Presentation on theme: "HCA Encounter Form Education May 2006"— Presentation transcript:
1HCA Encounter Form Education May 2006 Office / Outpatient VisitsDocumentation RequirementsBillable Time99211 ServicesConsultationsPreventative Medicine VisitsScreeningsModifiers
2Office Visits New vs. Established A “new” patient ( ) is someone who has not seen a provider (MD, PA, NP) within samegroup; same specialty; same group payor ID number within the last 3 years.An “established ( ) patient is someone that has seen a provider (MD, PA, NP) within samegroup; same specialty; shared group payor ID # within the last 3 years.New/Established designation is regardless of location of initial service. If a patient is seen in thehospital by Dr. A and later continues care with Dr. A in his/her office, they are established.If you are a new physician who has taken over patients from a retiring physician and the patient hasseen either that provider or another provider in the same group; same specialty; same payor IDnumber within the last 3 years, they will be established to you.
3Documentation The medical record is a “legal” document. The medical record should be complete and legibleThe reason for the visit should be clearThe date and legible identify of the observer clearly notedThe rationale for ordering diagnostic and other ancillary servicesshould be easily inferred.The patient’s progress, response to and changes/revisions inTreatment/diagnosis or need for continued treatment should be well documented.
4DocumentationOne of 2 things will happen when you provide an E&M office, outpatientconsultation or inpatient service to a patient.Either:You will spend 50% or more of the visit in a discussion; counseling; discussing mgmt options, coordinating care whereby then you need to document “time spent in these activities” orYou will spend 50% or more of the visit securing an HPI, Exam and determining the assessment and plan (eg. workup, treatment). If this occurs, a notation of time spent performing this review is NOT required. Instead elements of HPI, Exam and medical decision making will support your code selection.
5Billable Time (>50% of the total visit time) When the patient is present, counseling includes discussions on: Diagnostic results, impressions, and/or recommended studies; prognosis; risks and benefits of management (treatment) options;Instructions for management (treatment) and/or follow-up;Importance of compliance with chosen management (treatment) options;Risk factor reduction; and patient and family education.Coordination of Care w/other health care professionals*Remember to “document time” spent in discussion.
6The Documentation Process E&M Coding – when HPI, Exam and MDM predominant (>50% of total visit time)A provider note is broken up into 3 key sectionsHistoryExamMedical Decision Making
7The Documentation Process E&M Coding The HPI and Examination are described as:Problem FocusedExpanded Problem FocusedDetailedComprehensiveThe MDM (Medical Decision Making) is described as:Straightforward/MinimalLowModerateHigh Complexity Mgmt
8The Documentation Process E&M Coding - HPI The HPI requires:Reason for the VisitPresent Factors(timing, location, modifying factors, signs/symptoms, duration, quality, context, and/or severity)Review of SystemsPast, Family, Social History
9The Documentation Process E&M Coding - Exam The Exam requires:1995 or1997 guidelines
101995 Exam Guidelines Body Areas (ea. are a count of 1) Head/Face Neck AbdomenChest, including breast & AxillaeGenitalia, groin, buttocksBack, including spine“Each” extremity
111995 Exam Guidelines Systems (ea. are a count of 1) Constitutional EyesEars, Nose, Mouth, ThroatCardiovascularRespiratoryGIGUMusculoskeletalSkinNeuroPsychHematologicLymphaticImmunologic
121997 Exam GuidelinesIn 1997 the AMA and CMS proposed a different set of guidelines for documentation ofthe provider exam. 9 specialties participated and developed individual specialtytemplates to represent what they believed incorporated elements of their exam.Single System (S) Multi-Specialty (M)Cardiovascular AnyoneENTGIGUSkinNeuroMuscloskeletalPsych
13Difference between 1995 & 1997 Exam You could and still say: HEENT: Normal1997You would have to state the elements reviewed within asystem/body area – eg. Oropharnyx is clear, TM’s are normal
14Medical Decision Making 1 of 3 Key CategoriesCategory 1:Self-limiting/minor problem (stable, improved) 1 ptEstablished problem (stable, improved) 1 ptEstablished problem (worsening, not optimally responding) 2 ptsNew Problem w/o workup 3 ptsNew problem with workup 4 pts1pt=minimal; 2pt=low risk; 3pt=moderate risk; 4+pts= high riskNote: Please list all problems affecting your decision making on that visit.Please indicate if problem is new; worsened; stable, mild/seriousexacerbation and/or life-threatening.
15Medical Decision Making 2 of 3 Key CategoriesCategory 2:Review/order labs (regardless of # ordered/reviewed) 1 ptReview/order radiology tests (regardless of # ordered/reviewed) 1 ptReview.order EEGs, EKGS (regardless of # ordered/reviewed) 1 ptsDiscuss results w/interpreting provider 1 ptObtain old records other then from pt 1 ptReview/Summarize old records and or obtain history from someoneOther then patient and/or discussion of case w/another healthcareProvider ptsIndependent Review of image/specimen/tracing 2 pts1=minimal2=low risk3=moderate risk4+= high risk
16Medical Decision Making 3 of 3 Key CategoriesCategory 3:Minimal (reassurance, no OTC, no medication mgmt)ColdsURI w/o FeverBug biteLow risk (1 stable Chronic problem, acute uncomplicated illness)SinusitisVaginitisURI w/FeverBronchitis (not serious/pneumo)Headache w/o nausea vomitingLow back pain
17Medical Decision Making 3 of 3 key areas continuedModerate risk (2+ stable CI, 1 CI w/mild exacerbation; undiagnosed new problem)Hard node in breast w/workupHeadache/migraine w/nausea/vomitingBlood in stools3+ stable chronic problemsMild exacerbation of 1 chronic illnessHigh risk (significant exacerbation of a CI, threat to life/self)Chest painSignificant Shortness of Breath; COPD pt.Multiple Chronics evaluated (HTN, Diabetes, Renal Failure, COPD, Hyperlipidemia)Significant exacerbation of 1 chronic illness
18New Patient Visit (99201-05) Consultations (99241-45) HPI Exam MDM Code1PF,0ROS,OPFS 1 body area/system (95) Straight (10 min)Update 1 CI (97) 1 element (97) (15 min)1PF;1ROS;OPFS 2-7 Ltd sys/areas (95) Straight (20 min)Update 1 CI (97) 6-11 elements (97) (30 min)4PF;2-9ROS;1PFS 2-7 Ext sys/areas (95) Low (30 min)Update 3 CI (97) 12 elements (97) (40 min)4PF;10ROS;2PFS 8 sys/areas (95) Moderate (45 min)Update 3 CI (97) All Boxed Areas (97) (60 min)4PF;10ROS;2PFS 8 sys/areas (95) High (60 min)All Boxed Areas (97) (80 min)
19Established Office Visit (99211-99215) HPI Exam MDM CodeDoes not require the presence of a physician (5 min)1PF,0ROS,OPFS 1 body area/system (95) Straight (10 min)Update 1 CI (97) 1 element (97)1PF;1ROS;OPFS 2-7 Ltd sys/areas (95) Low (15 min)Update 1 CI (97) 6-11 elements (97)4PF;2-9ROS;1PFS 2-7 Ext sys/areas (95) Moderate (25 min)Update 3 CI (97) 12 elements (97)4PF;10ROS;2PFS 8 sys/areas (95) High (40 min)Update 3 CI (97) All Boxed Areas (97)
2099211 Billable ServicesExamples of office/clinic visits generally billable using 99211:A blood pressure eval for an est pt whose physician requested a f/u visit to ck blood pressureRefilling medication for a patient whose prescription has run out to hold him over until her can get an appointment (pt must be present in office suite)Discussion with patient in person following laboratory tests that indicate the need to adjust medications or repeat order of testsSuture removal following placement by a different physician/physician groupVisit for instructions/patient education on how to use a peak flow meterDiabetic counselingDressing change for an abrasion/injury
2199211 Non Billable ServicesExamples of services generally not billable using 99211:Blood draw - should be billed using CPT 36415Laboratory tests - the lab performing the test should bill the appropriate codesMonitoring of cardiology tests, such as thallium stress tests, where such monitoring is inherent in the performance of the testInjection of medication - use CPT drug administration code and drug code Influenza vaccination - use vaccination code and administration code only
22Consultations (99241-45) Place of Service: office/outpt/ER Documentation Criteria:Document name of referring physician nameIndicate in HPI that the visit is a result of a “request for consultation”Provide a written report to the requesting provider unless there is a shared record situation (aka inpatient; or same specialty consult)
23Consultations CPT Codes 99241-99245 If a provider requests (verbal or written) a consultation. If you are a specialist and you hold a particular expertise a member of your group can refer apatient for consultation to you.If you see a patient in the “outpatient” setting of a hospital per the request of a provider ofanother specialty or same specialty and your expertise is required.Code for a consultation in the ER, if the ER physician calls you in to evaluate whether or not apatient should be admitted. If they are not admitted by the provider or a member of his/herspecialty group then submit code If they are admitted and you are the admittingprovider then you can only code for the admission ( ).
24Preventative Medicine Visits CPT Code 99381-87 (new) 99291-97 (est) Preventative Medicine Visit Codes include payment for:The review of “stable” chronic problemsRoutine Screenings (eg. Pap smear, breast & pelvic, manual rectal exam)Risk Factor CounselingBillable 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 dayInjections, ImmunizationsProcedures Performed (exception Medicaid – they will only pay for procedure)Some ScreeningsLabs (Indicate signs/symptoms or diagnosis to support testing)
25Physicals - MedicareMC 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).
26Physicals Medicare “New MC Beneficiary” G0344: Effective 1/1/05 MC will pay physical / new MC enrollee / within 6 mthsG0366: 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.
27Medicare – “New MC Beneficiary” Required Documentation Initial Exam includes review of:HPIAttention to risk factors for disease detectionPast medical, Social & Surgical historyExperiences w/illnessesHospital staysOperationsAllergiesInjuries & treatmentsCurrent medication & supplementsFH (hereditary or place the individual at risk) History of alcohol, tobacco,illicit drug useDietPhysical activitiesPsych Eval - DepressionIndividual’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.
28Medicare – “New MC Beneficiary” Required Documentation EKGPerformance and interpretation of an EKG.Functional Abilities / Level of SafetyMininum review must include assessment of:Hearing impairmentActivities of daily livingFalls riskHome safetyExaminationMeasurement of individual’s height, weight, blood pressureVisual acuity screenOther age-appropriate factors as deemed appropriate by the provider based on the individual’s med/social history and current clinical standards.
29Medicare – “New MC Beneficiary” Required Documentation Risk Factor CounselingEducation, counseling and referral as deemed appropriate by the provider based on results of the reviewProvide Brief Written PlanA 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 screeningPap smear & pelvic examination screeningProstate cancer screening testsColorectal cancer screening testsDiabetes outpatient self-mgmt training servicesBone mass measurementsGlaucoma screeningMedical nutrition therapy for individuals with diabetes or renal diseaseCardiovascular screening blood testsDiabetes screening tests
30Physicals - Medicaid Will pay for physicals if pt ONLY has Medicaid Will not pay for physical if billed AFTER Medicare denial.Will not pay for physicals billed with screenings on same day.They do not recognize modifier 25 at all.
31Physicals – HMO’s “Managed Care Plans” Tufts/HPHC/HMOBlue Will pay for physicalsWill also pay for problems addressed during a physical (eg. UTI dx billed with )They will not pay for screenings if billed in conjunction with an annual physical unless high risk or abnormal dx submitted.They will however pay for screenings if billed with an E&M office visit code ( or ) vs. a physical cpt code.
32Screenings – Pap SmearCode a Q0091 for the collection of the pap smear.Code diagnosis code V76.2 (low risk of malignant neoplasm) or V15.89 (high risk)Coverage every 2 yrs.
33Screenings – Breast & Pelvic Code G0101 if “both” the breast & pelvic exam are performed.Code Dx. code V76.10If G0101 is billed with a Physical it will reject as a “bundled” service for Tufts, HPHC (blues pays)It is reimburseable when it is billed by itself as the “sole” service or with an E&M office visit code.Coverage every 2 years.G0101 requires the review and documentation of 7 out of 11 areas in GU system.
34Screening – Breast & Pelvic Documentation Requirements G0101 requires documentation of 7/11 elements:Inspection and palpation of breasts for masses or lumps, tenderness, symmetry or nipple discharge.Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses.Pelvic examination (w/or w/out specimen collection for smears and cultures) including:· External genitalia (general appearance, hair distribution, or lesions) · Urethral meatus (size, location, lesions, or prolapse) · Urethra (masses, tenderness, or scarring). · Bladder (fullness, masses, or tenderness). · Vagina (general appearance, estrogen effect, discharge, lesions, pelvic support,cystocele, or rectocele) · Cervix (general appearance, lesions, or discharge). · Uterus (size, contour, position, mobility, tenderness, consistency,descent, or support) · Adnexa/parametria (masses, tenderness, organomegaly, or nodularity)Anus and perineum.
35Screenings – Blood Occult Routine Code G0107 with diagnosis code V76.51Annual benefitDo not use “82270” in the absence of signs/symptoms or it will reject.
36Screenings – Digital Rectal Exam Code G0102 with diagnosis code V76.44Annual benefit. Note: not covered when billed with annual physical(eg. preventive medicine code)It is reimburseable if billed with an office visit.
37Screenings – Routine Labs (eg , 81000, 82270)In the absence of signs/symptoms these services will reject.It is critical that you link a diagnosis code (eg. definitive or signs/symptoms)when ordering a lab test when applies.
38ModifiersModifiers are 2 digit codes which accompany a 5 digit CPT code inorder to further describe a situation to support additional paymentwhen more then one service is being reported in the same sessionon the same day.Primary Care Modifiers25
39Modifier 25Modifier –25Should only be appended to evaluation and management (E/M)service codes HCPCS codes G0101(Breast & Pelvic Screening)and ProceduresYou do not need a modifier 25 when billing an office visit andalso billing for:1) Diagnostics (eg. EKG)2) Immunizations3) Screenings
40Modifier 25 Examples Modifier 25 Examples When the patient presents for a planned procedure and has a different problem that requires an E/M service (two different diagnoses would be used to distinguish the services)the patient presents with a "minor" problem and after evaluation the decision is made to perform a procedure. In the second example –25 is used if the procedure is minor in nature, meaning that the post-operative period is less than 90 days and the primary diagnosis would be the same for both.