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Coding and Billing for Internists Services Challenges and Opportunities June 2010.

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Presentation on theme: "Coding and Billing for Internists Services Challenges and Opportunities June 2010."— Presentation transcript:

1 Coding and Billing for Internists Services Challenges and Opportunities June 2010

2 Foundation on which Billing and Coding is Based AMA maintains CPT book of codes that describe physician services CMS supplements the CPT book as needed RBRVS, managed by CMS, determines payment for each physician service Each service has a relative value for each of three main components work, practice expense, and professional liability insurance, with each being adjusted to reflect geographic input price differences Medicare multiplies total, adjusted relative value for each service by a dollar multiplier, or conversion factor Medicaid, other government, and private payers generally use RBRVS as basis for payments

3 Medicare Payment Uncertainty Medicare annual payment updates lag behind medical inflation Flawed sustainable growth rate formula regularly calls for unsustainable cuts in Medicare physician payments Congress typically acts to replace an impending cut with a freeze or small increase around time it is to take effect Congress almost certainly will act to avoid large cut but is avoiding a complete long-term fix because its costly ACP participating in this messy process to represent the interest of its members

4 Focus on What You Control General coding and billing guidance Do what is medically necessary Document what you did according to guidelines Use up-to-date CPT and diagnosis codes Investigate payment denials Conduct periodic self audits Engage in continual coding and billing education Understanding coding and billing rules is vital to health of practice Coding and Billing Challenges and Opportunities

5 Challenge: Welcome to Medicare Exam Benefit Changes in 2009 resulting from 2008 law implementation: Patients now eligible 12 months after enrollment, instead of 6 months No longer required to perform EKG, but must advise/refer as needed Now required to conduct BMI and discuss advance directive Use new HCPCS G0402, instead of old G0344 Can bill medically necessary E/M on same date as appropriateuse modifier -25 ACP has contended pay too low; CMS increased pay for service for 2010 to $154, up from $92 CMS working to establish details of an annual wellness visit/preventive care plan benefit for 2011 as required by March 2010 federal health reform law

6 Challenge: Billing for Consultations Requirements for a billing a CPT consultation service code: Furnished at the request of another physician seeking opinion or advice Must make a treatment option(s) decision/recommendation Must provide opinion or advice in a written report back to the requesting physician Consulting physician can initiate treatment, e.g., diagnostic or therapeutic tests or procedures, during consultation visit On-going care furnished by the consultant after initially providing opinion or advice is billed using office, subsequent hospital, nursing facility visit codes

7 Dramatic Medicare Consult Policy Change CMS no longer recognizes CPT consult codes for Medicare payment purposes beginning in 2010 CMS rationale for change: Agency long-expressed concern that physicians did not bill consults correctly Reviews determined that Medicare overpaid as many consults billed were not supported by documentation Agency believes consult service work is clinically similar to office, hospital, NF visits

8 Dramatic Medicare Consult Policy Change Consults to be billed using CPT codes for: Office visits, 99201-99215 Initial hospital care (admit). 99221-99223 Initial NF care, 99304-99306 Change was unexpected and has far-reaching implications ACP position on Medicare consult payment policy is at nagement/payment_coding/medicare/changes2010/feesc hedule.htm#advocacy nagement/payment_coding/medicare/changes2010/feesc hedule.htm#advocacy

9 Documentation Implications of Consult Change Documentation rules for replacement codes apply based on code used, thus: No requirement that the requesting and consulting physician document request in medical record Consultant not required to send a written report with opinion /advice back to requesting physician No need for auditors to distinguish a request for a consult from a referral that constitutes a transfer of care Admitting physician bills initial hospital care code with a AI modifier to distinguish service from consultant(s)

10 Payment Implications of Consult Change To redistribute the money that Medicare paid for the no-longer-recognized CPT consult codes: Payment for each office visit increased about 3% Payment for initial hospital and initial NF care services increased about 1% In general, payments for consult services will be lower as a result of use of CMS-required replacement codes

11 Payment Implications of Consult Change Consult Code 2009 Payment Replacement Code 2010 Payment 99241$48.6999201$38.96 99242$90.9099202$67.45 99423$124.8099203$97.75 99244$184.3299204$151.49 99245$226.5299205$190.45

12 Payment Implications of Consult Change Consult Code2009 Payment Replacement Code 2010 Payment 99251$48.69 99252$75.75 99253$114.7099221$94.14 99254$165.5699222$127.33 99255$201.9999223$186.84

13 Payment Implications of Consult Change No clear guidance on how to bill low-level hospital consults as no initial hospital code match for 99251-99252 Consults furnished to established outpatients, 99211-99215, experience biggest payment hit Consult for pre-op clearance on known beneficiary dictates billing established patient office visit Physicians who do a significant number of consults will see overall revenue decline; those who do few see revenue rise Confusion when a secondary payer is involved

14 Payment Implications of Consult Change Can bill prolonged service code in addition to an office or hospital visit code (as appropriate and if documented) Consult can be billed as critical care service if it meets the CPT definition of critical care Coordination of care could suffer if consultants feel less compelled to send a written report to requesting physician Most private payers initially decided to continue to pay the CPT consult codes but more are adopting the Medicare policy

15 Tips for Billing Private Payers Consults Consultants can receive higher payments from private payers still recognizing CPT consult codes Consult can be furnished by a physician in the same group as the requesting physicianconsultant is expected to practice a different specialty but exceptions are made for same-specialty expertise The service resulting from a surgeons request to clear a patient as being fit for surgery can be billed as a consultation for major procedures Check if private payer follows the old Medicare rule that allows billing a consult for patient-initiated second opinions before major surgery or test

16 Challenge: Medicare Teaching Physician Regulations Medicare pays teaching/attending physician for services furnished involving a resident when: Services performed by teaching physicianduplicates resident service Services performed by teaching physician jointly with resident Services performed solely by resident under Primary Care Exemption For first two scenarios, teaching physician must personally see the patient, perform the critical/key portion of the service, and participate in the management

17 Teaching Physician Regulations Teaching physician must tether/link note to residents note Billing is based on the combination of the teaching physicians and residents documentation Examples of acceptable documentation: I saw and evaluated the patient. Discussed /w resident and agree w/residents findings and plan as documented in the residents note. See residents note for details. I saw and evaluated the pt and agree with the residents findings and plan as written. Examples demonstrate saw patient, performed key portion, and participated in management

18 Teaching Physician Regulations Examples of unacceptable documentation: Agree with the above. Rounded, reviewed, agree. Discussed with resident. Agree. Signature alone Other documentation tips: There is no royal we; use I to demonstrate involvement Can use template/macro, such as through EHR, but must sufficiently modify to reflect specific encounter/scenario

19 Suggested Teaching Physician Documentation I saw and evaluated the patient and reviewed (Residents Name) notes. I agree with the history, physician exam and medical decision making with the following additions/exceptions/observations : _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Attendings SignatureDate

20 Teaching Physician Primary Care Exception Teaching physicians can be paid for certain services furnished solely by a resident when they are provided in outpatient facilities for which resident time is counted toward the direct GME payment to the facility Teaching physician can only be paid for resident low-level outpatient E/M visit services, 99201-99203 and 99211-99213 Resident must have completed at least six months of training program Teaching physician cannot supervise more than four residents and must be immediately available to assist

21 Challenge: Billing for Incident-to Services Medicare allows physicians to bill for outpatient services performed by personnel that are incidental but integral and be paid as if the physician performed the service Incident to rules enable physician to bill 99211 when service furnished by office staff This minimal service can be performed by any clinical staff member, e.g., medical assistant, RN, PA More complicated incident-to rules pertain to billing of 99212- 99215 Service must be performed by CMS designated clinical staff PA, NP, CNS

22 Billing for Incident-to Services Conditions must be met to bill for higher-level PA, NP, CNS services Physician must perform the initial visit and establish the care plan for patient/condition Physician must provide direct supervision, defined as in the office suite but not necessarily in the same exam room, and be immediately available to assist Medicare pays 100% of its normal physician fee schedule amount PA, NP, CNS can provide services that fail to meet the incident-to rules The practitioner furnishing the service must be listed on the claim/bill Medicare pays the practice 85% of its normal fee schedule amount

23 Challenge: Billing Anticoagulation Management Services Medicare payment policy makes it challenging to be adequately paid for managing patients receiving long- term, outpatient anticoagulant drug, i.e., warfarin therapy ACP helped establish new CPT codes in 2007 to provide a more rationale way for physicians to bill and be paid for anticoagulation management services A code to report an initial 90-day period that involves at least 8 INRs, CPT 99363 A code to report each subsequent 90-day period that involves at least 3 INRs, CPT 99364 Codes encompass physician review and interpretation of each INR, patient instructions, dosage adjustments, and ordering additional tests

24 Billing Anticoagulation Management Services CMS refuses to pay for these new CPT codes, which would generally increase amount Medicare pays physician The agency retained its policy that the practice can bill a 99211 when office personnel has a face-to-face encounter with the patient, higher level when physician has direct contact ACP is concerned that some Medicare contractors may prohibit billing 99211 unless there is a change in drug regimen, treatment plan This compounds the problem by making an inadequate billing policy more restrictive Check with private insurers to see if they pay for CPT 99363 and 99364

25 Opportunity: E/M Counseling Exception Have option to select an E/M level of service based on time when counseling and/or coordination of care accounts for more than 50% of physician face-to-face time with patient Compare total physician time for encounter to CPT typical time Not subject to 1995 or 1997 E/M documentation guidelines Documentation should note amount of time counseling and what was discussed (must be medically necessary) List counseling time as fraction of total, e.g. ccc 15/25 in addition to describing pertinent issues discussed

26 Opportunity: Home Health Care Plan Certification/Re-certification Bill HCPC G0180 for certification of the initial home health care plan Medicare pays $58 Bill HCPCS G0179 for re-certification of care plan Use if patient has received home health services within past 60 days Medicare pays $44 Document thought-process in agreeing with plan and/or in changing to better meet patients needs Keep copy of approved care plan in record or be able to access it if needed CMS goal is incentive to physician to carefully review home health agency care plans to ensure appropriate utilization

27 Opportunity: Smoking Cessation Counseling Medicare covers for: Patients with disease caused or exacerbated by tobacco use; or Patients taking medications complicated by tobacco use Covers 2 attempts to quit per year Each attempt can involve up to 4 counseling sessions Bill CPT 99406 for 3-10 minutes of counseling Pays $13 Bill CPT 99407 for >10 minutes of counseling Pays $25 Append modifier -25 to office visit (or other service) done on same date

28 Opportunity: Screening Pelvic/Breast Exam G0101 - cervical or vaginal cancer screening; pelvic and clinical breast examination Medicare covers annually for women at high risk or of childbearing age with abnormal Pap in last three years, and every two years for all other female beneficiaries Pays $35 Can bill in addition to other same-visit/date services: Obtaining a smear for screening Pap test Q0091pays $40 Acute/chronic medically necessary service, e.g., 99213 Medicare non covered comprehensive preventive billed to patient, e.g., 99397

29 Opportunity: Use CPT Modifiers as Appropriate Modifier -25 – significant, separately identifiable E/M service furnished by the same physician on the same date as procedure or other service Can be used to bill an E/M service on the same date as a minor procedure, e.g., joint injection Can be used to bill an E/M service on the same date as a number of Medicare-covered preventive services, e.g., Medicare-covered screening pelvic/breast exam, HCPCS G0101 Can be used to bill an E/M service on the same date as another E/M service in limited circumstances, e.g., critical care service in addition to initial hospital if patient crashes

30 Opportunity: When a Patient is New Again You can bill a new patient service when neither you or a physician of the same specialty in your group practice have furnished a face-to-face professional service within the past three years Patient you provided a flex sig two years ago, not a new patient Patient for whom you read an x-ray two years ago (without seeing the patient) is a new patient Pay attention when providing office visits, new patient visits receive higher payment 99204 – pays $151 99214 – pays $98

31 Opportunity: Non-covered Medicare Services That Can Be Billed to Patients Telephone services 99441 - 5-10 min. medical discussion 99442 – 11-20 min. medical discussion 99443 – 21 -30 min. medical discussion Must be initiated by established patient call to physician Cannot be billed if face-to-face service results within 24 hours or if related to face-to-face service provided within past 7 days E-service 99444 – on-line service to established patient Physicians personal, timely response to patient inquiry that involves permanent storage of documentation pertaining to exchange

32 Non-covered Medicare Services that Can be Billed to Patients E-service (cont.) Can only be reported once during same episode of care over 7 days Not related to face-to-face E/M service within past 7 days Preventive Medicine Services, e.g. 99397 – periodic comprehensive preventive medicine evaluation, established patient, 65 years and older Medicare considers above services to be non covered, meaning that physician can bill patient his/her usual charge Not necessary to have patient sign an ABN form but good idea to discuss situation with patients in advance of billing them

33 Opportunity: Medicare Bonus Payment – PQRI Medicare pay-for-reporting program, the Physician Quality Reporting Initiative (PQRI) Report on how care furnished compares to evidence-based clinical guidelines for a variety of medical conditions, e.g. diabetes, heart disease Earn a 2% bonus for 2010 for reporting on how care provided aligns with quality measures, selecting from a variety of reporting methods ACP resources available at anagement/payment_coding/pqri.htm anagement/payment_coding/pqri.htm

34 Opportunity: Medicare Bonus Payment – E-Rx Earn a 2% bonus for 2010 for reporting e-prescribing events using a qualified e-prescribing system List code G8553 on claim form to indicate an e-prescribing event associated with eligible encounters, primarily office visits Receive bonus if correctly report code a minimum of 25 times in 2010 Other reporting options, e.g., through an EHR, are available ACP resources available at rescribing/medicare_program.htm rescribing/medicare_program.htm

35 ACP Contacts for Questions/Comments Regulatory and Insurer Affairs Department Brett Baker - Debra Lansey - Tenita Richards - Center for Practice Improvement and Innovation Margo Williams -

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