Coding for the Future!

Coding for the Future! American Society of Ophthalmic Registered Nurses November 11, 2012 Presented by Joy Newby, LPN, CPC, PCS Newby Consulting, Inc. 5725 Park Plaza Court Indianapolis, IN 46220 Voice: 317.573.3960 Fax: 317.705.0131 E-mail: help@joynewby.net 2 Disclaimer This presentation was current at the time it was published and is intended to provide useful information in regard to the subject matter covered. Newby Consulting, Inc. believes the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the manual are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed. The information contained in this presentation is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Any five-digit numeric Physician's Current Procedural Terminology, Fourth Edition (CPT) codes service descriptions, instructions, and/or guidelines are copyright 2011 (or such other date of publication of CPT as defined in the federal copyright laws) American Medical. For illustrative purposes, Newby Consulting, Inc. has selected certain CPT codes and service/procedure descriptions to be used in this presentation. The American Medical assumes no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this publication. 1

ICD-9-CM Codes For Fiscal Year 2013, there are no changes to the ICD-9-CM coding system, effective October 1, 2012, due to the partial code freeze in anticipation of the transition to the ICD-10 coding system or for any new technology. There will be no new, revised, or deleted diagnosis and procedure codes effective October 1, 2012, 4 ICD-10 ICD-10 Effective October 1, 2014 New for physicians and coders Laterality need to know which side was affected Encounter need to know if it was an initial encounter, subsequent encounter or sequela Activity need to know what the patient was doing when the injury occurred Place of Occurrence need to know where the patient was when the injury occurred 5 Getting Ready for ICD-10 Greatest Problem Lack of complete diagnostic statements 6 2

ICD-10 Not a one-to-one match between ICD-9 and ICD-10 codes: Multiple ICD-10 codes equate to one ICD-9 code Multiple ICD-9 codes equate to one ICD-10 code General Equivalent Mapping (GEM) 7 Diabetic Retinopathy ICD-9 vs ICD-10 Diagnostic statement in today s charts NPDR Typical coder assigns 362.03 Nonproliferative diabetic retinopathy NOS Good Coder asks the physician the severity of the NPDR, if the patient is a type 1 or type 2 diabetic, and whether the patient has macular edema Physician updates diagnostic statement in medical record 250.50 Type 2 diabetes mellitus not stated as uncontrolled with ocular manifestation 362.06 Severe nonproliferative diabetic retinopathy 362.07 Diabetic macular edema 8 Diabetic Retinopathy ICD-9 vs ICD-10 Diagnostic statement needed October 1, 2013 Type 2 diabetes, using insulin, with severe nonproliferative diabetic retinopathy with macular edema All coders assign E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema Z79.4 Long term (current) use of insulin 9 3

Cataract ICD-9 vs ICD-10 Diagnostic statement in today s charts Cataract ( CAT ) Typical coder assigns 366.10 Senile cataract, NOS Good Coder asks the physician for more specificity about the cataract and physician updates diagnostic statement in medical record 366.16 Nuclear sclerosis 10 Orbital Fracture ICD-9 vs ICD-10 Diagnostic statement in today s chart Orbital fracture Typical coder assigns 802.8 Other facial bones, closed Orbit: NOS part other than roof or floor Good coder questions physician about the fracture and physician updates diagnostic statement in medical record 802.6 Orbital floor (blow-out), closed 11 Orbital Fracture ICD-9 vs ICD-10 Diagnostic statement needed October 1, 2013 Initial encounter closed orbital floor fracture, batter hit by baseball in a public park S02.3XXA Fracture of orbital floor, initial encounter for closed fracture W21.03XA Struck by baseball, initial encounter Y92.320 Baseball field as the place of occurrence of the external cause Y92.830 Public park as the place of occurrence of the external cause 12 4

Eye Codes vs E/M Codes One of the most difficult coding decisions facing ophthalmologists is when to use an eye code vs an E/M code Documentation requirements General Ophthalmological Services better known as eye codes General definitions E/M codes Structured history and examination requirements 13 New Patient vs Established Patient Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. 14 Eye Codes Two levels of care for new and established patients Intermediate New patient 92002 Established patient 92012 Comprehensive New patient 92004 Established patient 92014 15 5

Intermediate Eye Code Definition An evaluation of a new or existing condition complicated with a new diagnostic or management problem not necessarily relating to the primary diagnosis, including history, general medical observation, external ocular and adnexal examination and other diagnostic procedures as indicated; may include the use of mydriasis for ophthalmoscopy 16 Comprehensive Eye Code Definition A general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs. 17 Comprehensive Eye Code - Initiation of Diagnostic and Treatment Programs Prescription of medication Initial recommendation for over-the-counter medication Arranging for special ophthalmological diagnostic or treatment services Requesting consultations from other physicians Ordering laboratory procedures Ordering radiological services Writing a prescription for lenses 18 6

Evaluation and Management Codes E/M Different code sets for place of service, including, but not limited to: Office and other outpatient Emergency Department Observation Inpatient hospital Inpatient nursing facility 19 E/M Codes - Components History Examination Medical decision making Counseling Coordination of care Nature of presenting problem Time 20 Documentation Documentation in the medical record should be complete, clear, and legible Who is the patient When was the service performed Who performed the service What service was performed Reason why the service was performed A key to common terms and abbreviations used in specific practices could assist the reviewer in interpreting the medical record and should leave little doubt as to what the provider documented 21 7

History of the Present Illness The history portion refers to the subjective information obtained by the physician or ancillary staff. Only the physician can perform and document the HPI Ancillary staff can perform and document the review of systems and past, family, social history 22 History of the Present Illness Q&A If the nurse takes the HPI, can the physician then state, HPI as above by the nurse or just HPI as above in the documentation? No. The physician billing the service must document the HPI. 23 Documentation Requirements When Using Scribes Most Medicare Administrative Contractors have specific documentation requirements and the following elements will be included: The scribe must be present during the encounter and documents in real time the actions and words of the physician as they occur Scribes may not interject their own observations or impressions into the medical record The physician is ultimately responsible for all documentation and must verify that the scribe s note accurately reflect the service provided 24 8

Documentation for Scribes Cont d Documentation instructions for scribes for the majority of MACs will also include a variation of the following requirements Document the name of the person "acting as a scribe for Dr. X." Physician co-signs the documentation indicating the note is an accurate record of his/her words and actions during that visit Some MACs require the physician append a statement indicating the information has been reviewed and represents an accurate record of the encounter 25 Office of Inspector General 2012 Work Plan Evaluation and Management Services: Trends in Coding of Claims E/M services from 2000-2009 Identify providers that exhibited questionable billing for E/M services in 2009 Medicare paid $32 billion for E/M services in 2009, representing 19 percent of all Medicare Part B payments. Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide 26 Office of Inspector General 2012 Work Plan Cont d Evaluation and Management Services: Potentially Inappropriate Payments Review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service based upon the content of the service and have documentation to support the level of service reported 27 9

Comprehensive Error Rate Testing Program (CERT) Produces a national Medicare fee-for-service error rate compliant with the Improper Payments Information Act. The CERT process is very simple: CERT contractor randomly selects a sample of submitted claims Medical records requests Review claims and medical records for compliance with Medicare coverage, coding, and billing rules Adjust overpaid/underpaid claims 28 CERT Findings The 2011 National Medicare Fee for Service (FFS) information Total Payment $336.4 billion Total Improper Payment Rate 8.2% Physician/Lab/Ambulance improper payment rate 9.2% Improper Payments $28.8 billion Incorrect E/M coding accounted for 12.2% of the overall Medicare FFS improper payment rate 29 2011 CERT Error Findings Medical necessity 4% of total errors Incorrect coding 35% of total errors Evaluation and Management (E/M) services down coded one or multiple levels based on documentation submitted Insufficient Documentation 61% of total errors 30 10

CERT Errors When the CERT contractor determines the service was incorrectly paid, they are scored as errors No documentation Provider never responded to CERT records request 31 Insufficient Documentation - Illegible Signature Physician billed 99205 CERT received a progress note with illegible physician signature that did not have legible identification of the individual who provided or documented the service. Submitted documentation was missing a valid provider signature. 32 Insufficient Documentation - Altered Record Physician billed 99204 CERT initially received progress notes with no signature. Upon request for additional information, the CERT received duplicate information with the addition of physician s signature. 33 11

Eye Code - Insufficient Documentation - Missing Signature Physician billed 92014, 67028 and J9035 (Avastin) CERT received copy of the physician's progress note for the comprehensive ophthalmological services that was not signed. Following a request for the missing information, CERT received documentation of eye exam, drawings, and Avastin documentation with illegible identifiers on submissions. The CERT also received a copy of a signed letter on professional letterhead to a colleague relating the beneficiary's office examination and procedures for DOS. 34 Insufficient Documentation Missing Signature Test Interpretation Physician billed 92083 and 92135 X2 CERT received a signed progress note with orders for the visual field and ocular coherence tomography CERT also received unsigned test interpretations 35 Sample Signature Attestation Statement Beneficiary Name I _(print full name of the physician/practitioner), hereby attest that the medical record entry for (date of service) accurately reflects signature/notations that I made in my capacity as (insert provider credentials, e.g. M.D.) when I treated /diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability. Physician Signature Date 36 12

Insufficient Documentation Signature Attestation Statement Not Dated Physician billed 99214 CERT initially received progress notes with no signature. Upon request, the CERT received a Signature Attestation Statement signed by the physician. Signature requirements were not met because the Signature Attestation Statement was not dated by author. 37 Late Entries in Medical Documentation The physician should document the service immediately or as soon as practicable after the service is rendered Missing information Create an addendum/late entry Date should reflect the date of the addendum/entry 38 Insufficient Documentation Late Entry Physician billed 99213 CERT received documentation created following the request for medical records. Physicians are encouraged to add a late entry to their documentation when all relevant information was not included in the notes created at the time of service or within a few days of the date of service Late entries will not be considered when determining whether the medical record supports the services include on the claim 39 13

Insufficient Documentation Illegible Handwriting Physician billed 99213 Documentation submitted was partially illegible in the note and signature. The reviewer was only able to decipher the exam portion that had a typed table that the provider periodically checked. The information was reviewed by the CERT s medical director to determine if the legible documentation supported a lower level of care or 99499. It was deemed too overall illegible to reasonably allow any payment for the visit code. In addition, the provider was not otherwise identified in the header, footer, or by addressograph. 40 Medical Necessity Not Documented Cataract Extraction with IOL Physician billed 66984 The physician initially submitted a copy of operative report for cataract surgery in the right eye. The information was missing the clinical documentation to support that an ophthalmic examination of the right eye was done, including patient history; assessment of functional status; acuity and refraction; external exam; testing, i.e., dilated examination of the fundus, slit lamp, ocular motility, glare test, confrontation fields, etc.; biometry for lens power calculation; and that the beneficiary met the criteria needed to support the medical necessity for lens removal and implantation of intraocular lens. 41 Medical Necessity Not Documented Cataract Extraction with IOL Cont d Upon request for additional information, the CERT received a duplicate copy of operative report and a copy of follow up visit, 1 week following left eye surgery with the intent to perform cataract on right eye, and a copy of a follow up post op of 1 day for right eye. The same documentation was submitted following a telephone request for additional documentation. Not submitted was the examination and test results and lens power calculations that would support the medical necessity for cataract surgery with lens removal and a new lens implanted per LCD requirements. 42 14

Insufficient Documentation - Medically Unnecessary Visual Field Physician billed 92014, 92015, 76514, 92135 and 92081 Received progress notes including ultrasound test and ophthalmic scan No reference is made to an automated visual field in the progress notes No order for the visual field and missing the physician s interpretation of the test 43 Incorrectly Coded E/M Code Physician billed 99214 Requires 2 of 3 components (detailed history, detailed exam, and moderate complexity medical decision making) Documentation submitted supports code change to 99213 Expanded problem focused history, detailed eye exam, and straightforward medical decision making. Essentially healthy pseudophakic lens and Return 1 year 44 Incorrectly Coded Eye Code Physician billed 92014 comprehensive eye code Submitted documentation includes progress notes with eye exam, history components and a patient questionnaire with the statement, Bothered by bright sunlight. (patient needs sunglasses). Patient questionnaire indicates medication for diabetes and HTN. Diagnosis submitted is senile nuclear cataract with plan for follow-up in 6 months Per CPT, comprehensive ophthalmological service always includes initiation of diagnostic and treatment programs 45 15

Incorrectly Coded Eye Code - Cont d Missing documentation to support comprehensive level of service for eye examination billed Change code from 92014 comprehensive level to 92012 intermediate level of service Per CPT, intermediate level services describe an evaluation of a new or existing condition complicated with a new diagnostic or management problem 46 Thanks for inviting me!!! 47 16