for the CMS Under Medicare conditions of participation for hospitals, physicians may delegate the task of entering chart information to scribes or other staff. But the physician remains responsible for dating, timing and authenticating the record entry. CMS also expects that scribes would use their own log-in for the electronic medical record system, it would not be appropriate for the scribe to make entries under the physician's user name and password. CMS on Scribes Joe Kuchler, Spokesman for the CMS National Government Services recently barred teaching hospitals in one of its regions from using scribes for medical residents and fellows. The creation of the medical record is a key part of residents' and fellows' training that is paid for under Medicare's graduate medical education program. CMS does not have any national GME payment policy on this, so its regional contractors are free to develop their own policy. 11

Carrier comments on scribes Medicare auditors have noted some physicians having individuals writing notes in the medical record for them, and then merely signing the note. This my be inappropriate. The physician is ultimately accountable for the documentation, and after the scribe's entry should sign and documentation confirmation that the note accurately reflects work done by the physician. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) on scribes Signing (including name and title), dating of all entries into the medical record electronic or manual. The role and signature of the scribe must be clearly identifiable and distinguishable from that of the physician or licensed independent practitioner or other staff. Example: Scribed for Dr. X by name of the scribe and title with the date and time of the entry 12

Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) on scribes The physician or licensed independent practitioner must authenticate the entry by signing, dating and timing (for deemed status purposes) it. The scribe cannot enter the date and time for the physician. Although allowed in other situations, a physician signature stamp is not permitted for use in the authentication of scribed entries-- the physician must actually sign or authenticate through the clinical information system. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) on scribes The authentication must take place before the physician and scribe leave the patient care area. Authentication cannot be delegated to another physician or licensed independent practitioner. 13

Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) on scribes If the organization determines that the scribe will be allowed to enter orders into the medical record, those orders entered into the medical record cannot be acted on until authenticated by the specific physician/licensed independent practitioner who provided the orders scribed. Authentication includes the physician signature (electronic or manual) and the date and time. CMS on scribes entering orders the person entering the order could be required to enter the order correctly, evaluate CDS (Clinical Decision Support ) either using their own judgment or through accurate relay of the information to the ordering provider, and then either make a change to the order based on the CDS intervention or bypass the intervention. We do not believe that a layperson is qualified to do this, and as there is no licensing or credentialing of scribes, there is no guarantee of their qualifications. Federal Register / Vol. 77, No. 171 / Tuesday, September 4, 2012 14

Scribes in the ED The scribe s note should include: The name of the scribe and acceptable signature. The name of the physician providing the service. Documentation by Maggie Greene acting as scribe for Rick Grimes, MD. Scribe signature, date & time. The physician s note should indicate: Affirmation that the physician personally performed the services documented. Confirmation he/she reviewed and confirmed the accuracy of the information in the medical record. Acceptable physician signature. I have reviewed the documentation recorded by the scribe and it accurately reflects services performed by me. MD signature, date & time. Licensed providers as Scribes Payers have expressed concern about Residents, Physician Assistants, Nurse Practitioners, Nurses, Medical Students, etc acting as scribes because of their ability to independently evaluate patients. Scribed documentation must be very clear and identifiable in comparison to documentation of services performed as a healthcare provider. 15

Todd Thomas, CPC, CCS-P (405) 749-2633 www.ercoder.com Todd@ERcoder.com Mid-Level Providers / Shared Visits 16

Mid-Level Providers / NPP s Physician Assistants (PA) and Nurse Practitioners (NP), are referred to as Non Physician Practitioners (NPP) by Medicare Any services for which Medicare will pay a physician are also covered when performed by a NPP. However, the services of the NPP are reimbursed at 85% of the Medicare allowable. Mid-Level Providers / NPP s The only way to avoid the 15% discount on the NPP services is to have the E&M service shared between the NPP and the attending physician. When the NPP and the MD share in the performance of the E&M service, the claim can be filed under the attending physician s ID number and the service will be reimbursed at 100% of Medicare allowable. 17

Mid-Level Providers / NPP s Medicare Carrier Manual Transmittal 1776 When a ED E/M is shared between a MD 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. Mid-Level Providers / NPP s Medicare Carrier Manual Transmittal 1776 However, 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 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. 18

Mid-Level Providers / NPP s This change in policy allows for an E&M service to be billed as a shared service under the MD s ID number as long as the attending physician has a face to face encounter with the patient and the NPP and MD are part of the same group Mid-Level Providers / NPP s Face to face encounter The physician must have contact with the patient and not simply review and/or co-sign the patient's medical record. A social salutation alone does not constitute a face-toface portion or physician work of an E/M service. The MD must perform and document some portion of the elements of the E&M service (history, physical exam, or medical decision making) in whole or part. 19

Mid-Level Providers / NPP s the level of service is determined from the joint work for the split/shared service. The documentation from each provider (physician/npp) must be documented and support the level of service billed. Terrence L Kay Director Division of Practitioner Services Centers for Medicare & Medicaid Services (CMS) Documentation of the Shared/Split E&M Service The medical record must clearly identify both the NPP and the physician who shared/split in rendering the service. The physician documents his/her encounter with the patient at the time of the service. The physician documentation should be linked to the NPP documentation of the shared/split service, and affirmatively state one (or more) element(s) of the encounter. This one (or more) element(s) may be an element of history, physical examination, or medical decision-making. Additionally, the NPP portion of the service must be within the scope of practice of the non-physician practitioner as defined by state law. HGSA Medicare Newsroom http://www.hgsa.com/newsroom/news02192003.shtml 20

Documentation of the Shared/Split E&M Service Is it necessary to have the physician sign the medical record when the NPP and the physician provide a shared/split visit? Can the NPP document that the physician agrees? Under a shared/split visit situation, both parties must document and sign the work they perform. A notation of "seen and agreed" or "agree with above" would not qualify the situation as a shared/split visit because these statements do not support a face-to-face contact with the physician. Only the NPP could bill for the services. What are you looking for to prove that the doctor had a face-toface with the patient for share/split visits? The doctor must document his/her work and sign the medical record. Documentation of the Shared/Split E&M Service Both the physician and the NPP performed part of the Evaluation and Management (E/M) service for the patient. The doctor left the documentation of the visit to the NPP. Is this a shared/split visit? No. To bill a shared/split visit, both the physician and the NPP must document the work they performed and sign their part of the medical record. Can we bill inpatient subsequent visits as a shared/split visit? Yes. You can bill a shared/split visit only if the visit meets the documentation requirements for facility services. For a shared/split visit, both the MD/DO and the NPP must document and sign the portion of the visit they performed. WPS Medicare Services 21

Documentation of the Shared/Split E&M Service A generic attestation will not suffice as documentation to support a shared service. To qualify as a shared visit, both the physician and the PA must each personally perform part of the visit, and both the physician and the PA must document the part(s) that he or she personally performed. When the supporting documentation does not demonstrate that the physician "performed a substantive portion of the E&M visit face-to-face with the same patient on the same date of service" as the portion of service performed by the PA the service cannot be reported as a shared service. Medicare MAC examples unacceptable documentation to support a split/shared visit "I have personally seen and examined the patient independently, reviewed the PA's Hx, exam and MDM and agree with the assessment and plan as written" signed by the physician "Patient seen" signed by the physician "Seen and examined" signed by the physician "Seen and examined and agree with above (or agree with plan)" signed by the physician "As above" signed by the physician Documentation by the PA stating "The patient was seen and examined by myself and Dr. X., who agrees with the plan" with a cosign of the note by Dr. X No comment at all by the physician, or only a physician signature at the end of the note 22

Suggested MD documentation Patient presents with (insert chief complaint) for (insert duration). My exam shows (insert relevant exam of affected system or area). I reviewed the PA's note and agree with PA's findings and plan. Patient presents with chest pain for 2 hours. My exam shows heart rate normal, regular rhythm, breath sounds are normal, clear throughout. I reviewed the PA's note and agree with PA's findings and plan Patient presents with (insert injury) to (insert location). My exam shows (insert relevant exam of affected system or area). I reviewed the PA's note and agree with PA's findings and plan. Patient presents with laceration to left hand. My exam shows a 3cm laceration on the palm of the left hand, distal neurovascular function and ROM are normal. I reviewed the PA's note and agree with PA's findings and plan. Shared/Split E&M Service If there is no EDMD involvement in the encounter it is perfectly acceptable for the service to be reported by the PA/NP. The EDMD should not participate in the encounter solely for the purpose of boosting reimbursement. EDMDs involvement in the encounter should be driven by medical necessity and the chart should reflect their participation to ensure accurate reimbursement. 23

Mid-Level Providers / NPP s The changes from Transmittal 1776 and the rules regarding shared services only apply to E&M services. Procedures performed by NPP s should be billed under their ID number and paid at 85% of the Medicare allowable. Please note this (Transmittal 1776) relates only to E/M services. There is no mention of procedures. Stephen D. Boren, MD, MBA, FACEP WPS Medical Director DIAGNOSTIC INTERPRETATIONS IN THE ED Presented by Stacie Norris, s MBA, CPC, CCS-P 48 24

Diagnostic Interpretations Will Payors Pay For Diagnostic Interpretations by the ED Provider? They SHOULD: Billable, medically necessary, separately identifiable service But the reality is, it depends on the payor Payor contracts Payor bundling Claims by other providers Diagnostic Interpretations- Medicare Medicare has very clear policy published on diagnostic interpretations in the ED Per Medicare Claims Processing Manual: Distinguishes between an interpretation and report and a review - I&R: complete written report similar to a specialist in the field - Review: Review of findings; i.e., EKGnormal 25

Diagnostic Interpretations- Medicare (cont d) Distinguishes between an Interpretation & Report and a Review : - I&R-Should be paid: complete written report, findings, relevant clinical issues & comparative data (when available) - Review-Included in E/M: Review of findings, i.e. EKG-normal Diagnostic Interpretations- Medicare (cont d) CMS states for hospitals to work with staff to make sure only 1 claim is submitted If 2 claims submitted, generally Medicare pays for 1 interpretation of an EKG or X-ray furnished to and ED patient When multiple claims received for the same interp, generally will pay for 1 st bill received May pay for 2 under unusual circumstances, with documentation provided 26

Diagnostic Interpretations- Medicare (cont d) Claims Manual: when 2 claims are received from the ED for the same interp, determine if the claim from the ER physician was the interpretation that contributed to the diagnosis and tx of the pt; if so pay that claim (contemporaneous interpretation). Determine if the radiologist s claim was actually quality control and institute recovery action CMS states the 2 parties should be encouraged to reach an accomodation as to who should bill for these interpretations. Diagnostic Interpretations-CPT CPT language generally supports the right of the ED provider to bill for diagnostic interp s (ED issues not addressed directly, but still useful): The actual performance and/or interpretation of diagnostic tests/studies ordered during a pt. encounter are not included in the levels of E/M services. CPT states that the codes may be used by any licensed provider, regardless of specialty. 27

Diagnostic Interpretations-Federal Register ED diagnostic interp s addressed in Federal Register (MFS Final Rule), 12/8/95: Medicare s Claims Manual language drawn from the Federal Register. Read this to understand Medicare s thought process on the issue. Useful for non-medicare appeals as a government source on the issue that supports the billing of the contemporaneous interp. Link to this Fed. Reg. edition on ACEP Website. Diagnostic Interpretations-Private Payors Private payors may bundle the diagnostic interpretation into the E/M level: If the physician group has a contract with the payor, it may be in the contract itself or in the payor s manual/policies/bulletins. Contract language should include not bundling services and/or include a separate fee schedule as an addendum. 28

Diagnostic Interpretations-Private Payors (cont d) Private payors may bundle the diagnostic interpretation into the E/M level (cont d) - Appeal all inappropriate denials» Protects rights for future action such as class actions or higher level appeals - Stay current with all payor manuals/updates - Work with state medical societies and physician groups to fight unfair payor policies - Meet with payor medical director to incite change Diagnostic Interpretations- Resources Resources for billing diagnostic interpretations/appealing denials: ACEP Website X-ray/EKG FAQ Sample appeal letters to fight payor bundling Official letters (e.g., Foley & Lardner) to support ED position Medicare: Medicare Claims Processing Manual 100.04, Ch. 13, Sect. 100.1 Federal Register, MFS Final Rule,12-8-95 State Medical Societies 29

Contact Information Questions? Stacie Norris, MBA, CCS-P, CPC Director of Coding Quality Assurance Zotec Partners Durham, NC Sanorris@zotecpartners.com 1-800-476-8646, Ext. 2855 Physician Feedback Mechanisms Presented by Stacie Norris, MBA, CPC, CCS-P s 60 30

Physician Feedback Mechanisms Physician Feedback Mechanisms Important part of every ED practice; may: Improve accuracy of CPT coding; Help quality measure performance; Assist in denials management; Contribute to ICD-10 documentation improvement; Contribute to more compliant medical records. Physician Feedback Mechanisms Physician Feedback: Key physician documentation education tool: Important for accurate and optimum coding of physician services; Physicians and NPP s may not know coding/billing guidelines; With ICD-10 becomes even more essential; Part of coder/billing professionals role. 31

Physician Feedback Mechanisms Physician Feedback (cont d): Several different documentation feedback options: Provider documentation inservices; Physician feedback reports; Include metrics, e.g. volume, RVUs lost Individual (specific) or grouped (general categories) chart feedback Benefit from sharing results across group. Physician Feedback Mechanisms- CPT Coding Physician Feedback For CPT Coding: CPT physician feedback program should provide feedback on: E/M coding History, Exam, MDM Critical care services Observation services Procedures. 32

Physician Feedback Mechanisms- CPT Coding Physician Feedback For CPT Coding (cont d): Compliance issues to consider: Avoid possible prompting problems Feedback/education given for accurate coding of services rendered Never for inappropriate upcoding Include feedback on other documentation areas such as quality measures and accurate patient records. Physician Feedback Mechanisms- Diagnosis Coding Physician Feedback For Diagnosis Coding: AKA Clinical Documentation Improvement Important for ICD-9 and ICD-10 start now Thorough, specific documentation is good documentation Communicate with physicians throughout the process Tailor the CDI program to their needs Get physician buy-in, explain benefits 33

Physician Feedback Mechanisms- Diagnosis Coding Physician Feedback For Diagnosis Coding (cont d): Denials management Communicate common areas of diagnosis denials Some denials solved with improved provider documentation/some not Provide education for those that can be mitigated Do so compliantly Physician Feedback Mechanisms- Other Areas Other Areas For Physician Feedback: Reducing send backs Signatures; Teaching physician guidelines; EMR/Template issues Copy/paste issues, inaccurate documentation, etc. Specific CPT/CMS guidelines 34

Contact Information Questions? Stacie Norris, MBA, CCS-P, CPC Director of Coding Quality Assurance Zotec Partners Durham, NC Sanorris@zotecpartners.com 1-800-476-8646, Ext. 2855 Hot Topics: Telemedicine Teaching Physician Rebecca Parker, MD, FACEP Chair, ACEP Board of Directors Executive Vice President, EmCare North Division President, Team Parker LLC 35

Telemedicine Telemedicine Rapidly evolving Payer approach varies by payer, state 16 states have laws requiring private payer payment 9 state Medicaid programs reimburse Focus on CMS policy and procedure 36

Telehealth or Telemonitoring The use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distances. Can be non-clinical: medical education, administration, research Includes telephone, fax, electronic mail, remote patient monitoring devices Telemedicine More narrow CMS: Telemedicine seeks to improve patient s health by permitting two way, real time interactive communication between the patient, and the physician or practitioner at the distant site includes at a minimum, audio and video equipment. As a condition of payment, the patient must be present and participating in the telehealth visit. 37

Telemedicine - Facility Originating site-location of the patient at time of service Distant site-location of physician or licensed professional delivering service Facility fee is to originating site: Office of practitioner, Hospitals, CAH, FQHC, Hospitalbased or CAH based dialysis centers (including satellite) SNF, Community Mental Health Centers Telemedicine - Facility Originating sites must be: In an address not in a metropolitan area OR if it falls in to a metropolitan area must be in a rural area and in a health professional shortage area http://datawarehouse.hrsa.gov/telehealthadvisor/teleh ealtheligibility.aspx 38

2014 HCPCS Provider Telehealth Codes Code Descriptor Total RVU time G0425 ED or initial inpt telehealth consultation 30 min 2.85 G0426 ED or initial inpt telehealth consultation 50 min 3.85 G0427 ED or initial inpt telehealth consultation 70 min 5.69 G0406 Follow-up inpt telehealth consultation, 15 min 1.1 limited G0407 Follow-up inpt telehealth consultation, 25 min 2.04 intermediate G0408 Follow-up inpt telehealth consultation, complex 35 min 2.93 2014 Expanded Telehealth Codes Nursing facility ESRD services Psychiatric and other behavioral healthservices Transitional care management http://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf 39

CMS Modifiers GT modifier via interactive audio and video telecommunications system (e.g. G0426 GT) GC modifier For demonstration programs in Alaska and Hawaii via synchronous telecommunications system Some other payers request no modifier Telemedicine Critical Care Yes can be reported Distant site must have real time access to patient medical record, progress notes, nursing notes, VS, lab, radiographic images Physician must be able to enter orders, video conference with health care team, family and observe patient 40

Telemedicine Critical Care Two new Category III CPT codes 0188T = 99291 0189T = 99292 As of 2014 assigned zero RVUs Resources American Telemedicine Society www.americantelemed.org Centers for Medicare and Medicaid Services http://www.cms.gov/medicare/medicare-general- Information/Telehealth/ Telemedicine Reimbursement Handbook (California) http://crihb.org/files/telemedicine-reimbursement- Handbook.pdf www.acep.org/reimbursement/ 41

Teaching Physician CMS Teaching Physician E/M Services by the teaching physician (TP) must be provided in one of four ways: Personally by a TP By a resident in the physical presence of a TP Jointly by a TP and resident at different times during visit, independently When resident admits late at night at TP sees at least within next calendar day 42

CMS Teaching Physician E/M TP documentation requirements include: Personally documenting his/her performance of and/or physical presence during the key or critical portions of the service TP determines the key portions Personally documenting his/her participation in the management of the patient EHR macros acceptable if TP adds personally in a secured (password protected system); resident or TP must customize enough to support medical necessity CMS Teaching Physician E/M Unacceptable CMS examples of TP documentation Agree with above Rounded, reviewed, agree Discussed with resident. Agree Patient seen and evaluated 43

CMS Teaching Physician E/M Acceptable CMS examples of TP documentation I performed a history and physical examination of the patient and discussed the management with the resident. I reviewed the resident s note and agree with the documented findings and plan of care. I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident s note. CMS Teaching Physician E/M Acceptable CMS examples of TP documentation I saw and evaluated the patient. I reviewed the resident s note and agree, except that the picture is more consistent with pericarditis than myocardial ischemia. Will begin NSAIDs. 44

CMS Teaching Physician - Procedures Minor procedures Less than 5 minutes Must be physically present during entire procedure, and personally document presence Major procedures More than 5 minutes Must be physically present during key portions (TP to determine) and immediately available CMS Teaching Physician Critical Care Only the TP time counts Combination of TP and resident note may support CC TP must personally document: Time TP spent providing CC Patient met CC criteria, and why Nature of treatment and management of TP 45

CMS Teaching Physician Modifier Requirement GC modifier Service performed in part by a resident under direction of a TP Usually what used for ED GE modifier Service performed by a resident without the presence of a TP under the primary care exception CMS Teaching Physician Medical Students CMS never pays for an independent evaluation or procedure by a medical student E/M services TP can use the student recorded ROS, PFSH if TP confirmed and documents confirmation Procedures If TP personally is performing evaluation or procedure they can involve student and directly supervise, allowing billing If a resident is supervising student, previous TP criteria for the resident must be met 46

Questions rparker@acep.org 847-712-3491 Ultrasound and Ultrasound Assisted Procedures Michael Granovsky MD, CPC, FACEP President LogixHealth 47

US Documentation Requirements Medical Necessity medical record documentation must indicate why the test was medically necessary. Interpretation a written interpretation and report must be completed and be maintained in the patient s medical record and describe the structures/organs studied and include an interpretation of the findings. identify provider performing/interpreting the study Image Retention appropriate image(s) of the relevant anatomy / pathology must be permanently stored and available for future review. 2014 CPT Requirements All diagnostic ultrasound examinations require permanently recorded images. A final, written report should be issued for inclusion in the patientʹs medical record. Does not require a separate sheet Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable. CPT 2014 48

2014 Complete vs Limited Studies For those anatomic regions that have ʺcompleteʺ and ʺlimitedʺ ultrasound codes, note the elements that comprise a ʺcompleteʺ exam. The report should contain a description of these elements or the reason that an element could not be visualized (eg, obscured by bowel gas, surgically absent). If less than the required elements for a ʺcompleteʺ exam are reported (eg, limited number of organs or limited portion of region evaluated), the ʺlimitedʺ code for that anatomic region should be used CPT 2014 Example: a complete abdominal ultrasound (76700) would consist of real time scans of the: liver, gall bladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta and inferior vena cava. CPT 2014 Common ED US Codes: FAST Exam 2 codes Focused Assessment with Sonography for Trauma 25 year old male rollover MVA. BP 80 s, HR 120, Belly firm. The physician performs a FAST exam 76705 limited abdominal US Same for AAA, biliary tract 93308 limitted trans thoracic echo Same for general limited echo 49

Ultrasound FAST Chest Ultrasound (E FAST) 76604 Ultrasound chest, real time with image documentation Sometimes a 3 rd component to trauma evaluation Hemothorax/Pneumothorax CPT Assistant clarification An US of the chest (76604) does not require an examination of the mediastinum Lung sliding or pleural fluid 50

US Guidance Procedures 36 year Old IVDA requires central venous access for antibiotics. The patient has a lot of scar tissue and mentions he is a difficult stick. Ultrasound Guided Line Placement +76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real time ultrasound visualization of vascular needle entry, with permanent recording and reporting. List separately in addition to code for primary procedure + Add on code Report in addition to the procedure performed i.e. 36556 central line 5 years or older Use for dynamic technique not static Static technique is not separately reportable 51

Central Line with Ultrasound Guidance Should state real time US Guidance Abdominal Procedures 48 year old male with ascites and prior abdominal surgeries requires US guided paracentesis. 52

Newer US Codes Reminder: US Codes Added in 2012 Ultrasound Guided Paracentesis 49082 Abdominal Paracentesis without imaging guidance 49083 with imaging guidance 49084 Peritoneal Lavage, including imaging guidance when performed 106 53

2013 US Thoracentesis Codes 32554 Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance 32555 Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance 32556 Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance 32557 Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance 107 2014 US Fluid Collection By Catheter 10030 (Image guided fluid collection drainage by catheter [e.g., abscess, hematoma, seroma, lymphocele, cyst], soft tissue [e.g., extremity, abdominal wall, neck], percutaneous) (Report 10030 for each individual collection drained with a separate catheter.) Note: requires placement of a catheter in the collection New CPT code Appendix G code 1. Procedures includes conscious sedation as an inherent part of providing the procedure 2. Second physician MCS in the facility setting (i.e. Emergency Department), the second physician can report 99148 99150 108 54

Ultrasound Modifiers 26 professional component only Typical for ED Ultrasound unless have combined billing with the Hospital 76 Repeat procedure by the same physician 77 Repeat procedure by another physician 27 y.o. male falls off a 15 foot ladder. c/o abdominal pain. Dr Jones performs a FAST Exam (negative) and order labs signing out to Dr. Smith. Dr. Smith is notified by the nurse the patient has become diaphoretic. Repeat FAST exam reveals free intra peritoneal fluid. 109 US Procedural Guidance: Needle Placement 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation Applies to many ED localization and needle placement procedures Suprapubic aspiration, lumbar puncture, foreign body removal CPT requires all guidance procedures to include permanently recorded images 76930 Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation Own unique needle localization code 55

US GUIDANCE PROCEDURES Code both the Ultrasound and the procedure Make sure both notes individually meet the documentation requirements US Guidance US Code Addtnl. CPT Lumbar puncture 76942 62270 Suprapubic Aspiration 76942 51100 Pericardiocentesis 76930 33010 US Guided Peripheral IV 76937 56

Pelvic Ultrasound 23 year old female presents complaining of lower abdominal fullness with nausea and vomiting. She is unsure of her last menstrual period. Pelvic Ultrasound Procedures US Evaluation of Pregnancy: Transabdominal:Ultrasound, pregnant uterus, real time with image documentation, limited 76815 Transvaginal: Ultrasound, pregnant uterus, real time transvaginal 76817 26 Not pregnant: Ultrasound pelvic non obstetric 76857 26 Non obstetric transvaginal ultrasound 76830 26 57

US Trans abdominal AAA Abdominal Aortic Aneurysm 67 year old male presents with syncope and back pain. A pulsatile mass is felt on exam. The ED physician performs an immediate retroperitoneal US and identifies a AAA 58

Coding for AAA Evaluation Limited Retroperitoneal Ultrasound 76775 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited Requires an archived image Does not require an ultimate finding of AAA Biliary Colic RUQ Sonogram 32 year old female presents with RUQ pain initially after eating, now constant 76705 Ultrasound, abdominal, real time with image documentation; limited single organ, quadrant 59

Kidneys: Limited Retroperitoneal 22 y.o. pregnant female presents with hematuria and left sided flank pain. 76775 Ultrasound, retroperitoneal Renal, aorta, nodes, real time with image documentation, limited A complete ultrasound examination of the retroperitoneum (76770) consists of real time scans of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality. Alternatively, if clinical history suggests urinary tract pathology, complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound. Post Void Residual Volume 74 year old male presents with frequency and dysuria, stating he has a constant urge to urinate. Evaluate for urinary retention Catheterize with foley Painless US measure post void residual 51798 Measurement of postvoiding residual urine and/or bladder capacity by ultrasound, non imaging Requires a numeric measurement Does not require an image 60

Soft Tissue Mass Used primarily to distinguish abscess from cellulitis Neck 76536 Upper Extremity 76882 Axilla 76882 Chest Wall 76604 Upper back 76604 Pelvic Wall 76857 Buttock 76857 Groin 76880 Perineum 76857 Lower extremity 76882 Lower Back 76705 Abdominal Wall 76705 CPT Assistant May 2009 page 7 Bill The Global or Apply the 26? Ultrasound codes are combined, or global, service codes that include both the technical component and the professional component Physician professional 26 Hospital technical TC What if the physician group buys the machine? Physical space, utilities, upkeep, over head, electricity DRG roll up of TC component within 72 hours of admission the 72 hour rule. 61

Hospital Strategies Start with low hanging fruit Line placement quality and safety Cardiac Activity during codes FAST Exam if + may be followed by a CT Post Void Residual non invasive Procedure Assistance abscess vs cellulitis Areas of frequent Radiology Pushback Ectopic Evaluation Biliary Studies Hospital Issues ED Limited Study & Radiology Complete CPT Theory: It is generally allowable under CPT for two different physicians to report a limited and a complete exam of the same anatomic description at different exam sessions Reimbursement reality most payers will only reimburse for the Complete when both a Complete and Limited are submitted for the same date 62

Medicare Reimbursement CPT Code Descriptor Work RVUs Total RVUs CMS Wk. Payment CMS Global Payment 76705 Abdomen 0.59 3.07 $20.80 $108.22 93308 Echo 0.53 3.45 $18.68 $121.61 76937 Line Placement 76815 Pregnancy Transabd. 76942 Needle Placement 0.30 1.02 $10.58 $35.96 0.65 2.55 $22.91 $89.89 0.67 2.07 $23.62 $72.97 Medicare Payment Issues Will typically pay 2014 MPPR discount of 25% for second study Governed by Local and National Coverage Determinations LCDs and NCDs Lists the reimbursable diagnosis codes Published on CMS website Example for 76705 922.2 CONTUSION OF ABDOMINAL WALL ACEP white paper http://www.acep.org/content.aspx?id=32182 63

Reimbursement Experience Robust use of US 1% 2% of patients Typical Professional Payments Medicare $30 Commercial $50 Contracting Issues Medicaid $9 Self Pay $6 Payments Macro View 40,000 visit ED 1 2% of patients receive US ~1500 studies annually More if additional procedure protocols $30k in revenue Non par relationships significantly improve per case revenue 64

Conclusions ED Physicians are trained to perform US studies Clinical and Residency Proficiency Experiential Pathway ED Physicians provide valuable US services that enhance patient quality and safety Rapid availability of FAST Exam Line placement We need to continue to educate Hospitals and Payers regarding the value of ED US Thanks! Michael Granovsky MD CPC FACEP President LogixHealth Mgranovsky@logixhealth.com 781 280 1575 65