MEDICARE: UNDERSTANDINGWHAT IS HAPPENING AND PREPARING FOR 2013

MEDICARE: UNDERSTANDING

WHAT IS HAPPENING AND PREPARING FOR

2013

Association of Northern California

Oncologists

January 2-4, 2013

• Why This Seminar Is NecessaryWhy This Seminar Is Necessary• Documentation and Chart ReviewDocumentation and Chart Review

– Why ReviewWhy Review– Coding Principles & MisunderstandingsCoding Principles & Misunderstandings

• Review PrinciplesReview Principles– Medical Necessity Very ImportantMedical Necessity Very Important– Complexity of Decision MakingComplexity of Decision Making– Frequency of visits vs illnessFrequency of visits vs illness

• EHR and TemplatesEHR and Templates– Chief Complaint Issues, Active Problem IssuesChief Complaint Issues, Active Problem Issues– Cloning and Decision MakingCloning and Decision Making

• Managing ChangeManaging Change– MAC Contract for J “E”MAC Contract for J “E”– 2013 fee schedule, Changes2013 fee schedule, Changes– Recovery Auditors (Formerly RACs)Recovery Auditors (Formerly RACs)– LCDs and NCDsLCDs and NCDs– OtherOther

WE WILL DISCUSS

REPORT ON SPECIAL STUDIES OF E & M

• Data Studies Show Medical Review is NecessaryData Studies Show Medical Review is Necessary– OIG Findings –Consistent increase in high E&M codesOIG Findings –Consistent increase in high E&M codes– BESS Data --- Nationwide & Local, 12 or more mos oldBESS Data --- Nationwide & Local, 12 or more mos old– CERT Data --- Nationwide & Local, recent findingsCERT Data --- Nationwide & Local, recent findings– Palmetto GBA Data Mining --- Local searchesPalmetto GBA Data Mining --- Local searches

• Who Was Reviewed in Recent StudyWho Was Reviewed in Recent Study– Outliers by Service Type / Specialty TypeOutliers by Service Type / Specialty Type– Outliers of the Outliers (2 St. Deviations or more)Outliers of the Outliers (2 St. Deviations or more)

• What Was RequestedWhat Was Requested– 5 Charts per Provider per Code, single chart per service5 Charts per Provider per Code, single chart per service

• PurposePurpose– General Education of Physicians / OfficesGeneral Education of Physicians / Offices– Denials Followed by Contact from POEDenials Followed by Contact from POE– Specific Education for Denied PhysiciansSpecific Education for Denied Physicians

TECHNICAL DENIALS• Many Chart Denials are for Technical ReasonsMany Chart Denials are for Technical Reasons

– Missing or illegible provider signature or use of a Missing or illegible provider signature or use of a signature stamp signature stamp

– Missing or unsigned physician orders Missing or unsigned physician orders – Illegible documentationIllegible documentation – Failure to provide documentation for all dates Failure to provide documentation for all dates of of

service requested service requested • If Technical Denials Prevented or Corrected--- If Technical Denials Prevented or Corrected---

Claim Paid First AttemptClaim Paid First Attempt– Up to 50% denials for technical reasonsUp to 50% denials for technical reasons– Office staff should prevent that from happeningOffice staff should prevent that from happening

MEDICARE MANUAL SAYS:

• Medicare will reimburse Medicare will reimburse for all services that are for all services that are reasonable and reasonable and necessary for the necessary for the diagnosis and treatment diagnosis and treatment of an illness or injury or of an illness or injury or to repair a damaged to repair a damaged organorgan

WE (PALMETTO) SAY:WE (PALMETTO) SAY:

• Only the physician Only the physician treating the treating the patient knows patient knows what is reasonable what is reasonable and necessary for and necessary for that patient being that patient being evaluated and evaluated and treated.treated.

•The only way The only way Palmetto GBA can Palmetto GBA can know if something know if something is reasonable and is reasonable and necessary is to necessary is to read the complete read the complete documentation documentation submittedsubmitted

PURPOSE OF DOCUMENTATION

• Communicate with Health Care Personnel– Physicians, colleagues– Other health care workers& caregivers – Remind yourself what is going on

• Communicate with Others– Quality review (PQRI, P4P)– Peer review (PRO, hospital, licensing

board, credentialing groups)– Patient transparency– Protect against liability issues– Insurance review personnel (pre and post

pay situations)

BEST FORMAT FOR DOCUMENTATION

• There is no best single format• Can use any & all variants

– History, Exam, Decision, Order– Subjective, Objective, Assessment, Plan– Pre-printed forms – if specific– Electronic records – if specific– Printed / written legible notes

• Explain to the reviewer– Nature of patient problems– How / why patient treated– What is next and why (decisions)– Expected outcome if known

DOCUMENTATION DOCUMENTATION POINTSPOINTS

• Templates/forms OK, but must be Templates/forms OK, but must be individualizedindividualized for each visit for each visit

• Patient name, date, time, and ID of Patient name, date, time, and ID of who documented chartwho documented chart

• Computerized notes okay if Computerized notes okay if individualized, but individualized, but medical medical necessity still rulesnecessity still rules on review on review

• Require time when service time Require time when service time related-e.g. face to face timerelated-e.g. face to face time

• If poorly legible, or not properly If poorly legible, or not properly signed--we must reject the claimsigned--we must reject the claim

• NEW PATIENT VS. ESTABLISHED PATIENTNEW PATIENT VS. ESTABLISHED PATIENT– DIFFERENT CODES AND PAYMENT FOR EACHDIFFERENT CODES AND PAYMENT FOR EACH– RACS KEEP LOOKING AT THIS DENIALRACS KEEP LOOKING AT THIS DENIAL– EFFECTS SAME SPECIALTY GROUPSEFFECTS SAME SPECIALTY GROUPS

• PLACE OF SERVICEPLACE OF SERVICE– INPATIENT OR OUTPATIENT (E.G. OFFICE)INPATIENT OR OUTPATIENT (E.G. OFFICE)– HOSPITAL, ED, SNF, ECF, HOME, ASC, OTHERHOSPITAL, ED, SNF, ECF, HOME, ASC, OTHER

• ““LEVEL” OF CARELEVEL” OF CARE– REGULAR (5 OUTPATIENT, 3 INPATIENT)REGULAR (5 OUTPATIENT, 3 INPATIENT)– CRITICAL CARE, OBSERVATION, EXTRA TIMECRITICAL CARE, OBSERVATION, EXTRA TIME– SPECIAL SERVICES (EYE, MENTAL HEALTH)SPECIAL SERVICES (EYE, MENTAL HEALTH)

CODING & DOCUMENTATION DISTINCTIONS

• CONSULTATION, –GONE FROM MEDICARE 2010CONSULTATION, –GONE FROM MEDICARE 2010

DEFINITION: NEW DEFINITION: NEW PATIENTPATIENT

• PATIENT WHO HAS NOT RECEIVED SERVICES FROM PATIENT WHO HAS NOT RECEIVED SERVICES FROM A PHYSICIAN OF A PHYSICIAN OF SAME SPECIALTY SAME SPECIALTY WHO BELONGS WHO BELONGS TO TO SAME GROUP PRACTICESAME GROUP PRACTICE FOR FOR 3 YEARS3 YEARS

• PATIENTS SEEN BY COVERING OR ON-CALL DOCTOR PATIENTS SEEN BY COVERING OR ON-CALL DOCTOR CONSIDERED PATIENT OF USUAL DOCTOR WHO IS CONSIDERED PATIENT OF USUAL DOCTOR WHO IS UNAVAILABLEUNAVAILABLE

• NO DISTINCTION MADE BETWEEN NEW AND NO DISTINCTION MADE BETWEEN NEW AND ESTABLISHED PATIENT IN EMERGENCY DEPT.ESTABLISHED PATIENT IN EMERGENCY DEPT.

• A REFERRAL VISIT NOT NEW IF SEEN FACE TO FACE A REFERRAL VISIT NOT NEW IF SEEN FACE TO FACE FOR ANY OLD OR NEW PROBLEM IN ANY PLACE OF FOR ANY OLD OR NEW PROBLEM IN ANY PLACE OF SERVICE WITHIN SERVICE WITHIN 3 YEARS3 YEARS

COGNITIVE (EVALUATION & COGNITIVE (EVALUATION & MANAGEMENT) SERVICESMANAGEMENT) SERVICES

• INVOLVE ALL PHYSICIANS WHO EXAMINE AND EVALUATE INVOLVE ALL PHYSICIANS WHO EXAMINE AND EVALUATE PATIENTSPATIENTS

• REQUIRE REQUIRE DOCUMENTATIONDOCUMENTATION TO SHOW LEVEL OF WORK & TO SHOW LEVEL OF WORK & LEVEL OF CODING FOR REIMBURSEMENTLEVEL OF CODING FOR REIMBURSEMENT

• ACTIVITY BASED, TIME BASED, OR BOTHACTIVITY BASED, TIME BASED, OR BOTH• ALL SURGERY / PROCEDURES HAVE SOME INHERANT E&M ALL SURGERY / PROCEDURES HAVE SOME INHERANT E&M

SERVICES INCLUDEDSERVICES INCLUDED• E&M DOC. GUIDELINES COMPLICATEDE&M DOC. GUIDELINES COMPLICATED• MEDICAL NECESSITY A KEY FACTOR IN DECIDING MEDICAL NECESSITY A KEY FACTOR IN DECIDING

APPROPRIATE E&M LEVELAPPROPRIATE E&M LEVEL• NECESSARY TO INTEGRATE DOCUMENTED CODING WITH NECESSARY TO INTEGRATE DOCUMENTED CODING WITH

MEDICAL NECESSITY OF SERVICEMEDICAL NECESSITY OF SERVICE

COMPONENTS OF (E&M) COMPONENTS OF (E&M) SERVICESSERVICES

• CHIEF COMPLAINTCHIEF COMPLAINT

• HISTORYHISTORY

• EXAMEXAM

• DECISION MAKINGDECISION MAKING

• COUNSELINGCOUNSELING

• COORDINATION COORDINATION

OF CAREOF CARE

• NATURE OF NATURE OF PRESENTING PROBLEMPRESENTING PROBLEM

• TIMETIME

CHIEF COMPLAINTCHIEF COMPLAINT• “A chief complaint is a concise statement describing

the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient's words.” …..from AMA CPT

• The reason for the encounter often sets the stage for what is needed in the history, exam, and decision tree.

• New problems MAY take more effort than old ones• Medicare does not pay for routine patient visits except

for one NEW TO MEDICARE visit and one annual healthy assessment visit

99213 billed-- denied

Should be 99212---infer the work Should be 99212---infer the work not the “regular check up”not the “regular check up”

PRESENTING PROBLEM

• A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter. The E/M codes recognize five types of presenting problems that are defined as follows:

• MinimalMinimal:: A problem that may not require the presence of the physician, A problem that may not require the presence of the physician, but service provided under the physician's supervision.but service provided under the physician's supervision.

• Self-limited or minorSelf-limited or minor:: A problem that runs a definite &prescribed A problem that runs a definite &prescribed course, is transient & UNLIKELY to permanently alter health status OR course, is transient & UNLIKELY to permanently alter health status OR has a good prognosis with management / compliance.has a good prognosis with management / compliance.

• Low severity:Low severity: A problem where the risk of morbidity without treatment A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected.recovery without functional impairment is expected.

• Moderate severityModerate severity:: A problem where the risk of morbidity without A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged treatment; uncertain prognosis OR increased probability of prolonged functional impairment.functional impairment.

• High severityHigh severity:: A problem where the risk of morbidity without treatment A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional treatment OR high probability of severe, prolonged functional impairment.impairment.

PRESENTING PROBLEM (OR PROBLEMS)

ELEMENTS OF HISTORY PAST HISTORYPAST HISTORY• A review of the patient's past A review of the patient's past

illnesses, injuries, and illnesses, injuries, and treatments treatments withwith significant significant information about:information about:– Prior major illnesses and injuries Prior major illnesses and injuries – Prior operations Prior operations – Prior hospitalizations Prior hospitalizations – Current medications Current medications – Allergies (eg, drug, food) Allergies (eg, drug, food) – Age appropriate immunization Age appropriate immunization

status status – Age appropriate feeding/dietary Age appropriate feeding/dietary

statusstatus

SOCIAL HISTORY•An age appropriate An age appropriate review ofreview of past & current past & current activities with activities with information about:information about: - - Marital status and living Marital status and living arrangements arrangements - Current employment - Current employment - Occupation history - Occupation history - Use of drugs, alcohol, & - Use of drugs, alcohol, & tobacco tobacco - Level of education - Level of education - Sexual history - Sexual history - Other relevant social - Other relevant social factorsfactors

REVIEW OF SYSTEMSREVIEW OF SYSTEMS• An inventory of body systems seeking to An inventory of body systems seeking to

identify signs and/or symptoms that the identify signs and/or symptoms that the patient may be experiencing or has patient may be experiencing or has experienced. For the purposes of the CPT experienced. For the purposes of the CPT codebook the following elements of a codebook the following elements of a system review have been identified …system review have been identified …

• The review of systems helps define the The review of systems helps define the problem, clarify the differential diagnosis, problem, clarify the differential diagnosis, identify needed testing, or serves as identify needed testing, or serves as baseline data on other systems that baseline data on other systems that might be affected by any possible might be affected by any possible management options.management options.

•Constitutional Constitutional symptoms (fever, symptoms (fever, weight loss, etc.) weight loss, etc.) •Eyes Eyes •Ears, nose, mouth, Ears, nose, mouth, throat throat •Cardiovascular Cardiovascular •Respiratory Respiratory •GastrointestinalGastrointestinal

•GenitGenitoourinary urinary • Musculoskeletal Musculoskeletal • Integumentary (skin Integumentary (skin and/or breast) and/or breast) • Neurological Neurological • Psychiatric Psychiatric • Endocrine Endocrine • Heme - lymphatic Heme - lymphatic •Allergy-immunologyAllergy-immunology

REVIEW OF SYSTEMSREVIEW OF SYSTEMS• In all documentation, you should see In all documentation, you should see all all

positivepositive findings and findings and pertinentpertinent negativenegative findings findings

• In regard to the present illness, we In regard to the present illness, we would expect:would expect:– Positive findings of system related to Positive findings of system related to

present illnesspresent illness– Pertinent negative findings to systems Pertinent negative findings to systems

related to present illnessrelated to present illness– Pertinent findings or comment on changes in Pertinent findings or comment on changes in

systems that are listed as co-morbidities or systems that are listed as co-morbidities or secondary problemssecondary problems

• Unrelated systems can be “within Unrelated systems can be “within normal limits, negative, normal or normal limits, negative, normal or unremarkable if they areunremarkable if they are

EXAM DOCUMENTATIONEXAM DOCUMENTATION

• PROBLEMPROBLEM FOCUSEDFOCUSED

• EXPANDED EXPANDED PROBLEM FOCUSEDPROBLEM FOCUSED

• DETAILEDDETAILED

• COMPREHENSIVECOMPREHENSIVE

• Limited exam of affected Limited exam of affected body area / organ sys.body area / organ sys.

• Limited exam affected Limited exam affected body area & symptomaticbody area & symptomatic related body areasrelated body areas

• Extended exam of affected Extended exam of affected body area and any other body area and any other symptomatic or related symptomatic or related body area.body area.

• General multi-system General multi-system … ..Or complete single … ..Or complete single system and symptomatic system and symptomatic or related body areasor related body areas

EXAM DOCUMENTATIONEXAM DOCUMENTATION

• For the purposes of these CPT For the purposes of these CPT definitions, the following body areas are definitions, the following body areas are recognized:recognized:– Head, including the face Head, including the face – Neck Neck – Chest, including breasts and axilla Chest, including breasts and axilla – Abdomen Abdomen – Genitalia, groin, buttocks Genitalia, groin, buttocks – Back Back – Each extremityEach extremity

12 TYPES OF EXAMS12 TYPES OF EXAMS

1. MULTISYSTEM1. MULTISYSTEM

2. CARDIOVASCULAR2. CARDIOVASCULAR

3. E.N.T.3. E.N.T.

4. OPHTHALMOLOGY4. OPHTHALMOLOGY

5. G.U. (Female)5. G.U. (Female)

6. G.U. (Male)6. G.U. (Male)

7. HEME / LYMPHATIC7. HEME / LYMPHATIC

8. MUSCULOSKETAL8. MUSCULOSKETAL

9. NEUROLOGICAL9. NEUROLOGICAL

10 PSYCHIATRIC10 PSYCHIATRIC

11 RESPIRATORY11 RESPIRATORY

12 SKIN12 SKIN

ANY PHYSICIAN CAN BILL A MULTI-ANY PHYSICIAN CAN BILL A MULTI-SYSTEM EXAMSYSTEM EXAM

ANY PHYSICIAN CAN BILL A SINGLE ANY PHYSICIAN CAN BILL A SINGLE SYSTEM EXAMSYSTEM EXAM

Multispecialty and 11 single specialty exams

DECISION MAKING• Decision making refers to complexity of Decision making refers to complexity of

establishing a diagnosis and-or selecting establishing a diagnosis and-or selecting management options as measured by:management options as measured by:– Number of possible diagnoses and/or the number of Number of possible diagnoses and/or the number of

management options that must be considered management options that must be considered – Amount and / or complexity of medical records, Amount and / or complexity of medical records,

diagnostic tests, and/or other information that must diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed be obtained, reviewed, and analyzed

– The risk of significant complications, morbidity, and-or The risk of significant complications, morbidity, and-or mortality, as well as co-morbidities, associated with mortality, as well as co-morbidities, associated with the patient's presenting problem(s), the diagnostic the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management procedure(s), and/or the possible management optionsoptions

COMPLEXITY OF DECISION MAKING

•Four types of medical decision making are recognized: straightforward, low complexity, moderate complexity, and high complexity. To qualify for a given type of decision making, two of the three elements in Table 1 must be met or exceeded.•Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless their presence significantly increases the complexity of the medical decision making.

Comorbidities / underlying diseases, Comorbidities / underlying diseases, in and of themselves, are not in and of themselves, are not considered in selecting a level of considered in selecting a level of E/M services E/M services unlessunless their presence their presence significantly increases the significantly increases the complexity of the medical decision complexity of the medical decision making.making.

DOCUMENTATION OF DOCUMENTATION OF DECISION MAKINGDECISION MAKING

• There are instances where no change in There are instances where no change in care is a complex and high level decision care is a complex and high level decision BUTBUT– This should be documented for reviewThis should be documented for review– Many EHR do not allow space for thisMany EHR do not allow space for this– May be shown in “rule outs”, “possible dx”, or May be shown in “rule outs”, “possible dx”, or

elements of physician thoughtselements of physician thoughts– Orders or plans may show decision makingOrders or plans may show decision making– Decision making relates to that visit onlyDecision making relates to that visit only– Where decision making is used to create higher Where decision making is used to create higher

level of code, we expect some indication in level of code, we expect some indication in recordrecord

SELECTING A CODE-CPT SELECTING A CODE-CPT AVERAGE TIMEAVERAGE TIME

• 99211: Typically, 5 minutes are spent performing or Typically, 5 minutes are spent performing or supervising these servicessupervising these services. .

• 99212: Typically physicians spend 10 minutes face to Typically physicians spend 10 minutes face to face with the patient.face with the patient.




•

Counseling and/or coordination of care with other providers or Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.and the patient's and/or family's needs.

MEDICAL NECESSITY OF E&M VISITS--OFFICE

• New Patient Visits:New Patient Visits: – No visits for No visits for 3 years3 years by physician by physician– Require Require all 3:all 3: History, PE, Decision making History, PE, Decision making

• Subsequent Patient VisitsSubsequent Patient Visits– Require Require any 2: any 2: Hx, PE, DecisionHx, PE, Decision– 99211: Brief visit, no MD (BP check, sutures out)99211: Brief visit, no MD (BP check, sutures out)– 99212: Single problem, easy to dx and resolve99212: Single problem, easy to dx and resolve– 99213: Average 10-15 follow up several problem99213: Average 10-15 follow up several problem– 99214: Complex patient, mult problems99214: Complex patient, mult problems– 99215: Require extensive visit with full workup-99215: Require extensive visit with full workup-

new serious problem or patient new serious problem or patient with with major risk to organ system or lifemajor risk to organ system or life

E&M VISITS-HOSPITAL• Initial In-Patient Visits:Initial In-Patient Visits:

– First visit in hospital – and Initial Referral VisitFirst visit in hospital – and Initial Referral Visit– Require Require all 3all 3: Hx, PE, Decision Making: Hx, PE, Decision Making– 99221, 99222, 99223 levels if meets criteria99221, 99222, 99223 levels if meets criteria– Usually full H&P needed by Attending MDUsually full H&P needed by Attending MD

• Subsequent Patient Visits in HospitalSubsequent Patient Visits in Hospital– Require Require any 2any 2: Hx, PE, Decision: Hx, PE, Decision– 99231: Brief visit-better-discharge soon99231: Brief visit-better-discharge soon– 99232: Average day, IVs, Dx tests, active Rx99232: Average day, IVs, Dx tests, active Rx– 99233: New or worsening problems-99233: New or worsening problems-

• Discharge day - discharge codes for attending Discharge day - discharge codes for attending physician- physician- (99231 for others)(99231 for others)

CRITICAL CARE CODESCRITICAL CARE CODES

• Critical care is the direct Critical care is the direct delivery by a physician(s) of delivery by a physician(s) of medical care for a critically ill medical care for a critically ill or critically injured patient. A or critically injured patient. A critical illness or injury critical illness or injury acutely impairs one or more acutely impairs one or more vital organ systems such that vital organ systems such that there is a high probability of there is a high probability of imminent or life threatening imminent or life threatening deterioration in the patient's deterioration in the patient's conditioncondition

• 99291 – 199291 – 1STST 30-74 MIN. 30-74 MIN.• 99292 – ADD. 30 MIN99292 – ADD. 30 MIN

• The following services are The following services are included in critical careincluded in critical care

• Interpretation of cardiac Interpretation of cardiac output measurements output measurements

• Chest x-raysChest x-rays• Pulse oximetry Pulse oximetry • Blood gasesBlood gases• Information data stored in Information data stored in

computers (eg, ECGs, blood computers (eg, ECGs, blood pressures, hematologic data)pressures, hematologic data)

• Gastric intubationGastric intubation• Temporary transcutaneous Temporary transcutaneous

pacing pacing • Ventilator managementVentilator management• Vascular access proceduresVascular access proceduresJust being in an ICU does not Just being in an ICU does not

necessarily warrant critical care necessarily warrant critical care codes!!!codes!!!

TOOLS YOU CAN USE FROM TOOLS YOU CAN USE FROM PALMETTOPALMETTO

• E&M Score Sheet Tool• Modifier Lookup • Denial Codes• National and Local Coverage Policies• On-line Claims Management Tool• Local Fee Schedules• Medicare Forms• FAQs• More available on our website

WHY AUDITS AND REVIEWS WHY AUDITS AND REVIEWS ARE NECESSARYARE NECESSARY

• Many physicians do not understand E&M coding Many physicians do not understand E&M coding rules – or don’t want torules – or don’t want to

• Electronic Records tend to automatically up-Electronic Records tend to automatically up-code many visitscode many visits

• Strict counting of number of elements does not Strict counting of number of elements does not always justify codealways justify code– Individual servicesIndividual services must be reasonable and necessary must be reasonable and necessary

for patient and date of servicefor patient and date of service– Frequency of servicesFrequency of services must be reasonable and must be reasonable and

necessary for patientnecessary for patient

• Outside reviewers find high number coding Outside reviewers find high number coding errorserrors– CERT -- OIGCERT -- OIG– RAC --ZBICRAC --ZBIC

PALEMTTO GBA DATA COLLECTEDPALEMTTO GBA DATA COLLECTED

……37 pages of physician names37 pages of physician names

……1065 docs had > 12 level 5 visits per year1065 docs had > 12 level 5 visits per year

……Large variety of specialties involvedLarge variety of specialties involved

……Northern California Only…if all three states taken Northern California Only…if all three states taken together would be three times highertogether would be three times higher

Radiology Srvs in California Radiology Srvs in California 71010 & 71020 … 5-8-201071010 & 71020 … 5-8-2010

• Southern California:Southern California:– 56% of the total amount denied due to NO 56% of the total amount denied due to NO

DOCUMENTATION received DOCUMENTATION received – 27% of the total amount denied was due to NO 27% of the total amount denied was due to NO

PHYSICIAN ORDERS receivedPHYSICIAN ORDERS received– 8% of the total amount denied was charges deemed 8% of the total amount denied was charges deemed

to be NOT MEDICALLY NECESSARY based on LCD for to be NOT MEDICALLY NECESSARY based on LCD for Radiologic Examination ChestRadiologic Examination Chest

– 8% of the total amount denied was for a combination 8% of the total amount denied was for a combination of biller errors, illegible documentation, incorrect / of biller errors, illegible documentation, incorrect / incomplete date of service or patient identification incomplete date of service or patient identification on documentation received, and missing, invalid, on documentation received, and missing, invalid, illegible provider signatureillegible provider signature

Radiology Srvs in California Radiology Srvs in California 71010 & 71020 … 5-8-201071010 & 71020 … 5-8-2010

• Northern California:Northern California:– 72% of total amount denied due to NO 72% of total amount denied due to NO

DOCUMENTATION received for reviewDOCUMENTATION received for review– 9% of total amount denied for invalid, illegible or 9% of total amount denied for invalid, illegible or

missing PROVIDER SIGNATUREmissing PROVIDER SIGNATURE– 9% of the total amount denied was charges deemed 9% of the total amount denied was charges deemed

payable to ANOTHER PROVIDER billing same payable to ANOTHER PROVIDER billing same procedure, date of service & beneficiaryprocedure, date of service & beneficiary

– 10% of the total amount denied for a combination of 10% of the total amount denied for a combination of illegible documentation, incorrect-incomplete date of illegible documentation, incorrect-incomplete date of service or patient ID on documentation received, no service or patient ID on documentation received, no chest X-ray report included with documentation, and chest X-ray report included with documentation, and charges that were deemed to be not medically charges that were deemed to be not medically necessary based on LCDnecessary based on LCD

EXAMPLE: SPECIALTY 11 (INTERNAL MEDICINE)

• There were 5,459 claims reviewed, out of which 3,724 There were 5,459 claims reviewed, out of which 3,724 claims were denied. The total dollars denied resulted in claims were denied. The total dollars denied resulted in a charge denial rate of 49% a charge denial rate of 49%

• The top denial reasons identified from the review are:The top denial reasons identified from the review are:– 46 percent – Missing or incomplete documentation for this date 46 percent – Missing or incomplete documentation for this date

of service of service – 35 percent – Level of service billed not supported; Down-coded 35 percent – Level of service billed not supported; Down-coded

claim claim – 7 percent – Illegible documentation 7 percent – Illegible documentation – 4 percent – Incorrect / incomplete / illegible patient 4 percent – Incorrect / incomplete / illegible patient

identification or date of serviceidentification or date of service

LOOKING AT MORE CLAIMS

• Reasonable and Necessary trumps pages and pages of documentation if only done for sake of “scoring points”

• Electronic health records try to increase billed codes

• Electronic health records– Often inconsistent– Sometimes incoherent– Still in their infancy– Doctors don’t know how to use or

update properly

No more, no more !!

LOOKING AT MORE CLAIMS

• Electronic Records Must be kept up to date for any visit

• Concurrent illness must be concurrent & significant

• Decision Making– Helpful if explained / listed / or

documented– Important to list changes in care

or diagnoses– Lab review should be included if

records asked for in a review– Excess verbiage on some EHR still

does not give extra value

Get me outta here

Problem list never Problem list never updated and updated and frequently has frequently has duplicate or even duplicate or even opposite diagnosesopposite diagnoses

Review of symptoms Review of symptoms negative---is this in past negative---is this in past week or in past ever….and is week or in past ever….and is it necessaryit necessary

73 Y/O female 73 Y/O female inpatient hosp or SNFinpatient hosp or SNF

ID note: ID note: afebrile but afebrile but draining draining wound—brief wound—brief historyhistory

Review of lab and low level decision making

Follow up visit 3 weeks later

THOUGHTS FROM AN THOUGHTS FROM AN ADDLED REVIEWERADDLED REVIEWER

• A Chief Complaint should not be a “regular visit”• Documentation should include all positive and pertinent

negative findings– ROS should not be negative, normal, or WNL regarding the chief

complaint or other positive problems

• Exam should include all positive and pertinent negative findings– Exam of principal problem or reason for visit should not be

normal, WNL or negative– If patient comes for oncology follow up, expect exam of areas

at risk and all related structures– Unrelated areas of body can be examined and stated as within

normal limits.– Frequent visits should are not always high level visits

MORE THOUGHTS FROM AN MORE THOUGHTS FROM AN ADDLED REVIEWERADDLED REVIEWER

• Repeated full histories (if unchanged) should not be cloned for each visit

• Documentation of most any visit should not be exactly the same –word for word-- as former visits– Complicated patients with multiple problems nearly always

have something different related to one problem

• Decision making is subjective– Some decisions come automatically to some docs and not to

others– Try to explain your thoughts as to how you plan to test,

diagnose or manage a patient– Chronic conditions that relate to your visit count– True morbidity and risk to patient also count toward decision

making

WHAT IF ONE IMPORTANT ELEMENT NOT PERFORMED• No real history available

– Patient comatose – Patient demented– Patient drugged

• Get history from other source (addendum)– From family– From old or new chart– When patients wakes up

• If patient on way to emergency surgery– Key elements (heart, lung, vital signs)– Rest of exam when patient available

• Emergency decision making usually high level

RESPONDING TO MEDICAL REVIEW & RECORD REQUESTS

• WHO CAN ASK FOR RECORDS / WHO CAN ASK FOR RECORDS / DOWNCODE OR DENY DOWNCODE OR DENY PAYMENTPAYMENT– MEDICARE A/B ADMIN. MEDICARE A/B ADMIN.

CONTRACTORS (MACs)CONTRACTORS (MACs)– PROGRAM INTEGRITY (ZPIC) PROGRAM INTEGRITY (ZPIC)

CONTRACTORCONTRACTOR– CERT CONTRACTORCERT CONTRACTOR– RAC CONTRACTORRAC CONTRACTOR– QIO QIO – BUNDLING AND MEDICAL BUNDLING AND MEDICAL

UNLIKELY EDITS (MUE)UNLIKELY EDITS (MUE)– PRIVATE INSURANCE PRIVATE INSURANCE

COMPANIES (FOR COMPANIES (FOR MEDICARE ADVANTAGE)MEDICARE ADVANTAGE)

MAC REVIEWS: WHO GETS MAC REVIEWS: WHO GETS REVIEWEDREVIEWED

DATA OUTLIERS DATA OUTLIERS • UNUSUAL FREQUENCY OF VISITSUNUSUAL FREQUENCY OF VISITS• UNUSUAL LEVEL OR PLACE OF UNUSUAL LEVEL OR PLACE OF

SERVICE FOR PATIENTSERVICE FOR PATIENT• POOR DOCUMENTATION IN PROBE POOR DOCUMENTATION IN PROBE

REVIEWS SENT TO CONTRACTORREVIEWS SENT TO CONTRACTOR• PATIENT COMPLAINTSPATIENT COMPLAINTS• REPEAT FALLOUTS & WARNINGSREPEAT FALLOUTS & WARNINGS• POSSIBILITY OF FRAUDPOSSIBILITY OF FRAUD

PREPARE FOR REVIEWS: DO

1. GET PERSONALLY INVOLVED2. COPY ALL OFFICE, FACILITY OR

OTHER RECORDS REQUESTED:

--PROGRESS / THERAPY NOTES (CURRENT AND

EARLIER IF HELPFUL TO EXPLAIN)

--NURSING NOTES, CLINICAL OBSERVATIONS, AND

ANY CONSULT NOTES IF HELPFUL

--LAB & DIAGNOSTIC TESTS IF RELATED TO SERVICE--ANY CHANGE IN DX, MEDS,

OR THE CURRENT CONDITION3. WHEN IN DOUBT SEND MORE

RATHER THAN LESS TO SUPPORT MEDICAL NECESSITY OF SERVICE

PREPARE FOR REVIEWS: DO

4. CHECK FOR 4. CHECK FOR CORRECT DATES & NAMESCORRECT DATES & NAMES ------CORRECT PATIENT & DATES OF SERVICE CORRECT PATIENT & DATES OF SERVICE

---CORRECT PHYSICIAN---CORRECT PHYSICIAN

5. SUBMIT TIMELY AND TO CORRECT ADDRESS 5. SUBMIT TIMELY AND TO CORRECT ADDRESS REQUESTED ON LETTERREQUESTED ON LETTER

6. KEEP RECORD OF INDIVIDUAL ASKING FOR 6. KEEP RECORD OF INDIVIDUAL ASKING FOR YOUR RECORDS AND WHY (WHICH SERVICES) YOUR RECORDS AND WHY (WHICH SERVICES) THEY ARE ASKING FORTHEY ARE ASKING FOR

7. CHECK FOR LEGIBILITY – CAN RETYPE NOTES IF 7. CHECK FOR LEGIBILITY – CAN RETYPE NOTES IF ALSO SEND ORIGINALALSO SEND ORIGINAL

8. CALL IF ANY QUESTIONS – 8. CALL IF ANY QUESTIONS – ---LOCAL CONTRACTORS CAN HELP---LOCAL CONTRACTORS CAN HELP

---NSMA MAY HAVE ANSWERS ALSO---NSMA MAY HAVE ANSWERS ALSO

IF YOU HAVE PROBLEMS IF YOU HAVE PROBLEMS YOU CANNOT RESOLVEYOU CANNOT RESOLVE

• CALL OR CONTACT THE IDENTIFIED PERSON AT CALL OR CONTACT THE IDENTIFIED PERSON AT PALMETTO & ASK FOR AN IN PERSON OR TELEPHONE PALMETTO & ASK FOR AN IN PERSON OR TELEPHONE MEETING---or CALL OUR PCCMEETING---or CALL OUR PCC– YOU SHOW YOU CARE ABOUT THE SITUATIONYOU SHOW YOU CARE ABOUT THE SITUATION– THE CONTACT ALONE MAY TEACH YOU HOW TO THE CONTACT ALONE MAY TEACH YOU HOW TO

SOLVE THE PROBLEM & FIX THE CLAIMSSOLVE THE PROBLEM & FIX THE CLAIMS• CALL ANCO OR YOUR COUNTY ASSOCIATION OR CALL ANCO OR YOUR COUNTY ASSOCIATION OR

CALIFORNIA MEDICAL ASSOCIATION FOR HELPCALIFORNIA MEDICAL ASSOCIATION FOR HELP– MEDICARE CONTRACTORS CARE ABOUT GOOD MEDICARE CONTRACTORS CARE ABOUT GOOD

RELATIONS WITH ORGANIZED ASSOCIATIONSRELATIONS WITH ORGANIZED ASSOCIATIONS• REMEMBER, YOUR ASSOCIATION STAFF CAN CALL US REMEMBER, YOUR ASSOCIATION STAFF CAN CALL US

TO HELP EXPLAIN THE REGS AND SOLVE THE TO HELP EXPLAIN THE REGS AND SOLVE THE PROBLEMS—WE ALL WANT TO HELPPROBLEMS—WE ALL WANT TO HELP

CERT AND MEDICAL INTEGRITY CERT AND MEDICAL INTEGRITY CONTRACTORSCONTRACTORS

• CERT Contractors: Livanta & Advanced MedCERT Contractors: Livanta & Advanced Med– Ask for only a single chart or caseAsk for only a single chart or case– Purpose to review the reviewersPurpose to review the reviewers– If denied money must be returnedIf denied money must be returned– Appeals possible if you disagree Appeals possible if you disagree

• ZPIC (Zone Program Integrity) ContractorsZPIC (Zone Program Integrity) Contractors– CalBisc (SafeGuard Systems) in J-1CalBisc (SafeGuard Systems) in J-1– PotentialPotential fraud or abuse cases fraud or abuse cases– Respond promptly, get all info, may be Respond promptly, get all info, may be

misunderstanding with patientmisunderstanding with patient

RAC-RECOVERY RAC-RECOVERY AUDITORSAUDITORS

• HDI (HealthDataInsights) for J1 HDI (HealthDataInsights) for J1 • Reviews old paid claims (up to 3 Reviews old paid claims (up to 3

years from date of claims)years from date of claims)– Reviews medical necessityReviews medical necessity– Reviews proper coding Reviews proper coding – Paid a % of what it brings inPaid a % of what it brings in

• Look at medical necessity & Look at medical necessity & incorrect coding for over and incorrect coding for over and under-payment in claims already under-payment in claims already paidpaid

• Can appeal denials several levels: Can appeal denials several levels: MAC-QIC-ALJ, etc.MAC-QIC-ALJ, etc.

RESPONDING TO ANY RESPONDING TO ANY REQUEST FOR RECORDSREQUEST FOR RECORDS

• Have a set office process for dealing with all ADRs Have a set office process for dealing with all ADRs (Additional Record Requests)(Additional Record Requests)

• Have one individual responsible for sending all records Have one individual responsible for sending all records as part of the set office processas part of the set office process– Experienced office person, or clinical person, or bothExperienced office person, or clinical person, or both

• Have a check off sheet that involvesHave a check off sheet that involves– Legibility (can add typed / printed addendum)Legibility (can add typed / printed addendum)– Correct name, date, physician listed in requestCorrect name, date, physician listed in request– Signature (signature sheet or attestation if needed)Signature (signature sheet or attestation if needed)– Correct address to send recordsCorrect address to send records– Timeliness of records being sentTimeliness of records being sent

• Know how and where to get hospital recordsKnow how and where to get hospital records• Send by certified mail (or equivalent)Send by certified mail (or equivalent)

APPEALS PROCESSAPPEALS PROCESS• Initial Determination from Initial Determination from

Palmetto GBAPalmetto GBA• Redetermination from Redetermination from

Palmetto GBAPalmetto GBA• Qualified Independent Qualified Independent

Contractor (QIC)Contractor (QIC)• Administrative Law Judge Administrative Law Judge

(ALJ)(ALJ)• Department Appeals Department Appeals

Board (DAB)Board (DAB)• Federal CourtFederal Court

APPEALS PROCESSAPPEALS PROCESS• Instructions come with any Instructions come with any

denial denial – Time frames for next levelTime frames for next level– Addresses for appealAddresses for appeal

• No penalty for new appealsNo penalty for new appeals– Fresh person with each Fresh person with each

appeal levelappeal level– Often higher level reviewOften higher level review

• Recommend appeals with Recommend appeals with CERT, RACCERT, RAC

• Useful to discuss with med Useful to discuss with med organizations and specialty organizations and specialty societies to see if other societies to see if other appeals winappeals win

JURISDICTION “E” MEDICARE CONTRACT

• As of January 1, initial JE contract award to Noridian Administrative Services

• Two contract challenges were initiated– Result to be announced end of January– Possible outcomes: initial award remains, award reversal,

or re-bidding starts over

• Palmetto will administer claims through end of June under all circumstances– All Medicare services to physicians will remain – CACs will continue

• If transition occurs, it will be smooth and seamless to physicians

PHYSICIAN FEE SCHEDULE

• 2013 Fee schedules are on-line now• Factors affecting fee schedules:

– SGR (Sustainable Growth Rate)– Sequestration based on Congressional law– Individual factors for some specialties (e.g. second

tests for Radiology, Cardiology, Ophthalmology)

• Remember, new or changed CPT or HCPCS codes could have new fees and descriptors

• Congressional law will effect fee schedule... changes will be on web when in effect

PHYSICIAN FEE SCHEDULE

• Finding the fee schedule– WWW. PalmettoGBA.com\J1B– Click Fee Schedules under “Top Links” box

upper left– Next screen, under “search this area” select

California and the region– Look through the Excel spreadsheet for the

codes you want.

• Alternative: click through the CMS Medicare Data Base in the upper part of page

EMR PROBLEMS• Cloning: cutting and pasting each visit• Medical necessity of level of service• Inconsistency of records: Hx, ROS, Exam• “Regular” or “follow up” visits• Documentation of individual visit

uniqueness for that day• Documentation of decision making• Activeness and duplication of chronic

problems and meds in list• Signatures, signatures, signatures

EMR PROBLEMS• Don’t forget level 2 “Meaningful Use” for

2013.• Information found in CMS website• http://

www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/beginners_guide.pdf

• http://www.cms.gov/EHRIncentivePrograms

RECOVERY AUDITORS (FORMALLY RACS)

• Recent Focuses:– Short hospital inpatient vs outpatient stays– New vs subsequent visit: eye and custodial care– Multiple endoscopic procedure codes– Excessive units ultrasound guidance– Excessive Units of Microslide Consultation– Pulmonary edema, resp. failure as inpatient vs

outpatient– Metastasis as secondary diagnosis (MS-DRG)– Incorrect billing CT scans– Hip fractures without complications MS-DRG– Hepatobillary disorders MS-DRG

RECOVERY AUDITORS (FORMALLY RACS)

• Things to consider:– Hospital admission by MD who knows patient…REASON

FOR SURGERY, ADMISSIOM– Document all primary and secondary problems– Use office lab sheets and progress notes when they

document hospital condition• Accurate coding for office services

– Remember modifiers, add on codes, IV codes– Remember multiple surgery rules– Document to support unusual test or procedure

• Appeal all denials, but have documentation to support appeals. Office notes PLUS specialty guidelines, peer-reviewed literature, etc.

UNDERSTANDING NCDs AND LCDs

• NCD: National Coverage Determination;– Made by CMS cannot be altered by contractor– Open for comments, from society, industry, interest groups– Same across country, slow, and very hard to change

• LCD: Local Coverage Determination;– Made by Palmetto, drafts presented tor advice & input– Formal open meetings and CACs – Must answer all comments– Reconsiderations if new evidence presented or new codes

• Time Frames;– Draft displayed 15 days prior to CAC– 45 day notice and comment– 30 day after final published before effective

UNDERSTANDING NCDs AND LCDs

• LCDs and many NCDs have associated coding information– Which CPT and ICD codes ALWAYS covered– Which CPT and ICD codes NEVER covered

• NCD & LCD usually have automated editing• Understand which NCDs and LCDs effect your

practice: they explain exactly how to code and bill.

• There is a new “exception process” for LCDs when appealed with adequate data and supporting evidence

FINAL THINGS TO FINAL THINGS TO REMEMBERREMEMBER

• Medical Necessity Trumps any level of detail if differentMedical Necessity Trumps any level of detail if different• With electronic recordsWith electronic records

– Watch for cloning (same words each visit)Watch for cloning (same words each visit)– Remember chief complaint and present illnessRemember chief complaint and present illness– Remember decision making is important aspectRemember decision making is important aspect

• Complexity of decision making is important aspectComplexity of decision making is important aspect– ConcurrentConcurrent related related diseasesdiseases– Number and interrelationships of medsNumber and interrelationships of meds– Risk to patient of action or inactionRisk to patient of action or inaction

• Inpatient consults are initial hospital visitsInpatient consults are initial hospital visits– Level of service compared to CPT requirementsLevel of service compared to CPT requirements– Remember reasonable and necessary trumps # of pagesRemember reasonable and necessary trumps # of pages

• Expect all positive exam signs and symptoms and all pertinent Expect all positive exam signs and symptoms and all pertinent negative onesnegative ones– If most negative, not likely a high level visit but give creditIf most negative, not likely a high level visit but give credit

• We can check dates of last few visitsWe can check dates of last few visits– How many appendix operations does one repeatHow many appendix operations does one repeat

Stay Up To Date With CMS Changes

Documents

MEDICARE: UNDERSTANDINGWHAT IS HAPPENING AND PREPARING FOR 2013