Dan Magdziarz, DO - acoep.org · • OGT / NGT placement (if staff unable to obtain) • Cardiac output interpretation • Transcutaneous pacing. ... Dan Magdziarz, DO

Reimbursement 2019A Field-Guide for Physicians in the Trenches

Dan Magdziarz, DO

Disclosures: • I am CEO and Founder of ChartOptima.com

• I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.

• I do not intend to discuss an unapproved / investigative use of a commercial product/device in my presentation.

Here’s What This Presentation Will Do for You...

1. Teach Emergency clinicians how to optimize their charting and reimbursement in the areas of Critical Care, Procedures, and Foundational E/M Encounters as outlined by AMA CPT 2019, Marshfield Clinic Grid, and CMS Documentation Guidelines for Evaluation / Management.

2. Utilize high-yield, interactive case studies to facilitate real-world application through the use of Differential Diagnoses, Multiple Diagnoses, and Key Medical Decision Making elements as appropriate.

3. Educate clinicians how to retain their reimbursement through practical tips which allow participants to overcome medical-legal pitfalls that commonly occur in EM charting.

In Emergency Medicine, Why Strive to Learn

How to Chart Smarter?

• You Can Optimize Your Reimbursement

• Increase Your Medical-Legal Security

• Ensure Your Longevity in the Role You Want

Here are the benefits:

This is the Reality:

What You Document Makes

A Difference.

• $ 7.21 = The potential realized from a proper ....Cardiac Monitor Interpretation.

• $ 50.10 = Obtained by documenting an ......appropriate Critical Care statement.

• $ 84.69 = Realized through distinguishing ....“complex” from “simple”abscess drainage.

• $ 113.16 = The difference between a level 3 …and 5 chart recovered by documenting ....optimally.

Based on 1 RVU = $ 36.04, 2019 Medicare Physician Fee 1

(precise amount geographic specific)

1. 2019 National Physician Fee Schedule Relative Value File, GPCI19, National Physician Fee Schedule Relative Value File Calendar Year 2019,

MCR-MUE-Practitioner Services. Published by CMS. Effective: January 2019.

Here Are the Reimbursement Topics That will Help You the Best:

• Critical Care

• High-Yield Procedures

• Medical Necessity Pearls

• EKGs / Cardiac Monitors

• Thriving in the Age of ALTO

• Orthopedic Pearls

• Medical Decision Making Keys

• Medical-Legal Pearls

Which of the following cases likely qualifies for Critical Care Time reimbursement?

A) 27 y/o male presents with suicidal ideation. The paramedics report the patient may have ingested an unknown amount of an OTC antihistamine. He arrives combative and tachycardic. He initially requires restraints and is given IM haloperidol / lorazepam. A certificate is completed by the Emergency physician. ER work up includes labs, EKG, Cardiac Monitor, UDS, and a discussion with Poison Control. The patient is ultimately medically cleared and admitted to psychiatry.

B) 18 y/o male presents with shortness of breath and is seen through your Fast Track. He is acutely dyspneic with accessory muscle usage. His history is significant for being intubated for asthma 5 months ago. During this encounter, he receives 3 re-exams, a few rounds of albuterol/atrovent nebs as well as solumedrol and magnesium sulfate IV. Chest X-ray reveals hyperinflation without pneumothorax or infiltrate. After 3 hours, he feels better and is discharged home.

C) 63 y/o male presents with chest pain and is found to have an inferior wall MI. He receives an EKG and Chest X-ray. Labs are ordered. Medications given include aspirin, heparin, normal saline 500 ml bolus. The patient goes into V-fib. He is defibrillated, and his rhythm returns to NSR. The patient returns awake and alert. His cardiologist and primary physician are both consulted by phone. Cardiologist is in house, and the patient leaves the ER for cath lab 26 minutes after arrival.

D) All of the Above

E) None of the Above

Case Studies in Critical Care ... Take a Look at the Service You Provide:

Answer:

Take Away Points in Critical CareThat Will Serve You Well:

• Critical Care services involve cases in which there is:

....“a high probability of imminent or life-threatening deterioration in the patient’s condition.”

• Many psychiatric encounters qualify for Critical Care Time reimbursement.

• Even cases involving patients ultimately “medically cleared” or discharged home can qualify for Critical Care.

• The patient’s room location should never dictate your medical care or level of service.

• Your documentation time counts towards Critical Care.

Critical Care Reimbursement -> Your Most Important Key for Success:

• Critical Care billing (30 - 74 minutes) generates ....$226.33 for each applicable case.

• Critical Care Time: generates $ 50.10 above a ....level 5 encounter CPT 99285.

“I spent 30 minutes of Critical Care time with this patient. This does not include time spent on separately reported billable procedures.”

• Based on 8.5% Critical Care Time national avg1

…..=> $ 15,480 annually per physician.

…..(15 shift / month; 9 hour shift length; 2.25 patients / hour)

1. 2017 CMS Medicare Acuity Data

Critical Care Time ->This is Your Reimbursement Potential:

• Based on a 6% Critical Care Time average, ....an ED group caring for 55,000 patients / yr ....can realize $ 165,330 / annually.

...This is what’s generated above level 5

...encounters CPT 99285.

• Optimize your group’s Critical Care just 2%

=> Optimize revenue $55,000 per year.

Know What Qualifies for

Critical Care Time

“A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”

Critical Care / AMA CPT 2019

• You know the obvious =>

Septic shock / Respiratory Failure / AGI Bleed

• What about the “not so obvious”? =>

Don’t settle for comfortably numb.

Critical Care Here is What’s Included:

• Your provision of care towards a critically ill or injured patient.

• Discussion of the case with the family or surrogate decision ../makers. (provided the conversation bears directly on the ../management of the patient)

• Review of records and computer information data interpretation. ./(i.e. EKGs, BPs, Lab data)

Critical Care Additional Services that Contribute:

• “All Things Respiratory” (Pulse oximeter interpretation / Chest X-ray i …..interpretation / ABG interpretation / Ventilator management)

• Discussion with the primary physician and consultants. (provided the i.iconversation bears directly on the management of the patient)

• Your Chart Documentation.

Don’t Overlook What Only You Can Accomplish:


This is how you appropriately reimburse in Critical Care.

Critical Care Also Included, Keep These in Mind:

• Vascular access procedures ....(peripheral IV if nursing unable to obtain, though not other lines)

• Blood draw (if staff unable to obtain)

• OGT / NGT placement (if staff unable to obtain)

• Cardiac output interpretation

• Transcutaneous pacing

Can this encounter be submitted for 35 minutes of billable Critical Care Time?

A) Yes

B) No

Your Advanced Practice Provider picks up a chart with the triage complaint of “generalized weakness”. The encounter turns out to involve a 46 y/o female with multiple sclerosis who is dehydrated, hypotensive, and septic. Your APP provides 20 minutes of Critical Care Time. You are also involved in the patient’s management and provide 15 minutes of Critical Care Time.

Answer:

One More Case Study ...Just Who Can Reimburse for Their Time?

Good to Know -> Who Can Reimburse for Critical Care:

• Emergency Medicine Physicians? Yes ... “I spent 30 minutes of Critical Care Time with this patient. This does not include time spent on separately ....”

• Your Advanced Practice Providers (APPs)? Likely Yes ... though submitted time must be exclusively the APP’s or the Physician’s (this time cannot be “shared” or combined).

• Your Residents? No ... only the Teaching Physician can submit Critical Care Time for billing.

• You and Your Physician Partners? Maybe ... you and your physician colleagues (who belong to the same group and specialty) can submit (certain) combined time ……………..for a given patient encounter for a single calendar day.

....Physician #1 : “I spent 30 minutes of Critical Care Time with this patient.” => 99291 AND

....Physician #2 : “I spent 45 minutes of Critical Care Time with this patient.” => 99292 for that encounter.

3 Most Valuable Tips for Optimizing in Critical Care:

1) Know what qualifies for Critical Care Time.

2) Be mindful of your time.

3) Actually chart your Critical Care statement.

“I spent 45 minutes of Critical Care time with this patient. This does not include time spent on

separately reported billable procedures.”

Practical Application in

Critical Care: Be Mindful of Your Time

• Sick patient? When you are done with your initial evaluation and care of a patient, note the time you spent with that patient’s initial care.

• If the initial time you spent caring for the patient is 15 - 20 minutes or greater, keep this in mind.

• Cases like these have a good likelihood of qualifying for critical care.

Critical Care: Realize The Value

in What You Do

• Talking to family with an obtunded patient?

Think Critical Care.

• Reviewing records in a complicated case?


• Managing respiratory?


• Talking to multiple consultants regarding a. a sick patient?


• EKG interpretation

• Intubation

• CPR

• Chest tubes

What’s Not Included in Critical Care:

• Central venous catheter

• Intraosseous lines

• Procedural sedation

• “Non-critical” conversations

Critical Care: All You Need to Succeed.




Chart smarter, not harder.

High Yield Procedures in Emergency Medicine

For those interested, some values are just “good to know”:

• Intraosseous line (CPT 36680) 1.69 RVUs -> $ 60.91

• Lumbar puncture (CPT 62270) 2.23 RVUs -> $ 80.37

• Central line (CPT 36556) 2.45 RVUs -> $ 88.30

• Cardioversion (CPT 92960) 3.13 RVUs -> $ 112.80

Based on 1 RVU = $ 36.04, 2019 Medicare Physician Fee Schedule RVU Conversion Factor (precise amount, geographic specific)

1. AMA Current Procedural Terminology (CPT) 2019 Professional Edition. 4th ed.

2. 2019 National Physician Fee Schedule Relative Value File. Published by CMS.

Some Additional Values You May Find Interesting:

• Thoracentesis w/ US (CPT 32555) 3.22 RVUs -> $ 116.05

• Intubation (CPT 31500) 4.07 RVUs -> $ 146.68

• Chest tube (CPT 32551) 4.53 RVUs -> $ 163.26

Based on 1 RVU = $ 36.04, 2019 Medicare Physician Fee Schedule RVU Conversion Factor (precise amount, geographic specific)

Which of the following qualifies this case for a “Complicated” Abscess Incision and Drainage?

A) The administration of IV antibiotics

B) The patient’s comorbidity - diabetes w/ hyperglycemia

C) The presence of abnormal vital signs (SIRS criteria)

D) The wound was probed to break up loculations

E) The patient’s admission to a monitored bed

46 y/o male presents with a chief complaint of right thigh swelling. Triage VS HR 110, RR 20, Temp 100.8, BP 94/62, Accu Check 384, O2 sat 98% RA. The patient has a thigh abscess with exam. He is treated with IV fluids, IV antibiotics, insulin subcut, and you incise & probe the wound to break up loculations. The patient is admitted to telemetry.

Answer:

Get Ready for the Challenge:Just When Are Your I&D’s “Complicated”?

Abscess Incision & Drainage:

On the Cutting Edge of Reimbursement

“Complex or Multiple” Abscess Drainage: 5.16 RVUs = $ 185.96

Don’t Overlook the Value of What You Do:

in comparison with...

“Simple or Single” Abscess Drainage: 2.81 RVUs = $ 101.27

$ 84.69 = The difference realized in appropriately documenting the details.

Abscess Incision & Drainage This is How You Optimize:

When Appropriate, Your Documentation Should Look Like This:

• “The wound involved multiple abscess ….which were drained via 3 incisions using ….#11 blades.”

• “The wound was probed using sterile ….forceps to break up loculations.”

• “The wound was packed with 1/4 inch ….iodoform gauze.”

Any of these 3 factors characterize a “Complex or Multiple” abscess drainage.

Properly detailing your service is what gets you paid in

Emergency Medicine.

+ $84.69

Laceration Repair: Make Sure You

Measure Up

• “Always Measure.” Don’t estimate wound lengths.

( 0 - 2.5 cm / 2.6 cm - 5.0 / 5.1 cm - 7.5 / 7.6 cm - 12.5 )

• With wound closure, these are very few trivial ....interventions. Note the important details:

• Any Extensive Cleaning

• Removal of Particulate Matter

• Any Debridement or Revision Wound Edges

• Simple vs. Layered Closure

• Be attentive => You’ll reimburse Optimally.

Laceration Repair This is How Your Documentation Should Look:

• “The wound was heavily contaminated by dirt particles and required copious irrigation.”

• “Using forceps, I removed several wood particles from the wound.”

• “The wound edges were devitalized & irregular / required debridement & revision using iris scissors.”

• “Lower leg 8 cm laceration multi-layer repair: ... the subcutaneous tissue was closed using 4-0 vicryl, …..6 buried horizontal mattress sutures. Next the skin was closed using 4-0 nylon, 16 simple interrupted …..sutures ...”

That’s how you reimburse in Emergency Medicine.

In regards to this patient’s encounter, which of the following is true?

A) The physician must have direct “hands-on” involvement with chest compressions or bagging ventilations in …...order to qualify for CPR reimbursement.

B) Since intubation was performed during the time of CPR, it cannot be submitted as a billable procedure.

C) Critical Care Time of 35 minutes can be reported. (this excludes the time spent on procedures)

D) Defibrillation can be submitted as a separately reported billable procedure.

E) CPR as well as a Level 5 visit (E/M encounter CPT 99285) can be submitted for billing.

A 42 y/o male is brought to the ED by ambulance after having a witnessed cardiac arrest. The patient’s initial rhythm is asystole. CPR is performed. You promptly intubate the patient. Over the next 35 minutes, the patient’s rhythm alternates between ventricular fibrillation and PEA. The patient is defibrillated multiple times and ACLS medications are given. After 35 minutes, the patient’s monitor reveals normal sinus rhythm. The patient now has ROSC. BP is 104/60. EKG reveals an inferior wall MI. The cardiologist on call is already aware of this case, and the patient is taken to cardiac cath lab - 10 minutes after ROSC. (45 minutes after ER arrival)

Answer:

Your Most Serious Study of the Day:Caveats of CPR

What’s “Good to Know” with CPR:

• The Emergency physician does not have to physically perform CPR (chest compressions or ventilations) . ....in order to reimburse for this service. According to the AMA (CPT Assistant 2012), the physician just ....needs to manage the CPR and be present “face-to-face”.

• Procedures (i.e. Intubation / Vascular access lines) performed during the provision of CPR can be ....submitted for reimbursement.

• CPR generates a very high (5.35) RVU => This is in addition to the E/M Encounter reimbursement for that ....visit (typically CPT 99285 = 4.89 RVUs).

Best Practice - Here’s How Your Documentation Should Look:

“CPR was performed in the Emergency Room and supervised by myself.”

CPR & Critical CareTime:

Be Sure to Keep these Separate!

• Any time spent while CPR is in progress ...cannot be counted towards Critical Care Time.

• Thus, even if 40 minutes are spent resuscitating a ....critically ill patient, this time cannot be counted as ....“Critical Care Time” (if CPR has been in progress .... .... throughout).

• Critical Care Time can be submitted for all ….Critical Care services that occur prior to or after ….the provision of CPR (“outside the CPR window’).

Be mindful of this - Here’s HowYour Documentation Should Look:

“I spent 30 minutes of Critical Care Time with this patient. This does not include time spent on

separately reported billable procedures.”

Moving on, Don’t Forget About the Tubes You’re Placing Everywhere:

• Procedure - NG Tube Placement (or OGT):

….CPT 51702 Gastric intubation and aspiration(s) therapeutic, necessitating physician’s skill ….RVU 0.63 = $ 22.70

"ED nursing was unable to place a nasogastric tube despite multiple attempts. I successfully inserted a NG tube though the patient’s nose, down the esophagus, and into the stomach. Gastric contents were suctioned.”

• Procedure - Gastrostomy Tube Placement:

….CPT 43762 Replacement of gastrostomy tube, not requiring revision of gastrostomy tract: ….RVU 1.09 = $ 39.28

“The patient’s gastrostomy tube dislodged prior to arrival. Using sterile technique, the area of the gastrostomy site entrance was prepped with betadine. Next, I successfully placed an 18 fr gastrostomy tube through the existing tract and into the stomach.”

Here Are Other Tubes of Interest:

• Procedure - Foley Catheter Placement:

CPT 51702 Insertion of temporary indwelling bladder catheter, simple: RVU 0.73 = $ 26.31

"ED nursing was unable to place a Foley catheter despite multiple attempts. Maintaining sterile technique, the area of the urethra was prepped with betadine, and I successfully placed a 16 fr coude Foley catheter into the bladder."

• Procedure - Suprapubic Foley Catheter Placement

CPT 51705 Change of cystostomy tube, simple: RVU 1.50 = $ 54.06

“The patient has a UTI in the setting of an existing suprapubic catheter. The patient's suprapubic catheter was therefore removed. Maintaining sterile technique, the area of suprapubic cystostomy entrance site was prepped with betadine, and I successfully placed an 18 fr Foley catheter into the bladder."

Additional Pearls: Optimizing Your Everyday Procedures

• Corneal Foreign Body removal using slit lamp (CPT 65222) / RVUs 1.48

(vs. 1.19 RVUs without slit lamp) Be sure you chart the details!

• Epistaxis Control Anterior, simple (CPT 30901) / RVUs 1.62 (Silver nitrate)

Anterior, complex (CPT 30903) / RVUs 2.25 (Anterior Nasal Tampon)

Posterior (CPT 30905) / RVUs 3.01 (Posterior Nasal Pack)

• Document Better, and You will Reimburse Better: “Procedure - Corneal Foreign Body removal using Slit Lamp: ...”

“Procedure - Posterior Nasal Pack insertion: ...”

Wrapping Up

High-Yield Procedures:

Special Caveats

• Intubation (CPT 31500) generates ….very high RVUs = 4.07

Videoscope assisted intubation provides no additional RVUs.

• Diagnostic Fiberoptic Laryngoscopy ….(CPT 31575) / RVUs = 1.91

Use for Foreign Body evaluation: good for pt care / also reimbursable.

A Quick Time for Reflection:

Any Questions?

In regards to your charting, all of the following will support the medical necessity of her visit except:

A) “The patient states she was directed to go to the ER by her primary physician.”

B) “The patient indicates her physician’s office indicated that no appointments were available until 3 days.”

C) “The patient reports her pain is severe.”

D) “The patient indicates she applied lidocaine patches earlier earlier w/o significant relief.”

E) The patient directs you to her insurance company’s “emergent diagnosis list” and you select the most compatible diagnosis.

A 48 year old female presents with an acute onset of back pain. She is tearful and concerned that something may be “seriously wrong.” This patient also relates she is afraid that her insurance company won’t cover this ER visit.

Answer:

Now to Charting “Medical Necessity”What You Need to Combat Denials:

Emergency Clinicians ...Anyone got this one wrong?

• Congratulations, the patient’s insurance company agrees with you!

• Multiple insurance companies now have policies in place which deny coverage for Emergency

...Room patients based on their own “diagnoses lists.”

(Anthem BCBS, newsroom.acep.org 2018; BCBS Mississippi, PRNewswire.com; Jan 2019; Centene, and others)

• “When a hospital, free standing emergency center or physician bills a level 4 (99284) or level 5 (99285)

…..emergency room service, with a diagnosis indicating a lower level of complexity or severity, the health

…..plan will reimburse the provider a level 3 (99283) reimbursement rate.”

(Centene: “Payment Policy: Leveling of Emergency Room Services”, CC.PP.053; Effective 10/01/2017)

• Claims are being denied based on final diagnosis instead of symptoms.

http://newsroom.acep.org

http://prnewswire.com

This is Not A Big Deal ...It’s Just Illegal.

• Insurance company policies which decrease or deny reimbursement based on final diagnoses are illegal.

• These violate the “Prudent Layperson Standard” regarding payments as required by federal

...(and most state) laws.

(as detailed in the Federal Balanced Budget Act 1997, Affordable Care Act 2010, and CMS Medicaid Managed Care Final Rule 2016).

• “Under the Prudent Layperson Standard, payment for emergency care is made for the initial evaluation

….and examination based upon the Nature of the Patient’s Presenting Complaint.”

• “A determination of a Medical Emergency focuses on the patient’s Presenting Symptoms rather than

.....the final diagnosis.”

(Prudent Layperson Fact Sheet (VA Puget Sound Health Care System))

The Prudent

Layperson Defined:

Getting to the Bottom Line

• “The Prudent Layperson” definition of an “Emergency Medical Condition” commonly in practice:

“Is any medical or behavioral condition of recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient’s health in serious jeopardy, cause serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy.”

(Prudent Layperson Fact Sheet (VA Puget Sound Health Care System))

• The Bottom Line: Government defined payment standards for reimbursement (PLP) revolve around the Nature of the patient’s Presenting Complaint rather than the final diagnosis.

• Many insurance companies now disagree, and the battle is underway. Physician led organizations are leading the way and engaging CMS.

Now Back to Reality ->What Emergency Physicians Can Do:

• Your History of Present Illness is key: Detailing the nature of the patient’s presenting complaint is integral in establishing the medical necessity for their visit.

• Also, in your charting, strive to highlight areas that support the prudent layperson and detail the appropriate severity of illness:

• “The patient was brought to the emergency room by ambulance ...”

• “The patient states she was directed to go to the ER from the urgent care clinic.”

• “The patient reports his ankle pain is severe.”

• “The patient reports taking naproxen earlier without significant relief.”

Other Ways You CanProtect the

Prudent Layperson:

• “The patient indicated that his primary ....physician’s office reported that no appointment ….was available until next week.”

• “The patient states that he is unable to bear …..weight on his injured knee.”

• Document pertinent Physical findings:

“The patient presents tachypneic with accessory muscle usage.”

• Always include a Differential Diagnosis:

“Gastroenteritis, Hepatitis, Appendicitis, Obstruction, Electrolyte Imbalance, Other”

• Include Multiple Diagnoses as appropriate:

“1. Dehydration, 2. Vomiting, 3. Hypokalemia, 4. Acute Renal Insufficiency”

For this encounter, is your Pulse Oximeter Interpretation directly reimbursable?

• Yes

• No

The is a 54 y/o male with a chief complaint of cough for the past 4 days. He reports his cough is worse over the past 2 days. He admits to having some associated shortness of breath during this time.

His vitals are stable other than a pulse oximeter reading of 89% on room air. Chest x-ray reveals right lower lung infiltrate. Labs are obtained. He receives nasal cannula o2, IV antibiotics, and is admitted to the hospital.

Your documentation includes the following: “The pulse oximeter was 89% on room air which is hypoxia as interpreted by me. The patient’s O2 sat improved to 95% on 2 L nasal cannula O2.”

Answer:

Your Next Case Study:Appreciate the Value in What You Do

Pulse Oximeters &

Your Reimbursement:

Do They at All Matter?

• The simple answer is ... Yes.

• Pulse Oximeters help detail the “severity of illness”:

Detailing that hypoxia was present in this encounter highlights your Medical Decision Making and can contribute to the difference between a level 4 and 5 visit.

(CPT 99284 = 3.32 RVUs vs CPT 99285 = 4.89 RVUs)

• Also, your Pulse Ox Interpretation helps to support the “medical necessity”:

Such documentation can help deter (or over-turn) denials from insurance payers.

Take a closer look at the history ... “cough for the past 4 days”.

BCBS Michigan Nov 2018

“Patients whose chief complaint has been present for greater than 72 hours is now considered non-emergent as the patient had ample time to schedule a visit in a lower acuity setting.”

(BCBS denial code M692)

So What’s the Big Deal?Just Ask Michigan BCBS

• This insurer has been denying Emergency Room coverage if the symptom ….associated with the chief complaint has been longer than 3 days.

• Similar to the previously “diagnoses list” policies, this practice is illegal. ....It violates the Prudent Layperson standard of payment.

• Your Charting (including Pulse ox Interpretation) can protect your patient ….against denials.

Does this patient’s visit qualify for E/M Encounter Reimbursement (99281-99285) in addition to the reimbursement your coders will submit for the G-tube placement procedure?

• Yes

• No

An 86 y/o female is brought in by ambulance with the paramedics stating the chief complaint that the patient “pulled out her G-tube.” The patient has a history of dementia, is non-verbal and non-ambulatory. The time frame was unspecified by nursing home staff. The paramedics relate the patient was tachycardic prior to arrival and appears dehydrated. With your exam, there is no gastrostomy tube in place, you place a new gastrostomy tube through the patient’s existing (still patent) opening. You know that this intervention is reimbursable. However, you now wonder if this ER visit qualifies for reimbursement for as an E/M Encounter?

Answer:

Another Case for You,and More Surprises:

More Bad Payer Behavior Is On The Rise:

“Payment Policy: Problem Oriented Visits Billed with Surgical Procedures”

“If the problem-oriented visit is appended with modifier -25 or without modifier -25, and clinical claims review supports a significant and separately identifiable E&M service, the health plan will reimburse the surgical procedure plus 50 percent of the problem-oriented E&M code.”

Centene; Reference Number: CC.PP.052 ; Effective 11/1/2017

• Translation: If a patient has a procedure performed in the Emergency Room, Centene will reimburse the E/M encounter (typically 99283 - 99285) at only 50%.

• Another internally generated policy. This is not an industry standard nor consistent with payment policies of government-sponsored health plans.

• This and similar policies are being challenged by Patient & Emergency Medicine advocates … But you may wonder, what can the “physicians in the trenches” do?

Your Medical Decision Making is

More Important Than You Think:

• Your solution to addressing payer bad

behaviors -> Detail ALL of the services you

provide:

• Equip your Coders, Revenue Cycle

Management Companies, and Advocating

Agencies with the details they need to defend

against payer bad behaviors.

• Your charting can appropriately outline

the Nature of the Presenting Problem / reflect

the patient’s Severity of Illness / and highlight

the Medical Necessity of the patient’s visit.

Physicians, You Do Have a Role in This

Here’s How Your Documentation Should Look:

• “I discussed the case with the paramedics, they report that NH staff indicated the patient pulled out her G-tube ….sometime last night. The patient was tachycardic prior to arrival.”

• “The computer records were reviewed for this patient and revealed the patient had gastrostomy tube placed August ….2018. She had a creatinine of 1.8 at that time.”

• “The patient’s mucous membranes appeared dry.” / “Heart - tachycardic, rhythm regular”

• “Differential Diagnosis: G-tube dislodgement, Tract disruption, Laceration, Dehydration, Hypoglycemia, Electrolyte ….Imbalance, Other”

• “Labs - see chart / reviewed” / “0.9NS 500ml IV bolus given”

• “Diagnosis: 1) Dislodged Gtube 2) Dehydration 3) Hyponatremia 4) History Dementia”

Moderate Sedation Really Driving Your Reimbursement Upwards … Right?

• Not so fast => Only $ 12.61 as reimbursed by Medicare.

• With your reductions, the Moderate Sedation portion ../(CPT 99152) only codes for 0.35 RVUs.

• You'll reimburse higher by charting just 2 Cardiac ../Monitor Interpretations!

“Moderate Sedation: I spent 10 minutes of intra-service time with this patient.”

What about Those Cardiac Monitor Interpretations?

“The cardiac monitor revealed normal sinus rhythm with heart rate in the 80s as interpreted by me. The cardiac monitor was ordered secondary to the patient’s chest pain and to monitor the patient for dysrhythmia.”

AMA CPT 93042 / RVUs 0.20 …..Reimbursement = $7.21

• In less than 30 seconds, by appropriately performing and ....charting 2 Cardiac Monitor Interpretations, you can ....realize $14.42.

• More than your reimbursement for an entire Moderate ....Sedation procedure.

• Over $80,000 can be generated from the proper ....documentation of Cardiac Monitor Interpretations alone ....at one site in 1 year.

Your Service Adds Up ->Keeping Your Pulse on Reimbursement:

8 Cardiac Monitor Interprets / shift $ 57.68 = Amount per provider per shift.

6 main-side shifts / day $ 346.08 = Generated at the site in 1 day.

365 days / year $ 126,319.00 = Realized at the site in 1 year.

1. Reference: CMS : National Correct Coding Initiative Coding Policy Manual for Medicare Services; January 1, 2019

• CMS’s “National Correct Coding Initiative” does not permit Cardiac Monitor interpretations to be submitted on ...Medicare patients toward which Critical Care services have been rendered.1

• Still, even in the setting of robust Critical Care Time (e.g. 10% for group) => Over $80,000 generated.

Cardiac Monitor InterpretationsThis is What You Need:

1. An order for the cardiac monitor must be placed by the .../provider.

2. An interpretation must be made of rhythm and rate.

3. The reason for the cardiac monitor should be documented.

• “The cardiac monitor revealed SVT with heart rate in the 180s as interpreted by me. The cardiac monitor was ordered secondary to the patient’s palpitations and to monitor the patient for dysrhythmia.”

• Don’t forget, take 2 seconds and check the order.

What About Your EKG

Interpretations?

AMA CPT 93010 / RVUs 0.24 Reimbursement = $8.65

• Over $ 150,000 can be generated from the proper ....documentation of EKG interpretations alone at one ....site in 1 year.

• Can I bill? ... It depends (subject to policies based on ....statute, regulation, and / or contractual agreement) ... ....likely, yes.

• About 80% of Emergency Medicine practices submit ....EKG interpretations for financial reimbursement.1

Yes, These Are Important.

1. Granovsky, M. “The Most Common ED Procedures”; ACEP Coding Conference 2018, faculty presentation.

Your EKG Interpretations This is How You Reimburse:

“EKG interpretation: Normal sinus rhythm with heart rate in the 60s. Normal axis. No LVH. No significant ST/T abnormalities are apparent. No significant change compared with the patient’s April 2016 EKG, as interpreted by me.”

1. An order must be placed for the EKG.

2. Three or four elements must be included as part of ….your EKG interpretation.

3. Documentation must be present that supports the ….need for this diagnostic test.

• Rate & rhythm

• Axis

• Atrial / Ventricular hypertrophy

• Comparison with previous EKG

EKG Elements That Apply They’re Right Here:

• ST / T abnormalities (or absence)

• PR / QT intervals

• QRS width

The Best Charting Reimbursement Caveats for Your EKGs:

• An order must be placed.

• CPT guidelines require a “separate” report.

• Reason should be apparent.

“EKG: Atrial fibrillation with heart rate in the 110s. Normal axis. No LVH. ST depression in leads V3 through V6 apparent. No significant change compared with the patient’s July 2015 EKG, as interpreted by me.”

• “As interpreted by me”

• Turf wars may apply.

Which of the following therapies will likely help relieve his pain?

A) Trigger Point Injections

B) Osteopathic Manipulative Therapy

C) Sphenopalatine Ganglion Blocks

D) Easy Access to the Nurse’s Call Light

E) All of the above except D.

A 36 y/o presents with a chief complaint of severe headache. He indicates he was a history of migraines. His headache is similar to those in the past though prior to arrival he has taken sumatriptan, hydrocodone, and even extra-strength acetaminophen without significant relief.

Answer:

Your Reimbursement in the Age of ALTOALTO = Alternatives to Opioids

Trigger Point Injections:

• Based on the total number of muscles treated, not the number of injections.

• Be sure to specify the muscle(s) being treated.

CPT 20552 Injection of single or multiple trigger points, 1-2 muscles RVUs 1.09 / $ 39.28

CPT 20553 Injection of single or multiple trigger points, 3 or more muscle RVUs 1.24 / $ 44.69

“Procedure - Trigger Point Injection: Using sterile technique, 2 muscles were injected for pain control. Bupivicaine 0.5% 2m was injected into each trapezius muscle at the C6 paraspinal region.”

Headache Management in the EDAnd All Things ALTO

Sphenopalatine Ganglion Injection:

• “Enter if your dare.”

Visc. Lidocaine on Cotton tip vs. Injection

(CPT 64505: RVU 2.69)

What About OMT

in the ED?

Yes, Your Service is Valuable

• Here’s the Reimbursement for your ….OMT service:

98926 Osteopathic manipulation treatment (OMT); 3-4 body regions involved1.02 RVUs / $ 36.76

98929 Osteopathic manipulation treatment (OMT); 9-10 body regions involved2.05 RVUs / $ 73.88

• Additionally, Your E/M Service is likely ...Reimbursable (2019 CPT Guidelines):

Associated Emergency Department services (CPT 99281 through 99285) “may be reported separately if the patient’s condition requires a significant, separately identifiable E/M service above and beyond the usual pre-service and post-service work associated with the procedure.”

• Therefore, keeping this in mind:

1. Always detail the “Nature of the Presenting Problem” in your HPI.

2. Always include a Differential Diagnosis!

OMT in the Emergency RoomThis is How You Chart It:

• OMT Codes => 98925 thru 98929, categorized by the number of body regions involved.

All for the same service, in increments of 1-2 body regions. (1-2) => (9-10)

• Be sure to detail the specific body region(s) being treated:

Head / Cervical / Thoracic / Lumbar / Sacral / Pelvic Lower Extremities / Upper Extremities / Rib cage Abdomen / Viscera

Here’s How Your Documentation Should Look:

“Procedure - OMT: I manipulated lesions in the Cervical, Thoracic, and Lumbar regions.

Using HVLA technique, the patient’s paraspinal right C6, left T3 through T6, and right L3 lesions were treated with OMT with good results.”

What About Your 2 A.M. Special?

Dental Nerve Blocks

• 64450 “Injection, anesthetic agent, other peripheral nerve or branch”

1.28 RVUs / $ 46.13

“Procedure - Dental Nerve Block: Using a 27 gauge needle, 2ml of Bupivicaine 0.5% was injected in the buccal vestibule just superior to the patient’s left 1st upper premolar.”

• 64400 “Injection, Injection, anesthetic agent, trigeminal nerve, any division or branch”

2.08 RVUs / $ 74.96

“Procedure - Inferior Alveolar Nerve Block: Using a 27 gauge needle, 2ml of Bupivicaine 0.5% was injected using an intra-oral approach just medial to the lower portion of the ramus of the mandible on the right.”

For All Those Interested:

Other Nerve Blocks That Are Useful

• Intercostal Nerve Block(s):

64420 “Injection, anesthetic agent, intercostal nerve, single”

1.92 RVUs / $ 69.20

64421 “Injection, anesthetic agent, intercostal nerves, multiple”

2.64 RVUs / $ 95.14

• Femoral Nerve Block:

64447 “Injection, anesthetic agent, femoral nerve, single”

1.91 RVUs / $ 68.83

Time to Pausefor Reflection:

Additional Questions?

If You Always Wanted to Know ... Here They Are:

• Shoulder dislocation reduction = 8.29 RVUs / $ 298.76

• Elbow dislocation reduction = 9.60 RVUs / $ 345.98

• Ankle dislocation reduction = 10.71 RVUs / $ 385.98

(Based on 2019 Medicare Physician Fee / RVU Conversion Factor, 1 RVU = $ 36.04)

• CPT 25605 “Closed treatment of distal radius fracture” = 14.57 RVUs!

“Procedure: Fracture Reduction - Distal Radius. The risks, benefits, alternatives were explained to the patient. Informed consent was obtained. Using in-line traction, volar pressure was applied to the distal fracture fragment. The fracture was reduced and the patient’s deformity was resolved ...”

Switching Gears to OrthopedicsHigh Value Procedures

Hip Reductions and

Your Reimbursement

Question: In regard to Emergency Medicine reimbursement ...Which of the following is most important to document with your hip reductions?

The Difference is in the Details.

A) The anatomical position of the dislocation (anterior vs posterior).

B) The involvement of neurovascular compromise.

C) The presence of any overlying wound (skin avulsion / laceration).

D) The involvement of a post-arthroplasty hip.

E) The presence of an associated acetabular fracture.

Answer:

Hip Reductions There is Power in Your Charting:

• Hip Reduction involving a ....Traumatic Hip = 5.17 RVUs

• Hip Reduction involving a ....Post-Arthroplasty Hip = 11.52 RVUs

• Thus, $ 228.86 is what’s realized when ....you specify “post-arthroplasty” hip.

“Procedure – Post-Arthroplasty ..Hip Dislocation Reduction: …”

Don’t Forget to...Document the Orthopedic “Small Stuff”

Remember to document the procedure even though you might not sweat it.

• Nursemaids elbow reduction = 2.23 RVUs / $ 80.37

• Finger interphalangeal reduction = 7.29 RVUs / $ 262.73

• Patellar dislocation reduction = 9.66 RVUs / $ 348.14

* Based on $ 36.04 / 1 RVU (2019 Medicare Physician Fee Schedule : RVU Conversion Factor)

• Your active involvement in splint application is the best way

….to ensure reimbursement.

“Direct supervision only” may be restricted by local payer rules.

• Be sure to adequately document the application of the splint:

One of the most commonly documented re-inspection terms =

Neurovascular notations:

“A long arm splint was applied by myself. The patient remained

neurovascularly intact distally after splint application as

evaluated by myself.”

With Splints, Your Best Bet is to be Hands-On:

Other Commonly Acceptable Notations in Splint Application

• “An ulnar gutter splint was applied by myself. ….The splint was maintained in the desired …..position after application as evaluated by ….myself.”

• “A long leg splint was applied by myself. The ….splint was intact after application as ….evaluated by myself.”

• “An digital splint was applied by myself. The ….splint was effective in immobilizing the injury …..after application as evaluated by myself.”

Here’s the value of the service you provide:

• Short Arm splint: CPT 29125 => 1.13 RVUs

• Long Arm splint: CPT 29105 => 1.38 RVUs

• Short Leg splint: CPT 29515 => 1.42 RVUs

Which of the following most accurately describes overall RVU reimbursement in Emergency Medicine?

A) 99281-99285 = 65%; Procedures = 20%; Critical Care = 15%

B) 99281-99285 = 75%; Procedures = 15%; Critical Care = 10%

C) 99281-99285 = 83%; Procedures = 9%; Critical Care = 8%

D) 99281-99285 = 89%; Procedures = 6%; Critical Care = 5%

(Granovsky, M; ACEP Reimbursement & Coding Conference 2018; “The Most Common ED Procedures”)

You just completed a “very challenging” shift. On the ride home, you wonder if you will be paid appropriately for all the work you have done. You remind yourself that “I’m just a physician”, not a billing expert or medical coder. You were trained to care of patients, not reimbursement issues. You think “What, if anything, can I do?” ... First, let’s take a look inward:

Answer:

Your Medical Decision MakingThis is the Key to Your Success:

Your Everyday Service Makes UpThe Foundation of Your Reimbursement

The DNA of RVUs (Relative Value Units):

• Level 1 Encounter: CPT 99281 0.60 RVUs = $ 21.62





(Based on 2019 Medicare Physician Fee / precise amount geographic specific)

• The difference between a level 3 and 4 patient encounter = $ 56.58



Your Reimbursement

Potential is Greater Than

You Think:

• Every year more than $ 68,000,000 ....is left on the table by Emergency ....Physicians.1

(Estimate based on assessment of Medicare Part B downcoding losses by ED Providers.)

• This is the unrealized reimbursement ....that stems from inadequate ....Documentation by Clinicians.

1. Blakeman, J. EDPMA QCDC Co-Chair / Member of American Academy of Emergency Medicine Practice Management Committee. Physician reimbursement,

medical coding, and policy development expert. Personal correspondence May 9, 2018)

Here’s The Bottom Line for Medical Decision Making (MDM):

• Emergency Medicine’s E/M CPT 99281-99285 are ...determined via MDM elements.

• Medical Decision Making (MDM) is calculated ...using audit tools which focus on:

1) The Number of Diagnosis and Treatment Options

2) Amount and / or Complexity of Data Reviewed

3) Level of Risk Table

• “Marshfield Clinic Grid” scoring systems are ….used nationwide to evaluate documentation.

(Though CMS maintains their use is neither encouraged nor prohibited.)

These point systems parallel CMS 1995 E/M Documentation Guidelines and CPT essentials regarding MDM.

• A number of specific diagnostic and active interventions in EM score “points” or register various degrees of “risk” within the Marshfield Clinic Grid framework.

You can optimize your reimbursement by being mindful of the service you provide and by charting all that’s “counted” as important!

Here’s How You Can Optimize in the Area of Diagnostics:

The Marshfield Clinic Grid assigns points and makes distinction for:

• LABS ordered and / or reviewed.

• X-RAYS ordered and / or reviewed.

• INDEPENDENT VISUALIZATION of an image or tracing.

• DISCUSSION OF TEST RESULTS with the performing physicians (i.e radiologist)

These are Medical Decision Making elements.

Including These in Your Charting can Help Make the Difference between a Level 3, 4, or 5 Reimbursement.

When Appropriate, Your Charting

Should Look Like This:

• “Labs - CBC, BMP, Troponin I, PT/PTT - ….see chart / reviewed.”

• “Blood cultures x 2 - ordered.”

• “EKG - NSR with HR 70s, No LVH, t wave inversion ….in leads v3-v4-v5, no ectopy, no ST abnormalities ….as interpreted by me.”

• “Chest X-ray - no focal infiltrate, no pneumothorax, ….as interpreted by me.”

• “CT Head - see chart. I discussed the results with ….the radiologist.”

• “VQ scan - see chart / reviewed.”

Other Factors that Contribute to your MDM (and Reimbursement)

Historical Interventions:

• Medical record review with summation of old records.

“The computer records were reviewed for this patient. The patient was admitted to our hospital with chest pain last month. CTA of the chest at that time was negative for PE.”

• History obtained from another party with elaboration.

“The patient’s wife was at bedside and she contributed to the patient’s history. She indicated the patient just had a cardiac stress test at St Frances hospital.”

• Decision to obtain medical records or history from another party.

“The patient’s stress test report from St. Frances hospital was requested.”

Your Interventions Do Matter,

More Important MDM Elements:

Therapeutic Interventions:

• Medications ordered

“2 L N/C, Aspirin 325mg po, SL nitro 0.4mg”

• Parenteral controlled substance administr.

“Morphine 2mg IV”

• Administration of IV fluids w/ or w/o additives

“Normal saline 500 ml bolus”

Final MDM DetailsThat Will Serve You Well :

Active Interventions:

• Drug therapy requiring intensive monitoring for toxicity. (i.e. cardizem drip)

“Cardizem 5mg / hr gtt and the patient was placed on a cardiac monitor during this therapy.”

• DNR or De-escalation of care decisions.

“The patient indicated he does not want any intubation or mechanical ventilation should his condition continue to deteriorate.”

• Discussion with other health providers.

“The case was discussed with the primary physician on call and the patient was accepted for admission to the hospital.”

In Conclusion...

There are Virtually No “Trivial Interventions”

• All of these details play a pivotal role in

calculating the overall complexity of a

case.

• In regards to Your Medical Decision

Making, each of these elements has

value.

• Adhere to the Guiding Axiom:

“If You Did It, Be Sure to Document It.”

You will succeed!

MedicoLegal Pearls That Will Benefit Everyone:

"A 12 y/o male is seen for abdominal pain and discharged home.

.He returns 2 days later with a ruptured appendix."

• At first glance, you might think, what happened in the above encounter?

• Did the clinician "miss" the diagnosis of appendicitis?

• True, human error does occur ... and we are all human.

• However, in a number of patient encounters, the root cause lies elsewhere.

What Makes You Better than Your

Colleagues?

If you've practiced Emergency Medicine long

enough, you've seen everyone else's “bounce

backs”.

What makes you sure that your colleagues

haven't seen yours?

• Disease Processes Evolve Over Time -

regardless of a physician's clinical ability and

excellence in care.

• It’s best not to trivialize or overlook this simple

reality.

• In many of these cases, your documentation

is the key to detailing the quality of your care.

How Could You Be?

It’s Best to Gain Wisdom From This Case.

"A 12 y/o male is seen for abdominal pain and discharged home. He returns 2 days later with a ruptured appendix."

In reviewing this chart, suppose you find the following documentation:

• "Disposition re-exam: The patient appears in no acute distress, mild epigastric tenderness with palpation, abdomen is soft and otherwise non-tender. No McBurney's point tenderness. No new complaints.”

• "I discussed the case with the patient's pediatrician, Dr. Spencer, and he will follow-up the patient in the office as an outpatient."

• "The patient and mother were counseled about the nature of the medical problem including the differential diagnosis of appendicitis and appropriate follow-up was discussed."

• "The mother was instructed to have the patient return to the Emergency Department if the patient becomes worse, has any problems, or develops new symptoms, including any localization of pain to the right lower quadrant, fever, or vomiting."

Suppose All Emergency Care was the SameOnly One Issue...

"A 12 y/o male is seen for abdominal pain and discharged home. He returns 2 days later with a ruptured appendix."

In reviewing this chart, suppose you find the following documentation:

• No re-exam

• No discussion with primary physician

• No counseling

Assume all of the above were performed by this provider. (just not documented)

This case instantly becomes open to scrutiny and review.

This Doc Advocating “Best Practices”

Never Worked in My ER

• Challenge yourself to take note of the next chart you review.

You might think that re-exam, consultation, and counseling documentation falls under best practices ...

… and thus would be natural for you and all of the clinicians in your group.

You may be surprised by the omission of such “simple” detail.

• When the ER gets busy, charting frequently takes a back seat.

Understandably so - when our work gets hectic, the drive is to take care of patients first.

• When the Emergency Room gets busy, take a quick pause, and chart what matters.

In this arena, an ounce of prevention is certainly worth a pound of cure.

Emergency Clinicians,

Here’s What You Can Learn From This:

Keep in Mind These 3 Key Charting Tips:

1) Document a disposition re-exam. ….(every patient, every time)

2) Document your discussions with the …..primary and / or consulting physicians.

3) Document your counseling.

When Disease Processes Evolve ...

Your Documentation will Make All the Difference!

Emergency Medicine ReimbursementPearls That Will Make You Stronger:

• Stay sharp with your HPIs ->

...A “must have” for “Nature of the Presenting Problem”

• Always include a Differential Diagnosis

...“Every chart, every time” -> instant tool for MDM.

• List Multiple Diagnoses, as appropriate

....Can support Medical Necessity / Severity of Illness

• Level 5 Encounters: HPI 4 / PMSF 2 / ROS 10 / PE 8

....Essential ... No Level 5 Reimbursement without!

Emergency Medicine Reimbursement Pearls that will Make You Wiser:

• “Always Document a Disposition Re-exam”

….(MedicoLegal) All patients -> you’ll never regret it.

• “Always Chart your consultations with PCPs &

…..Consultants.” (MedicoLegal & Reimbursement)

• APPs and Medicare Patients -> “Face to Face”

....Prevents 15% loss ... Rule of 1s!

• No scribe, supercoder, or super-computer system can accomplish what only You Can Do.

• Emergency Medicine Clinicians - You do have a role in this.

• Chart smarter, not harder - You will succeed.

In conclusion... What You Document Makes a Difference:

You Can Positively Impact Your Reimbursement.

Dan Magdziarz, DO

CEO & Founder, ChartOptima LLC

(630) 863-5294

www.ChartOptima.com

[email protected]

Have any questions? Feel Free to Contact Me:

Documents

Dan Magdziarz, DO - acoep.org · • OGT / NGT placement (if staff unable to obtain) • Cardiac output interpretation • Transcutaneous pacing. ... Dan Magdziarz, DO