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HCA Encounter Form Education May 2006 Medicare Physicals Documentation Requirements Procedures Home Health Certification.

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Presentation on theme: "HCA Encounter Form Education May 2006 Medicare Physicals Documentation Requirements Procedures Home Health Certification."— Presentation transcript:

1 HCA Encounter Form Education May 2006 Medicare Physicals Documentation Requirements Procedures Home Health Certification

2 Preventative Medicine Visits CPT Code (new) (est) Preventative Medicine Visit Codes include payment for: The review of “stable” chronic problems Routine Screenings (eg. Pap smear, breast & pelvic, manual rectal exam) Risk Factor Counseling Billable Separately When Billed on Same Day as Physical are: E&M Office Visit codes (for re-management of existing problems or new problems (need mod 25) Do not bill 2 new E&M’s in same day Injections, Immunizations Procedures Performed (exception Medicaid – they will only pay for procedure) Some Screenings Labs (Indicate signs/symptoms or diagnosis to support testing)

3 Physicals - Medicare MC does not pay for physicals ( ; ) other then new mc beneficiaries (next slide) They will pay for services (eg. medically necessary follow-up or new problems addressed during a physical. They will pay for problems addressed during a physical when a modifier 25 is affixed. MC will pay for screenings performed during a physical if the service is performed during a covered period. (eg. paps covered every 2 yrs).

4 Physicals Medicare “New MC Beneficiary” G0344: Effective 1/1/05 MC will pay physical / new MC enrollee / within 6 mths G0366: EKG (global) G0367 (EKG tracking only) G0368 (EKG Inter & Rep Only) Medicare does not pay for routine annual physicals ( ; ) Medicare will pay for services (eg. medically necessary follow- up or new problems) billed w/physicals. Mod 25 needs to be affixed to codes.

5 Medicare – “New MC Beneficiary” Required Documentation Initial Exam includes review of: HPI Attention to risk factors for disease detection Past medical, Social & Surgical history Experiences w/illnesses Hospital stays Operations Allergies Injuries & treatments Current medication & supplements FH (hereditary or place the individual at risk) History of alcohol, tobacco, illicit drug use Diet Physical activities Psych Eval - Depression Individual’s potential (risk factors) for depression including current or past experiences w/depression or other mood disorders. Refer to appropriate screening instrument for persons without a current diagnosis of depression recognized by a National Professional Medical Organizations.

6 Medicare – “New MC Beneficiary” Required Documentation EKG Performance and interpretation of an EKG. Functional Abilities / Level of Safety Mininum review must include assessment of: Hearing impairment Activities of daily living Falls risk Home safety Examination Measurement of individual’s height, weight, blood pressure Visual acuity screen Other age-appropriate factors as deemed appropriate by the provider based on the individual’s med/social history and current clinical standards.

7 Medicare – “New MC Beneficiary” Required Documentation Risk Factor Counseling Education, counseling and referral as deemed appropriate by the provider based on results of the review Provide Brief Written Plan A checklist or alternative provided to the individual for obtaining the appropriate screening and other preventive services which are covered separately under Medicare Part B. 11 points checklist: Immunizations (pneumococcal, Influenza, Hep B and their administration. Mammography screening Pap smear & pelvic examination screening Prostate cancer screening tests Colorectal cancer screening tests Diabetes outpatient self-mgmt training services Bone mass measurements Glaucoma screening Medical nutrition therapy for individuals with diabetes or renal disease Cardiovascular screening blood tests Diabetes screening tests

8 Injection – Administration Codes Bill Administration along w/”J” Supply Code when appropriate Identify Type of Injection Immunization90471; Immunization – Pedi Codes Infusion “hydrate” up to 1 hr90760 ea additional Infusion “therapeutic/diagnostic” Initial Infusion up to 1hr90765 ea additional up to 8 hrs90766 Addl sequential infusion up to 1 hr90767 concurrent infusion90768 Injection, single/initial; IM or SQ (eg. Depo; B12)90772 Injection, intra-arterial90773 IV push, initial/single drug90774 each additional new drug90775

9 Injection – Administration Codes Immunizations - Pedi The new pediatric administration codes were developed to recognize “physician time” spent counseling parents on the risks (e.g., reactions) and benefits of vaccination for children under 8 yrs. of age. Note: Discussions and/or counseling performed by a nurse with the parents does not qualify for use of Instead the nurse would use the old codes admin under 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day ea addl injection (single or combination vaccine/toxoid), per day admin under age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day ea addl admin (single or combination vaccine/toxoid), per day

10 Telephone Calls ( ) Telephone Calls (CPT Codes ): Simple, intermediate or complex phone calls made by a physician to the patient or other health care allied professional that are *medically necessary to manage and coordinate patient care. Documentation Required: Date of call Reason for call Treatment given Involved parties named (other then pt) Follow-up instructions

11 Telephone Calls What Supports Medical Necessity? AMA Examples of Reimbursable Telephone Services: Services that involve a new diagnosis or require a new treatment plan (eg. acute respiratory illness) when the equivalent service performed in person would have led to a service charge itself. Patient maintenance services, such as management of insulin-dependent diabetics with multiple blood-sugar checks and insulin changes. Treating relapses of a previous condition when this can be adequately assessed by phone, but a significant investment of physician time and judgment are involved (eg. irritable bowel; asthma; congestive heart failure; flare-up of gout) Reporting laboratory results (for laboratory work not done in conjunction with an office visit) that require a significant change in medication or further diagnostic tests (eg. adjustment of warfarin after a prothrombin time is done; addition of a second drug when treating hyperlipidemia; or ordering gallbladder studies when liver functions are abnormal on routine studies).

12 Telephone Calls - continued Extended personal counseling by telephone when the specific situation of an urgent nature, where a physical exam is not essential or necessary to perform the service, and where failure to perform the service could lead to patient harm. An established patient with acute exacerbation of a severe anxiety disorder or depression, commonly involving discussion of medications or recommended psychotherapy needs, mental status and mood assessment, and recommendations for further immediate care. A test result entails a referral for a significantly complex procedure, with the potential for morbidity, complex preparation, and/or hospitalization; however, the discussion, consent and instructions do not require a face-to-face encounter (eg. breast lump found on mammogram; positive treadmill entails a cardiology referral and possible angiogram; patient refusal of a test or treatment previously discussed in detail necessitates further discussion and counseling). Nursing or rest home calls when the patient has a significant change in condition, such as a change in vital signs, respiratory infection, or fall. Extended counseling with family when done by telephone (eg. cases in which there are significant intrafamily conflicts or deficits in understanding related to a patient under direct care).

13 Home Health Aide Certification – Form 485 G0180: Physician certification services: Patient is NOT present Certification covers 60 days Completed by the ordering provider You can bill both a G0180 and a G0181 within a 30 day period. Provider Note includes review & supportive documentation on: Initial and subsequent reports on patient’s status patient’s responses to the oasis assessment adequate contact with the home health agency to follow-up on initial/subsequent management plan(s). G0179: Physician "recertification" srvs - Patient is NOT present documentation ncludes patient’s status patient’s responses to the oasis assessment adequate contact with the home health

14 Procedures Foreign Body Removal Ear Wax Removal69210 (hearing loss pays; impacted cerumen does not) Hearing Loss (389.90) pays Otalgia (388.70) pays EKGs EKG Routine93000 (mod 76 repeat)

15 Procedures Lesions Lesion / Skin Tags11200 (up to 15) (ea. addl grp of 10) Lesions / Common or Plantar Wart17000 (1) plus (for ea. addl – indicate) Example: 6 removed bill x1 and x5 = 6 Lesions / Flat Warts, Molluscum /Milia17110 up to or more report code. Lesion / Vulva56501 Lesion / Vaginal57061 Lesion / Penis (cryo)54056

16 Procedures Gyn / Contraceptive Management Diaphragm or Cervical Cap Fitting57170 Insertion of IUD58300 Removal of IUD58301 Fitting and Insertion of pessary or other intravaginal support device57160 Airway Management Nebulizer Treatment94640 Nebulizer Treatment (subsequent) Inhaler Instructions (teaching) Spirometry94010 Bronchospasm Evaluation94060

17 Procedures Incision & Drainage ; Puncture Incision & Drainage (abcess, cyst) Incision & Drainage of Pilonidal Cyst10080 Incision & Removal of Foreign Body, subcut10120 Incision & Drainage of Hematoma, seroma or fluid collection10140 Puncture aspiration of abscess, hematoma, bulla or cyst10160

18 Procedures Paring/Cutting/Trimming/Excision Paring/Cutting of benigh hyperkeratotic lesion (corn or callus) single lesion11055 Paring/Cutting or benign hyperkeratotic lesion corn/callus 2-4 lesion11056 Trimming of non-dystrophic nails, any #11719 Debridement of 1-5 nails11720 Debridement of 6-10 nails11721 Avulsion (toenail plate)11730 Excision of nail / nail matrix11750 Wedge Excision of nail fold11765

19 Procedures Epitaxis Control Nasal Hemorrhage, Anterior Packing; Simple30901 Control Nasal Hemorrhage, Posterior Packing, Initial30905 Packing, Subsequent30906 No Modifier is Necessary Excisions Excisions Lesion (trunk, arms, legs)BenignMalignant 0.6 to 1.0cm to 2.0cm to 3.0cm

20 Procedures Aspiration and/or Injection “ Small Joint ”, bursa or ganlion cyst (eg. fingers, toe) “ Intermediate joint ”, bursa or ganglion cyst (eg. temporomandibular, acromioclavicular, wrist, elbow or ankle (olecranon bursa) “ Major Joint ”, bursa or ganglion cyst (eg. shoulder, hip, knee joint, subaromial bursa).

21 Procedures Tendon/Ligament / Ganglion Cyst / Injections / Excisions There must be an inflammatory process in a given tendon (tendonitis) or tendon sheath tenosynovitis) CPT Codes: Injection of carpal tunnel with local anes or corticosteroid Injection(s); single tendon sheath, or ligament,plantar fascia) Injection(s); single tendon origin/insertion Aspiration and/or injection of ganglion cyst(s) any location Excision of Ganglion, wrist (dorsal or volar); primary Excision of Ganglion, wrist (dorsal or valar) recurrent

22 Procedures Trigger Point Injections Use Injection(s); single or multiple trigger point(s), one or two muscle(s) – regardless of the # of injections in those muscle groups Use Injection(s); single or multiple trigger point(s), three or more muscle(s) – regardless of the # of injections within those muscle groups

23 Procedures EXCISION CPT Codes (size, location needed) (benign) (malignant) Excision codes are used to reflect “full-thickness” (through dermis) removal of a lesion Select a cpt code based on lesion diameter plus the most narrow margins required which equals the excised diameter. Codes are also based on body area /location (eg. trunk/arms/ legs is 1 body area) Use Modifier 59 when multiple lesions are removed in a single body area (eg. reflect different lesions, different site, different methods in same body area) Use Modifier 58 – for all re-excisions (eg. didn’t get all margins – pt. comes back) Select a CPT code after the path report has returned as malignant lesions require different coding and reimburse at a much higher rate. Simple Suturing codes ( less then 0.5 cm) - ( ) are bundled into excision codes. You can code additionally for simple (greater then.05cm) intermediate or complex repairs Code only the most complex procedure when multiple procedures are performed on same lesion/same day. Example: If a physician removes a self-contained cyst and not an “area” of skin code as excision vs. debridement. (eg. Sebaceous Cyst)

24 Procedures SHAVING CPT Codes (Shaving of Epidermal or Dermal Lesions) Shaving = sharp removal of epidermal and dermal lesions without a fullthickness dermal excision. Code Partial thickness removal (not through dermis) as shaving. Shaving codes are used when lesions are completely removed w/scalpel, scissors. Typically shaving does not require sutures.

25 Procedures DEBRIDEMENT CPT Codes Surgical excision of dead, devitalized, or contaminated tissue and removal of foreign matter from a wound.

26 Procedures BIOPSY CPT Codes – Biopsies remove a “portion” of a lesion for diagnostic purposes. Excisional biopsies removes “all”. Multiple biopsies on the same lesion may only be coded as a “single lesion” You cannot code a biopsy and removal in the same day. Different days yes. Modifier 59 needed when you biopsy “one” lesion & “excise” another on the same day. Note: modifier 59 should be affixed to biopsy code. No modifier is necessary if the biopsy and excision are performed on separate days. You can code an E&M office visit ( ) with a biopsy if the patient presents with If

27 Procedures Wound Repair Simple Suturing simple repair scalp, neck,axillae,ext genitalia,trunk and/or extremities (includes hands/feet) 2.5cm or less simple repair of face, ears, eyelids, nose, lips and/or mucous membrances 2.5cm or less.


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