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Disclaimer
This material is designed to offer basic information for coding and billing and is presented based on the experience, training and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the presenter does not accept any responsibility or liability with regards to errors, omissions, misuse, or misinterpretation. This presentation and handout is intended as an education guide only.
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Agenda
Government Enforcement Activities CMS: Recovery Audit Contractors Program (RACs) Top Physician Audit Targets & E/M Risk Areas
How to Correctly Choose the Correct Code and Avoid Under-Coding and Under-Documentation
Medical Necessity History taking (HPI, ROS and PFSH) Exam (medical necessity) Medical Decision Making (Diagnosis, Data and Risk)
Correctly Document and Bill Incident to Shared Visits Consultations
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Additional Handouts
1. E/M Documentation Guide & Training Checklist
2. Documentation Tips for Common Physician CPT Coding Issues
3. Checklists for
Observation Versus Inpatient Services (3)
Incident to & Shared Services
4. Consultations Coding
5. First Coast Service Options 3rd Quarter 2006 Bulletin “Requirements for the Payment of Medicare Claims-A selection of Some Important Criteria”
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Increase in Improper Payments
Medicare is among the top three Federal Programs with improper payments.
Office of Management and Budget (OMB) report, November 17, 2009:
$98 billion in improper payments in FY 2009;
over half ($54 billion) coming from the Medicare and Medicaid program.
37.5 percent increase over the $72 billion in 2008
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Increased Government Scrutiny
Program Safeguard Contractors – Zone Program Integrity Contractors (ZPIC)
Medicare Strike Force
Comprehensive Error Rate Testing (CERT)
Widespread Probe Audits
Ie. Planned Widespread Service Specific CPT 99213 (All specialties)
Recovery Audit Contractors (RACs)
Medicaid Integrity Contractors (MIC)
Stop Medicare Fraud (SMF)
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RACs Identified $1B
The RAC demonstration ended in March 2008, but the Tax Relief and Health Care Act of 2006 (Section 302) instructs CMS to use RACs to identify Medicare underpayments and overpayments nationwide by 2010.
On July 11, 2008 CMS issued the RAC Evaluation Report to Congress identifying $1.03 billion in improper Medicare payments (March 2005 to March 2008)
Most of the improper payments identified occurred when healthcare providers submitted claims that did not comply with Medicare‟s coverage or coding rules.
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RAC Permanent Program
Recovery Audit Contractor (RAC) Permanent Program was effective 10/1/08 and a major concern is their ability to extrapolate.
Practice (# of MDs) Max records every 45 days:
Solo Practitioner 10
Partnership (2-5MDs) 20
Group (6-15MDs) 30
Group (16+ MDs) 50
Best Defense: Good Documentation!
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How Do Physicians Get Selected for Audit?
E/M services are estimated to account for $40B in overpayments.
Random audit, for example all level 4 and 5 visits.
Claim specific, for example OIG on Consults (March 2006 report identified $1.1B overpayment).
High number of work RVUs when compared to peers.
Outlier when utilization (bell curve) compared to peers.
Code levels audits were not part of the RAC demonstration, but the permanent program will include physician E/M services.
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Areas of Vulnerability
Areas of vulnerability for physician practices includes any services provided in the hospital setting. If the service is on the RACs target for hospital services,
they will already have reviewed the physician‟s record as part of the hospital documentation review.
This includes inpatient admissions that should have been observation.
Physician coding issues identified on: CERT audits; and
Recent OIG work plan reviews.
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CERT Top 5 Up-Coded E/M Services
# CPT Description Projected
Improper
Payment
Error Rate
1 99214 Established Office Visit (Level 4) $ 244K 5.5 %
2 99233 Subsequent Hospital Visit(Highest Level)
$ 220K 16.8 %
3 99215 Established Office Visit (Level 4) $ 129K 18.6 %
4 99244 Office Consultation (Level 4) $ 120K 17.5 %
5 99223 Initial Hospital Care (Highest Level)
$ 107K 12.7 %
Source: CERT Data (Improper Medicare Fee For Service Payment Report May 2008)11
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Different Coding Pattern Among Physicians in Same Practice
The conflicting distribution of established office visits between the two physicians points to disparate coding methods and appears to be an anomaly.
This type of conflict is often seen by carriers as an opportunity to conduct a review of the practice*
-20.00%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
99211 99212 99213 99214 99215
Pr actice
National
`
-20.00%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
99211 99212 99213 99214 99215
Pr actice
National
`
*One physician can get the whole practice audited.
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“Presumptive Coding”
Only using one level of an E/M service in a category, will increases the risk for audit
The physician is using CPT 99214 385% more often than his national compare group, significantly increasing his risk for third-party audits.
-20.00%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
99211 99212 99213 99214 99215
Pr actice
National
`
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Compliance Risk-
Are You an Outlier?
0
10
20
30
40
50
Dr. Adams Dr. Jones Dr. Smith Dr. Thomas
Modifier -25 Usage
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E/M Risk Areas
Distinguish Between Code Categories Using Admission codes instead of Observation services when the
patient does not meet inpatient criteria
Over-Coding and Under-Coding Medical Necessity
Under-Documentation of High Level Codes Comprehensive Exam History: ROS & PFSH
Documentation for Time-Based EM Codes Distinguish Between Consultations and Referrals
CMS has eliminated Consultations codes effective 1/1/10
Documentation for “Incident-to” and Shared Visit Rules
See Handout for Documentation Tips!
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Physician Certification on Claim Form
“Physicians are required to comply with all the applicable statutes, regulations and guidelines in order to be reimbursed by Medicare Part B. They have a duty to be knowledgeable in the statutes, regulations and guidelines regarding coverage for Medicare services.”
Physicians certify that they are knowledgeable of Medicare‟s requirements in the provider enrollment form they submit and each time they submit CMS 1500 claim form, or have such form submitted on their behalf.
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Physician Certification on Claim Form
Services performed were medically indicated and necessary for the health of the patient;
Were personally furnished or incident to the physician‟s professional service by an employee under immediate personal supervision, except as otherwise expressly permitted by the regulations. For services to be considered as “incident” to a physician‟s professional
service, 1) they must be rendered under the physician‟s immediate personal
supervision by his/her employee, 2) they must be an integral, although incidental part of a covered physician‟s
service, 3) they must be of kinds commonly furnished in physician‟s offices, and 4) the services of non-physicians must be included on the physician‟s bills.
Any one who misrepresents or falsifies essential information to receive payment from Federal funds requested by this form may upon conviction be subject to fine and imprisonment under applicable Federal laws.
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Under-Documentation
Issue Under-documenting (E/M) service when the nature of the presenting problems and severity of illness supports a higher level code.
Solution Document the required history, exam and medical decision-making to support the code selected.
Code selection is usually predictable within the first few moments and during the history taking of the patient encounter.
Conditions posing an immediate threat to life or limb qualify for the highest level, whereas patients whose conditions reflect minor or well controlled problems are at the lowest.
Review clinical examples from AMA’s CPT manual Appendix C.
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Medical Necessity – Over Coding
Issue Over-coding E/M service when the presenting problems, patient acuity or decision-making complexity supports a lower level code.
Solution “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.”
“ It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.”
“ The volume of documentation should not be the primary influence upon which a specific level of service is billed.
Documentation should support the level of service reported.”
Source: Medicare Claims Processing Manual, Pub.100-04, Chapter 12, 30.6.1.A
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Under-Coding
Issue Under-coding E/M service when the documentation, presenting problems, exam level, patient acuity or decision-making complexity supports a higher level code.
The nature of the presenting problem drives documentation in the same way that it evokes the medically-indicated examination and medical decision-making.
Solution Assign the appropriate code based on the level of each of the key components actually performed and documented which are: history of present illness, exam, medical decision-making; and in come cases: counseling, coordination of care and time
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Evaluation and Management (E/M)Services
E/M codes describe services provided by physicians to evaluate patients and manage their care. These codes are widely used by physicians in all specialties and describe a very large portion of the medical care provided to patients of all ages.
The various levels of E/M services describe the wide variations in skill, effort, time, responsibility, and medical knowledge required for the prevention or diagnosis and treatment of illness or injury, and the
promotion of optimal health.
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Components of E/M Services
E/M Service
History ExaminationMedical Decision
Making
HPI ROS PFSH
Number of Diagnosis
or Treatment Options
Amount/ Complexity
of Data
Risk of
ComplicationsChief Complaint
Contributing Factors:• Counseling, • Coordination of Care, • Nature of Presenting Problem, • Time
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Which Set of Guidelines?
The 1995 and 1997 documentation guidelines (DG).
The major difference in the guidelines is in the criteria for the examination with two readily identifiable grey areas in 1995 DG: Expanded Problem Focused exam vs. a Detailed exam
Both require at least two body areas and/or systems with a “limited” or an “extended exam”.
Comprehensive single system exam A single system exam is “complete”.
Practitioners may choose which guidelines to use based on which set benefits the practitioner.
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Documentation is Important for…
Evaluation, planning and monitoring of patient‟s health;
Communication among practitioners; Accurate and timely claims review and payment; Utilization review and quality of care evaluations; Collection of data that may be useful for research
and education; and To serve as a legal document to verify care provided.
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Steps to Determine E/M Level
1. Determine the category or subcategory of service
2. Determine Medical Necessity – Nature of Presenting Problem
3. Determine the level of History obtained (HPI, ROS, PFSH)
4. Determine the level of Examination performed
5. Determine the complexity of Medical Decision MakingA. Number of diagnosis or management optionsB. Risk of significant complications, morbidity and/or mortalityC. Amount and/or complexity of data to be reviewed
6. Determine if Time is a dominant factor7. Determine Final E/M Level
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New Patient Definition
A new patient is defined by CPT as a patient who has not received any professional services from the physician or another physician of the same specialty, who belongs to the same group practice, within the past three years.
In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available.
Patients seen in consultation in the hospital, are considered established patient when they come to your office for the first time.
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Medical Necessity
Presenting problem- how sick is the patient?
New Patient Visits: Levels 3-5 are reserved for sick or injured patients
Lower levels are for patients who present with minor and/or well controlled condition/s
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Nature of Presenting Problem-New Patients
Use clinical examples in AMA‟s CPT book.
For example
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Nature of Presenting Problem-New Patients
Consider using CPT Appendix C Clinical Examples:
99205Example
Family Medicine
New patient, 69-year-old with severe chronic obstructive pulmonary disease, congestive heart failure, and hypertension.
99213
Example
Internal Medicine
50-year-old female, established patient, with insulin-dependent diabetes mellitus and stable coronary artery disease, for monitoring.
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Nature of Presenting Problem-Subsequent Hospital Visits
CPT Code Descriptions for 99231-99233-
Subsequent Hospital Visits (rounds)
CPT
99231
Patient is stable, possible ready for discharge
CPT
99232
Patient has a new, minor problem such as fever.
CPT
99233
Patient is unstable, or has developed a significant complication or new problem
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History
The levels of E/M services are based on four types of history:• Problem Focused• Expanded Problem Focused• Detailed• Comprehensive
Each type of history includes some or all of the following elements:
• Chief Complaint• History of Present Illness (HPI)• Review of Systems (ROS)• Past, Family and/or Social History (PFSH)
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History of Present Illness (HPI)
Location -left leg, right eye
Quality -burning, stabbing, dull
Severity bad, intolerable, slight
Duration -2 days, 72 hours
Timing - at night, after eating
Context - when I walk
Modifying factors
-better after rest
Associated signs & symptoms
-redness, swelling,
Fever
New PatientsConsult:
Level 3+ = 4 HPI
All other levels = 1 HPI
Established
Patients:
Level 4 = 4 HPI
All other levels = 1 HPI
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Review of System (ROS)
ROS elements typically reference signs and symptoms, of which both positive and negative responses are considered. Look for indications “pt denies pain,” “after further questioning the…”)
ROS should be medically necessary. It may be considered necessary to obtain a complete ROS when a patient
presents as an initial new patient, but not for every follow-up.
New PatientsConsult:
Level 4+ = 10 ROS
Level 3 = 2 ROS
Level 2 = 1 ROS
Established Patients:
Level 5 = 10 ROS
Level 4+ = 2 ROS
Level 3 = 1 ROS
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Past, Family and Social History (PFSH)
Past history: past experiences with illnesses, operations, injuries and treatments, and medications;
Family history: review of medical events in the patient's family, including age at death, diseases which may be hereditary or place the patient at risk.
Social history: review of past and current activities, for example occupation, smoking, alcohol use (EtOH), sexual activity, marital status, etc.
New PatientsConsult:
Level 4+ = 3 PFSH
Level 3 = 1 PFSH
Established Patients:
Level 5 = 3 PFSH
Level 4 = 1 PFSH
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Selecting the History Level
A CC
The Chief Complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis,
physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient‟s words.
B HPI (MD. Only)
Location
Quality Severity Duration Timing Context Modifying factors Associated signs & symptoms
-left leg, right eye -burning, stabbing, dull -bad, intolerable, slight -2 days, 72 hours -at night, after eating -when I walk -better after rest -redness, swelling, Fever
Brief 1-3 elements
Brief 1-3 elements
Extended 4 or more elements or Status of 3 chronic or inactive conditions
Extended 4 or more elements or Status of 3 chronic or inactive conditions
C ROS
Constitutional Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endoctrine Hematologic/lymph Allergic/immune. “All others negative”
-weight loss, fever -blurriness, swelling -runny nose, sore throat, Mouth soars, tinnitus -chest pain, edema, HTN, Dyspenia, etc -cough, wheezing -naseau, vomitting, or diarrhea, change in appetite -dysuria, urgency, joint pain -skin, breast, bruising -dizziness, tremors, LOC -insomia, memory loss -intolerance to heat -enlarged lymph nodes
None Pertinent to problem
1 system
Extended
2-9 systems
Complete
10 or more systems, or some systems with statement “all others negative”
D PFSH Past History Family History Social History
-the patient‟s past experiences with illnesses, operations, injuries and treatments -a review of medical events in the patient‟s family, including diseases which may be hereditary or place the patient at risk -an age appropriate review of past and current activities
None Pertinent 1 or 2 history Areas
Complete* 2 or 3 history areas
HISTORY LEVEL: 3 of 3 must be met on the vertical graph.
Problem Focused History
Expanded Problem Focused History
Detailed History
Comprehensive History
CC: leg painPt fell off a chair about five hours ago and landed on knee. Leg has been red and painful, and is swollen”. Pt denies motor disturbances including balance, coordination. Pt takes Zoloft.
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Special Circumstances
Patient is unable to give a history
(ROS) and (PFS) History taken from an earlier encounter
A comprehensive service may be performed and documented but… A comprehensive service is not always medically necessary
or billable
Unless Preventive, a Chief Complaint (CC) must be identifiable This is the first step in establishing medical necessity
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Exam: 95 Versus 97
„95DG Body area or organ system
1 body area or organ system
2-7 body areas or organ systems, limited exam
2-7 body areas or organ systems, extended exam
Multi-system exam of 8 or more organ systems. Cannot combine with body areas.
„97DG Multi-system exam
1-5 bullets from one or more systems or body areas
6-11 bullets from one or more systems/areas
12-17 bullets or at least 2 bullets from each of 6 systems /areas
Perform all bullets from at least 9 systems/ areas, and document at least 2 bullets from EACH of 9 systems /areas
Exam Level: Problem Focused Expanded PF Detailed Comprehensive
See „97 guidelines for single organ system exams for Cardio, ENT, Eye, GU, Hema, Muscu, Neuro, Psych, Resp, Skin
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Select Exam Level
Constitutional (vital, gen app)
Eyes Respiratory Genitourinary Skin Psych Organ Systems Ears,nose
mouth, throat Cardio Gastro Musculoskeletal Neuro Hematologic
Head, face Genitalia, groin, buttocks
Abdomen Extremities Body Areas
Neck Chest, breast, axillae Back, spine
Level Probl. Focus Expanded PF Detailed Comprehensive
Exam: 1 body area or organ system
2-7 body areas or organ systems, limited exam
2-7 body areas or organ systems, extended exam
Multi-system exam of 8 or more organ systems. Cannot combine with body areas.
All lower level exams (not comprehensive) can combine organ systems and body areas.
BP 100/70. Normal gait.Some tenderness, no effusion. The medial and lateral collateral ligaments are intact.
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Medical Decision Making (MDM)
Medical Decision Making (MDM) refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the following elements:
A. The number of possible diagnosis and/or the number of management options that must be considered.
B. The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed.
C. The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient‟s presenting the problem(s), the diagnostic procedure(s) and/or possible management options.
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MDM Documentation
For a presenting problem with an established diagnosis the record should reflect: improved, well controlled, resolving or resolved; inadequately controlled, worsening, or failing to change as
expected. This could be explicitly stated or easily inferred from the
documentation. If the problem is mentioned but not addressed, this
information is considered History. If there is an underlying or co morbid condition that will
impact the treatment options or disease progression/stability this should be addressed in the assessment and plan.
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MDM-Selecting the Level
Final Result of Complexity for MDM
A. Data ≤1 2 3 ≥4
B. Risk Min Low Mod High
C. DX/TX ≤1
Minimal
2
Limited
3
Multiple
≥4
Exten
Type of
MDM
Straight
Forward
Low
Complexity
Mod
Comp
High
Compl
Bring total points from tables A, B and C
MDM determined by 2 out 3 on vertical graph
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MDM – A. Data Reviewed
4. Selecting Level of Medical Decision Making (MDM) (complete A,B,C, bring totals to Final Result of Complexity)
A. Data to be Reviewed (Complexity of Data) Points
Review and/or order of clinical tests 1
Review and/or order of tests in radiology section of CPT (nuclear medicine and all imaging except echocardiography and cardiac cath) 1
Review and/or order of tests in the medicine section of CPT (examples: EEG, echocardiography, cardiac cath, non-invasive vascular studies, pulmonary functions studies, psychological testing, endoscopy)
1
Discussion of test results with performing physician 1
Decision to obtain old records and/or obtain history from someone other than patient 1
Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider
2
Independent (personalized) visualization of image, tracing or specimen itself (not simply review of report) 2
Total A:
I.e.Positive Strep Test, Data Reviewed = 1 points
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MDM- B. Table of Risk
B. Table of Risk or Complication and/or Morbidity or Mortality
B. Presenting Problem Diagnostic Procedure Ordered Management Options Selected
Min One self-limited or minor problem, e.g. cold, insect bite, tinea corporis
Lab tests requiring venipuncture
Chest x-rays ·KOH prep – EKG/EEG
Urinanalysis -Ultrasound, echo
Rest - Gargles
-Urinanalysis -Ultrasound
Low Two or more self limiting or minor problems
One stable chronic illness, e.g. well controlled hypertension, non-insulin dependent 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 - Skin biopsies
Clinical laboratory test requiring arterialpuncture
Over the counter drugs
Minor surgery with no identified risk factors
Physical therapy
Occupational therapy
IV fluids without additives
Mod 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 systemic symptoms, e.g. pyelonephritis, pneumonitis, colitis
Acute complicated 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 catherization
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
Prescripiton drug management
Therapeutic nuclear medicine
IV fluids with additives
Closed treatment of fx or dislocation wi/o manipulation
High One or more chronic illness with severe exacerbation, progression, or side effects of treatment.
Acute or chronic illnesses 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
An abrupt change in neurological status, eg seizure, TIA, weakness, or sensory loss
Cardiovascular imaging studies with contrast with identified risk factors
Cardiac electrophysiological 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)
Parental controlled subst.
Drug therapy requiring intensive monitor for toxicity
Decision not to resuscitate or to deescalate care because of poor prognosis
Bring results to Line B in Final Result for Complexity
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MDM- C. Diagnosis and Treatment Options
C. Number of Diagnosis or Treatment Options # Point =
Selllf- Llimited or minor (stable, improved or worsening) 1 Max =2
Established problem (to examining physician); stable, improved 1
Established problem to (examining physician);worsening (not improved) 2
New problem (to examining physician);no additional workup planned 3 Max =3
New problem (to examining physician); additional workup plan 4
Multiply the number by the points for results, bring total to final Total C:
Impression:1. Otis Media- Est.worsening= 2 points2. Strep Pharyngitis = Estb. Stable = 1 point
Total 3 points
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Final MDM Complexity
Final Result of Complexity for MDM
A. Data ≤1 2 3 ≥4
B. Risk Min Low Mod High
C. DX/TX ≤1
Minimal
2
Limited
3
Multiple
≥4
Exten
Type of
MDM
Straight
Forward
Low
Complexity
Mod
Comp
High
Compl
Bring total points from tables A, B and C
MDM determined by 2 out 3 on vertical graph
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Final E/M Level
IP Consult (3of 3) 99251 99252 99253 99254 99255
OP Consult (3 of 3) 99241 99242 99243 99244 99255
OP Visit New (3of 3) 99201 99202 99203 99204 99205
History PF EPF D C C
Examination PF EPF D C C
MDM SF SF L M H
Level I II III IV V
Avg. Time IP Consult 20 40 55 80 110
Avg. Time OP Consult 15 30 40 60 80
Avg. Time OP Visit 10 20 30 45 60
Note: Level 4 & 5 both require a comprehensive exam and history (including 10 point ROS) Without this, no higher than Level 3.
2 out of 3, but not higher than MDM
*Established OP visit (2 of 3)
99212 99213 99214 99215
PF EPF D C
PF EPF D C
SF L M H
II III IV V
10 15 25 40
*99211= Minimal problem that may not require presence of physician
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New Patient -Level 4 Surprise
If 99205 (99245, 99255) = Comprehensive History and Exam and High MDM:
PF= Problem Focused, EPF=Expanded Problem Focused, D=Detailed, C=Comprehensive, SF=Straightforward, L=Low, M=Mod, H= High
OP 99201 99202 99203 99204 99205
History PF EPF D C C
Exam PF EPF D C C
MDM SF SF L M H
Then Detailed History and Exam and Moderate MDM = ?? 99204? 99203?
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When Time is Dominant Factor
If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service.
Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reductions or discussion with another health care provider.
Does documentation reveal total time. Time: Face to face in outpatient setting or Unit/Floor inpatient setting?
Yes No
Does documentation describe the content of counseling or coordination of care? Yes No
Does documentation suggest that more than half of time was counseling or coordinating care? Yes No
If the answers to the questions are yes, select the service in appropriate grid in Section 5, resulting in highest level either by “average time” or by components (history, exam, decision). **Documentation example: “20 minutes of the 30 minute visit spent counseling the patient on..…”
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Medical Records-Complete and Legible
Documentation should include:
Reason for encounter
Assessment, clinical impression or diagnosis
Date and legible identity of observer
Rationale for ordering diagnostic or other ancillary services should be easily discernible
Past and present diagnosis
Identification of appropriate health risk factors
Patients progress, response to treatment, and any revisions to treatment or diagnosis
Documentation should support CPT and ICD-9 codes submitted on claims
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Common Errors
No documentation or incomplete documentation Missing signatures Consistently assigning the same level of service Billing a consult instead of an office visit Using invalid codes on the bill, due to use of old coding
resources or forms Unbundling procedure codes Not listing chief complaint Abbreviations that are easily misinterpreted Billing services included in global fee as a separate service Not using a modifier or using an inappropriate modifier for
accurate payment of a claim
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Incident-to Errors
Physician assistants and nurse practitioners performing services for physicians not following billing specific guidelines related to the physician‟s relationship to the patient and the physician‟s presence in the office.
Incident-to does not apply in the hospital setting.
Physician settlement and conviction (Jun 2007 OIG Semi-Annual Report): $1 million settlement paid by a Michigan physician practice
for services furnished by non-physician practitioners which were billed as though provided by physicians.
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“Incident-to” Basic Requirements
The service or supplies are an integral, although incidental, part of the physician‟s or practitioner‟s professional services;
The services or supplies are of a type that are commonly furnished in a physician‟s/NPP‟s office or clinic;
The services or supplies are furnished under the physician‟s/ practitioner‟s direct supervision and included in the physician‟s bill;
The services or supplies are furnished by an individual who qualifies as an employee of the physician/NPP or professional association or group that furnishes the services or supplies;
The service is part of the patient‟s normal course of treatment, during which a physician personally performs an initial service and remains actively involved in the course of treatment.
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What is a Shared Visit?
A split/shared Evaluation and Management (E/M) visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified non-physician practitioner (NPP) each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service.
The physician may bill the service when he or she performs a substantive portion of the service in a face-to-face encounter.
A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision- making key components of an E/M service.
(Medicare Claims Processing Manual, Pub.100-04, Ch.12, 30.6.13H)
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Shared Visits Apply to the Following E/M Codes:
Hospital setting: Hospital admissions (99221-99223)
Subsequent hospital visits (99231-99233)
Discharge management (99238-99239)
Observation care ( 99217-99220, 99234-99236)
Emergency department visits (99281-99285)
Prolonged care (99354-99357)
Hospital provider based office visits (99201-99215)
Physician office setting: Established office visits (99211-99215) with an established
plan of treatment.
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2010 Consultations and Shared Visits
Split/shared visits do not apply to: Consultations (99241-99255) Prior to 1/1/2010
Critical care services (99291-99292)
Procedures.
Provider can split/share a consultation-type service when using an applicable split/shared E/M code (such as hospital or office/outpatient E/M codes). (Physician ODF 4/14/10)http://medicare.fcso.com/EM/168518.asp
Remember that split/shared in the office setting (non provider based) requires “incident-to” guidelines to be met, therefore shared visits cannot be used for new problems.
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OIG Report on Modifier -25
November 2005 Office of Inspector General (OIG) report:
In calendar year 2002, Medicare allowed $1.96 billion for approximately 29 million claims using modifier 25.
450 claims reviewed and 35% of claims submitted using modifier -25 did not meet program requirements
Resulted in $538 million in improper payments.
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Modifier -25 CPT Definition
“A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. “
“The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.”
Source: AMA‟s Current Procedure Terminology (CPT), Appendix A Modifiers
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CMS Clarification on Modifier -25
Transmittal 954, dated May 19, 2006 clarified when and how to use modifier -25 during the global period including how to document its use. The patient does not need to have an additional/different
diagnosis to justify reporting the E/M service with modifier -25.
Although providers do not need to submit documentation with the claim, both the physician or qualified non-physician practitioner must still document the medical necessity of the E/M service and procedure in the medical record to justify the claim for services.
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Appropriate Use of Modifier -25
Preventative medicine service with problem oriented E/M service.
Minor surgical procedure with problem oriented E/M services.
Two separate visits on the same date for unrelatedproblems. Both visits must be medically necessary and modifier should be
append to the second visit code.
Critical care codes preoperatively or to patients who have suffered trauma or burn during the post op surgical period.
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Inappropriate Use of Modifier -25
The provider decides major surgery is necessary (use modifier -57 instead).
The physician performs ventilation management in addition to the E/M service.
The provider performs a procedure on a separate day from the E/M service.
With a surgical code, non E/M service (modifier -25 explains the separately identifiable E/M service, not the procedure) See modifier -59 for more information.
A patient comes in specifically for a minor procedure and receives an E/M service for that procedure. (For example scheduled injection.)
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Service Included with Immunization Administration CPT Codes:
Administrative staff services such as: making the appointment,
preparing the patient chart,
billing for the service, and filing the chart;
Clinical staff services such as: taking routine vital signs,
obtaining a vaccine history on past reactions and contraindications,
presenting a VIS and answering routine vaccine questions,
preparing and administering the vaccine with chart documentation, and
observing for any immediate reaction
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Medical Necessity Documentation
Issue Under-documentation of medical necessity
Solution Clearly identify all presenting complaints.
Documentation should clearly reflect history, exam and medical decision making associated with each presenting complaint.
Document all physician work related to each presenting complaint
Time
Diagnostic Testing
Therapeutic interventions
Co-morbidities
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Under-Documenting High Level Codes
Issue Level 4 and 5 consultations/new patient office visits and level 2 and 3 admission requirements not documented.
Solution All require documentation of comprehensive exam and comprehensive history.
Without it, the service billed cannot be higher than level 3 consultation/new patient visit and not higher than a level 1 admission.
99241-99255 Consultations (IP +OP)
99201-99205 New Patient Office Visit
99221-99223 Admissions
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Under-Documenting Comprehensive Exam
Issue Under-documenting comprehensive exam needed for level 4 and 5 consultations/new patient office visits and level 2 and 3 admissions.
Solution „95 DG Multi-system exam: 8 or more organ systems. Cannot combine with body areas (Organ systems include Const., Eyes, ENT, Cardio, Resp, Gastro, GU, Musc, Skin, Neuro, Psych, Hematologic)
„97 DG Multi-system exam: Perform all bullets from at least 9 systems/areas, and document at least 2 bullets from EACH of 9 systems /areas.
99241-99255 Consultations (IP +OP)
99201-99205 New Patient Office Visit
99221-99223 Admissions
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Under-Documenting History: ROS
Issue Under-documenting comprehensive history needed for level 4 and 5 consultations/new patient office visits and level 2 and 3 admissions.
Solution ROS – complete review of system (at least 10) is reviewed.
“all other systems negative” shortcut: “At least ten organ systems must be reviewed. Those systems with positive or negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such notation, at least ten systems must be individually documented”.
99241-99255 Consultations (IP +OP)
99201-99205 New Patient Office Visit
99221-99223 Admissions
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Under-Documenting History: PFS
Issue Under-documenting comprehensive history needed for level 4 and 5 consultations/new patient office visits and level 2 and 3 admissions.
Solution PFSH- need 3 elements (Past, Social and Family History).
Don‟t use the term “unremarkable” or “not relevant”, as these can be flags that you skipped family history.
Use: “Past family and social history reviewed and otherwise non-contributory”.
99241-99255 Consultations (IP +OP)
99201-99205 New Patient Office Visit
99221-99223 Admissions
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Incorrect Documentation of Time
Issue Incorrectly documenting time when using time as the determining factor for E/M services.
Solution Document total time, the content of the counseling or coordination of care, and document that more than half of the time was spent on counseling or coordination of care. (i.e. “20 minutes of the 30 minute visit spent counseling the patient on…”)
Tip Don‟t use it all the time!
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References
The Center for Medicare and Medicaid Services (CMS) Medicare Claims Processing Manual Publication 100-4, Chapter 12-§30.6
Current Procedural Terminology (CPT) Manual, American Medical Association
1995 & 1997 Documentation Guidelines for Evaluations and Management Services, CMS
First Coast Service Options (FCSO) Web material and Bulletins
Office of Inspector General (OIG) 2008 Work Plan CMS Recovery Audit Contractors Evaluation Report,
July 2008
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