Best Practices in Billing and Coding. Janet Bull, MD, FAAHPM, HMDC Four Seasons

Best Practices in Billing and Coding Janet Bull, MD, FAAHPM, HMDC Four Seasons

Disclosure o Salix Pharm Scientific Advisory Board o Grant Funding CMS Innovations, HRSA, AHRQ

Disclaimer o o o The information enclosed was current at the time it was prepared for presentation. Medicare and other payer policy change frequently; links to the source documents have been provided for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. This presentation is a general summary that explains certain aspects of the Medicare Program and other reimbursement and compliance information, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

Objectives o Understand the auditing process o Understand the basics of billing by complexity o Discuss when to use time vs complexity in billing o Gain an understanding of the importance of educating providers and instituting a compliance program

What is our current reality? o OIG 2014 Work Plan Focus on Medicare Physician Part B Focus on GIP level of care Focus on duplicative billing for medications Part D and NH

Audit Triggers o Random Sampling CMS is required to audit 10% of its providers o Focused Medical Review each quarter Medicare reviews specific CPT codes and figures the mean for each of the codes looks for outliers o Complaints by staff False Claims Act o Patient complaints required by law to investigate

Audit Triggers o High number of billings per provider o Overutilization of one procedure code o Failure to collect the co-pay for Medicare o Submitting unspecified diagnosis on a consistent basis

Recent 99233 Probe Error Rate o NC 45% CDR o SC 47% CDR o VA 45% CDR o WVA 52% CDR Incomplete or no documentation 70% Down coded 15% Illegible 7% Will be extended to ALL other states

50% of time physicians NOT billing correctly!

And recognize. o Documentation must support coding and billing If it s not documented, wasn t done If it s not legible it doesn t count If it s not signed it s not acceptable

Coding is determined by o Who are you? o Who is the patient? o Where is the patient? o Time or complexity? o Nuances to our field

Who are you? o Hospice employed physician? o Hospice contracted physician? o Not hospice employed physician who is hospice AOR? o Not hospice employed physician who is consulting physician? o Nurse practitioner? o Physician assistant?

Hospice Provider Billing AOR * o Direct patient care related to terminal diagnosis If MD employed/contracted by hospice Hospice bills Medicare Part A. Billings paid at 100% rate by MAC (ie, Palmetto) If MD not employed by hospice bill Medicare part B with a GV modifier IF NP acting as attending (patient must be informed and choose NP) Medicare Part A Billings paid at 85% of physician rate * Attending of record on election statement

Hospice Attending of Record o If AOR Not employed/contracted by hospice they bill Medicare Part B Use GV modifier if care related to hospice Use GW modifier if care unrelated to hospice Can bill for Care Plan Oversight If your physicians are complaining that they are NOT getting paid, ask them if they are using the GV modifier.

Care Plan Oversight by PMD o Covers a 30-day period o Review of care plan, etc. o Only billable by attending physician not employed by hospice o Activities and time spent must be documented o CPT code 99377: 15-29 minutes/month o CPT code 99378: >30 minutes/month

Palliative Care Provider Billing o All billings Medicare Part B o Billings paid based on physician fee schedule Medicare pays 80% of allowable o Must show additional 20% billed to patient or insurance/medicaid o NP/PA receive 85% of physician rate o Can bill as attending or consulting o Need order for PC consult (hospital and NH) o Paid by the MACs (Medicare Administrator Contractor)

o Who are you? o Who is the patient? o Where is the patient? o How should I bill? Complexity or Time? o Nuances to our field

Who is the Patient? o New patient has not been seen by the physician or the physicians in the same sub specialty group within the past 3 years. o Established patient has received face to face service from the physician or member of the physicians group within 3 years. Example: Patient discharged from PC seen 2 years later in the clinic setting established pt

Quiz Time A hospice consult is requested on a COPD patient who has been discharged home after a prolonged hospitalization for respiratory crisis. Patient was followed by the palliative care team in the hospital. Hospice admits and physician visits patient at their home and performs a 90 minute H&P Both HPC care teams are employed by the same organization and use the same tax ID status. What should you bill?

And the answer is. A. Bill new home patient 99345 B. Bill established home patient 99350 C. Bill established patient with prolonged service code 99350 + 99354 D. Don t bill

o Who are you? o Who is the patient? o Where is the patient? o How should I bill? Complexity or Time? o Nuances to our field

Location Determines CPT Code o Inpatient Skilled Nursing Home/ Hospital/GIP Hospice Initial vs. Subsequent o Outpatient/ALF/Domicillary/Home: New vs. Established

Inpatient Billing o Hospital, SNF, GIP IPU Initial as of 1/2010 this code is used by the admitting physician, AND the consultants, since there are no consultant codes. Attending uses modifier AI Subsequent - used for all other visits in which the physician is participating in the ongoing management of the patient s condition.

Outpatient Billing o Home, ALF, Domiciliary, Clinic or Office setting New first visit by physician within 3 years of being seen by anyone in the practice Established any visit that is not new

Skilled Nursing Facility o Bill initial codes (99304-6) in the Nursing Home o If Admitting Physician - use the modifier AI o Most Skilled Nursing Facilities require a physician to be the Attending (cannot use mid-levels as attending) o Nurse practitioners can now bill initial patient visits in the NH setting fully operational as of 1/1/12

o Who are you? o Who is the patient? o Where is the patient? o How should I bill? Complexity or Time? o Nuances to our field

Quiz What are you currently basing your coding on - time or complexity? A. 100% time B. 100% complexity C. > 50% time D. > 50% complexity How should you bill?

Types of Coding o There are two methods for determining CPT Levels Intensity (Component or Element coding) Time Intensity trumps time!

Time vs. Complexity o Need to understand both well o Common mistake is to just bill on time o When >50% time is spent in coordination and counseling, time code should be used. (face to face time in outpatient setting/face to face + floor time in inpatient unit)

Complexity Trumps Time o If you complete a complex visit and fulfill/exceed all the key components in less than the typical time you still bill at the higher code. o Example - Subsequent hospital care 99232 typically 25 minutes 99233 typically 35 minutes I meet the key components for a 99233 in 15 minutes so I bill the 99233.

Evaluation & Management Codes First, determine which CPT E&M code to use Location of the patient New vs. Established (outpatient) Initial vs. Subsequent (inpatient) Then choose right level of service Most often at levels 3, 4 or 5 in our world Based on documentation of Key Components: 1. History 2. Exam, and 3. Medical decision making OR Time = counseling/coordination of care

Billing by Complexity Key elements in selection of level o History Problem focused Expanded problem focused Detailed Comprehensive o Physical same as above o Medical decision making Low, Moderate, High

Key Component 1: History History = HPI ROS Review of Systems PFSH past hx, past family, past social Hx Problem Focused, Expanded PF, Detailed or Comprehensive

Component 1 History/HPI a. Chief Complaint (Reason for Visit) is required at all levels (establishes medical necessity) b. History of Present Illness (HPI): Status of 3 Chronic problems OR Elements: 1. Location body area 2. Quality sharp, burning, deep 3. Severity intensity of illness 4. Duration how long symptoms last 5. Timing relation to events 6. Modifying factors precipitating or alleviating factors 7. Associated signs (objective evidence) or symptoms (subjective evidence)

Chief Complaint o Concise statement describing symptoms, problems, condition, physician recommended return, or other factor that is the reason for the encounter. o Chief complaint must be explicitly stated or easily inferred from documentation: Severe abdominal pain for past 8 hours (explicit) Follow up on medication adjustment o Gives a reason for the visit helps to establish the Medical Necessity.

History of Present Illness o Chief Complaint is required at all levels Reason for the encounter/visit Supports the medical necessity o History of Present Illness elements: Location body area Quality sharp, burning, deep Severity intensity of illness Duration how long symptoms last Timing relation to events Modifying factors precipitating or alleviating factors Associated signs (objective evidence) or symptoms (subjective evidence)

Selecting Level of History To qualify for a given level of history, all 3 elements in the history table must be met. HPI ROS PFSH Level Brief (1-3 elements) n/a n/a Problem Focused Brief (1-3 elements) Problem Pertinent (system directly related to problem identified in HPI) N/A Expanded Problem Focused Extended (4 or more elements) Extended (system directly related to problem identified in HPI & a limited # of add l systems - 2-9 total Pertinent (1 or all 2 of the PFSH depending on E/M category) Detailed Extended (4 or more elements) Complete (system directly related to problem identified in HPI + all add l systems or a minimum of 10 systems) Complete (2 or all 3 of the PFSH depending on E/M category) Comprehensive

ROS Guidelines Complete = ten (10) systems Documentation should include: o Patient s pertinent positive and negative responses Must be documented for each system related to the problem Those systems with positive or pertinent negative responses must be individually documented o For the remaining systems, a notation indicating all other systems are negative or the remaining # systems are negative is permissible

Component 1 History/Review of Systems Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic ROS Pertinent (1), Extended (2-9) or Complete (>10)

Component 1 History/Past, Family and Social History Consists of: Past medical history (the patient s past experiences with illnesses, operations, injuries and treatments); o Family history (a review of medical events in the patient s family, including diseases which may be hereditary or place the patient at risk) o Social history (an age appropriate review of past and current activities smoking, alcohol, work risks). PFSH Either Pertinent (just one) or Complete (2 to 3)

o Component 2 = Physical Exam 1995 Guidelines Comprehensive: Gen l multi-system (8+ OS/BA) or complete single system organ system exam. Body Areas: Head, including face Neck Chest, incl. breasts & axillae Abdomen Genitalia, groin, buttocks Back, incl. spine Each extremity Organ Systems: Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic

Component 2 - Exam Problem Focused A limited exam of the affected body area or organ system (1+ BA/OS) Expanded problem focused Detailed Comprehensive A limited exam of the affected body area or organ system and any other symptomatic/related area(s)/system(s) (2-7 BA/OS) An extended exam of the affected body area(s) or organ system(s) and any other symptomatic or related area(s)/system(s) (2-7 BA/OS) more detailed Gen l multi-system (8+ BA/OS) or complete single organ system exam.

Component 3 Complexity of Medical Decision Making Complexity of Medical Decision-Making: Risk assessment Data ordered or reviewed Diagnosis and Management

TABLE OF THE RISK OF COMPLICATIONS, MORBIDITY AND MORTALITY Level of Risk Presenting Problems Diagnostic Procedures Ordered Management Options Selected Minimal Level I - II *One self-limited problem, e.g., cold, insect bite, tinea corporis *Lab tests requiring venipuncture *Chest X-rays *Urinalysis *Ultrasound [e.g., echocardiography] *KOH prep *Rest *Gargles *Elastic Bandages *Superficial Dressings Low Level III *Two or more self-limited or minor problems *One stable chronic illness [e.g., wellcontrolled hypertension or non-insulindependent diabetes, cataract, BPH] *Acute uncomplicated illness or injury [e.g., cystitis, allergic rhinitis, simple sprain *Physiologic tests not under stress [e.g., pulmonary function tests] *Non-cardiovascular imaging studies with contrast [e.g., barium enema] *Superficial needle biopsies *Clinical lab tests requiring arterial puncture *Skin biopsies *Over-the-counter drugs *Minor surgery with no identified risk factors *Physical therapy *Occupational therapy *IV fluids without additives Moderate Level IV *One or more chronic illnesses with mild exacerbation, progression or side effects of treatment *Two or more stable chronic illnesses *Undiagnosed new problem with uncertain prognosis [e.g., lump in breast] *Acute illness with systemic symptoms [e.g., pyelonephritis, pneumonitis, colitis] *Acute uncomplicated injury [e.g., head injury with brief loss of consciousness] *Physiologic tests under stress [e.g., cardiac stress test, fetal contraction stress test] *Diagnostic endoscopies with no identified risk factors *Deep needle or incisional biopsy *Cardiovascular imaging studies with contrast and no identified risk factors [e.g., arteriogram, cardiac catheterization] *Obtain fluid from body cavity [e.g., lumbar puncture, thoracentesis, culdocentesis] *Minor surgery with identified risk factors *Elective major surgery [open, percutaneous or endoscopic] with no identified risk factors *Prescription drug management *Therapeutic nuclear medicine *IV fluids with additives *Closed treatment of fracture or dislocation without manipulation High Level V *One or more chronic illnesses with severe exacerbation, progression or side effects of treatment *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 w/potential threat to self or others, peritonitis, acute renal failure *An abrupt change in neurologic status [e.g., seizure, TIA, weakness or sensory loss] *Cardiovascular imaging studies with contrast with identified risk factors *Cardiac electrophysiologic tests *Diagnostic electrophysiologic tests *Diagnostic endoscopies with identified risk factors *Discography *Elective major surgery [open, percutaneous or endoscopic] with identified risk factors *Emergency major surgery [open, percutaneous or endoscopic] *Parenteral controlled substances *Drug therapy requiring intensive monitoring for toxicity *Decision not to resuscitate or to de-escalate care because of poor prognosis One criteria must be met or exceeded.

Complexity of Medical Decision Making Risk Data Dx/Mgt MDM Low 2 2 low Mod 3 3 mod High 4 4 high Need to meet or exceed 2 of the 3 elements for any given type of MDM

Coding Using Components Σ History + Examination + Complexity of Medical Decision-Making = the E&M Level

Coding Pearls o Chief complaint reason for visit o Hx, Exam & MDM all subsequent visits and established visits only need 2 out of 3 key components to bill for a particular level of care o HPI all subsequent visits only need interval history (no need for PMH, SH, FH) o The most important component is medical complexity assessment and plan

Extender codes o The Prolonged Physician Service with Direct Patient Contact series (99354-99357) are used when a physician provides prolonged service involving direct (face to face) patient contact that is beyond the usual service (typical time) in either the inpatient or outpatient setting. o The prolonged time does not have to be continuous but in-out times must be recorded o Each code is reported separately in addition to appropriate E/M service code

Prolonged Service Codes o Inpatient 99356 Companion code to E/M Use for first 30 min over time threshold Direct face to face time (CPT floor time)* Each additional 30 beyond 45 min - 99357 o Outpatient 99354 Companion code to E/M Direct face to face time Each additional 30 min beyond 45 min - 99355 * Medicare requires

Adding prolonged service codes to your E/M code that is based on components because you spent a lot of time is different than time based coding

Quiz Time o Subsequent hospital visit for lung ca pt with nausea. You spent 10 min reviewing notes, 15 min obtaining detailed GI history, and 5 min with exam. You diagnose gastroparesis and spend 25 minutes discussing etiology/ treatment. Bill? Total time 55 min A. Time based billing 99233 + 99356 B. Complexity based with extender 99232+99356 C. Complexity visit 99232 Subsequent visit codes 99231 15 min 99232 25 min 99233 35 min

Quiz Time o Time vs Complexity 99232 base code (typical time 25 min) o Total time = 55 min <50% counseling o Time over base code 55-25 = 30 o Bill extender code since 30 min over threshold (25 +30) 99356

Time Based Coding 50% rule > 50% time spent in coordination and counseling of care Documentation required about how time was spent

Providing detail via a checklist: Counseling may include discussion of: Diagnostic results, impressions, and/or recommended diagnostic studies Prognosis Risks and benefits of management or treatment choices Instructions for management (treatment and/or follow-up) Importance of compliance with chosen management (treatment) options Treatments initiated or adjusted Risk factor reduction Patient and family education Must documented the time and how it was spent And MUST say more than 50% of [ amount] of time was spent in counseling and coordination of care

What is time? o Time is calculated differently in the hospital and nonhospital settings o Floor/unit time for institutional setting o Face-to-face time only for office, home

Time-Based Coding - Outpatient Face to Face Time for office and other outpatient settings face-to-face time is defined as only that time which the physician spends face to face with the patient and/or family. Face-to-Face Time is considered a valid proxy for the total work done before, during, and after the visit. Therefore, Non face-to-face time (pre- and postencounter time) is NOT included in the time component for outpatient work (assumed to be included in the CPT level).

AMA vs. CMS o The AMA sees F2F with the surrogate as the same as F2F with the patient o CMS does not and has not reimbursed for time that is not F2F with the patient o This is an example of the CPT definition not being fully adopted by CMS o This is also an example of the Golden Rule the one with the Gold makes the Rules.

Addendum Slides

Nuances in HPC Billing o Incident to Palliative care o Shared/split visit Palliative care o Concurrent care o Discharge codes o Transition codes

Incident to Billing o Cannot use in the hospital/nh setting o Initial visit must be performed by physician o Typically used in a clinic or office situation o Physician must be physically present and act in a supervisor role o Reimbursement based on 100% of physician rate and billed under physician provider number * Great for PC Clinic

Split/Shared E/M Service o Hospital Inpatient/Outpatient/ ED Setting When the E/M is shared between a physician and NPP from the same group practice, and the physician provides any face-to-face portion of the E/M encounter, service may be billed under either s PIN/NPI. Physician documentation of something from at least one E/M key component. Can use with PC fellows (billing under attending NPI) Once again, Palliative Care only - not hospice.

Split/Shared E/M Service o Office/Clinic Setting When an E/M service is a shared/split encounter between a physician and a NP/PA the service is considered to have been performed incident to if the requirements for incident to are met and the patient is an established patient. Billing may be done under the physician s provider number. If incident to requirements are not met, the service must be billed under the NP s/pa s PIN/NPI, and paid at 85% of the fee schedule

Examples of Shared/Split Visits o If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit on the same day, physician or NPP may report the service for billing. Patient seen. Breath sounds more distant today. Agree with above plan. <signature, MD/DO> o In the office setting the NPP performs a portion of an E/M encounter & the physician completes the E/M service. If the incident to requirements are not met, service must be reported using the NP s NPI.

NPs in Hospice/Palliative Care o NPs may bill Part A Medicare Hospice and be reimbursed IF they are listed as the Attending of Record at the time of election. o NPs typically may not serve as the Attending of Record in a NH o NPs can do the face to face encounter which in and of itself is non billable

PAs in Hospice/Palliative Care o Cannot be Attending of record for hospice o Cannot ever bill on a hospice patient o Cannot do the face to face encounter o Billing in palliative care is the same as NPs a great resource for PC programs

Discharge Codes Codes used to report the total duration of time spent by a Physician for final hospital discharge of a patient. The codes include, as appropriate, final exam of the patient, discussion of the hospital stay (even if the time spent by the physician on that date is not continuous), instructions for continuing care to all relevant caregivers, and preparations of discharge records, prescriptions and referral forms. 99238 30 minutes or less 99239 more than 30 minutes

CPT on D/C Services Clarification on Hospital D/C Services (99238/39) from the AMA s cpt Assistant, November 2009, Volume 19 Issue 11: Q: Can a physician bill for a hospital death summary if he or she is not present in the hospital at the time of the patient s death? If yes, what would be the CPT code(s) to report? A: The hospital discharge services codes may be used to report discharge services to patients who die during the hospital stay. The attending physician may be needed to perform the final examination of the patient, discuss the hospital stay with the family members prepare records completion of a death certificate in the office is not reported as a discharge service.

Palliative Care Only o Transition Codes o Chronic Care Management Codes

Transition Codes o Require communication with patient/cg within 2 business days of discharge o Includes medication reconciliation o 99495 F2F within 14 days of discharge/ pts of moderate complexity o 99496 F2F within 7 days of discharge/high complexity o Payments about double standard visit o Can only be billed by one provider one managing the transition

Chronic Care Management Code o Two or more chronic conditions with exacerbations, decompensating, or functional decline. o Comprehensive care plan established, implemented, revised, or monitored o 99490 20 min clinical staff time directed by physician or other HCP

You caught a virus from your computer and we had to erase your brain. I hope you ve got a back-up copy!

Common Pitfalls - Assumptions o Most Common Pitfall! Executive Leadership assumes Physicians know how to document They run their own private practice, they must know how to do it Documentation from a coding/documentation compliance perspective is not inherent to Physicians!

Pearls Regarding Billing o Gain understanding of most common codes o Use templates for documentation o Use billing cheat sheets o Have experts in house o Develop QAPI o Use outside consultants

Best Practices in Billing/Coding o Identify the Internal Experts (you may be surprised) o Identify Physician Champions of Compliance o Education For Providers For admin and billing staff o Documentation is the Key Provide Cheat Sheets (trying to teach new tricks!) o QAPI o Consider Outside Audit Mock Payer Review

OIG s Physician Compliance Guidance In the Third-Party Medical Billing Compliance Program Guidance, the OIG recommended that a baseline, or snapshot, be used to enable a practice to judge over time its progress in reducing or eliminating potential areas of vulnerability. This practice, known as benchmarking, allows a practice to chart its compliance efforts by showing a reduction or increase in the number of claims paid and denied.

Compliance Guidance o The practice s self-audits can be used to determine whether: Bills are accurately coded and accurately reflect the services provided (as documented in the medical records); Documentation is being completed correctly; Services or items provided are reasonable and necessary; and Any incentives for unnecessary services exist.

Auditing/Monitoring o What type of quality checks do you have in place? Assessing physician/npp documentation Assessing contract physician documentation o YOU are billing for these services. Are they being documented appropriately? Annual Code Changes o Changes to coding rules Annual Rule Changes o Are we in compliance today?

What Are You Looking For? o Evaluation & Management Consultation vs. Referral Levels of E/M service o Can you read it? o Can you tell who provided the service? o Can you tell in what setting service was provided?

Education Needs o Recognize the importance of continued education o Educate physicians/npps as new hires! o Regulations change frequently have a plan to keep up with changes o Develop templates that meet coding criteria o Use billing/coding master guide sheets

Agency Education Needs o Assign someone to own o Knowledgeable about provider billing o Understand nuances of hospice/pc billing o Review new transmittals from Medicare o Review agency provider billing/coding o CME yearly

Assessing Providers o Track code by providers see who are your outliers on both ends o Know the rules for the most frequent E/M codes you use o Develop benchmarks for your agency

Summary Slide Isn t this painful?! I need palliation Legibly document what you do and how for how long it takes to do it! Think Complexity first - but can use time-based coding given the unique priority of communication in our field Know when and how to use extender codes Recognize the importance of accuracy in this area audit internally for compliance! Bill for the work you do!

Questions? jbull@fourseasonscfl.org