Presentation on theme: "John F. Bishop, PA, CPC, CPMA, CGSC, CPRC President John Bishop and Associates, LLC Physician, Provider Coding, Auditing Compliance and Reimbursement Consulting."— Presentation transcript:
John F. Bishop, PA, CPC, CPMA, CGSC, CPRC President John Bishop and Associates, LLC Physician, Provider Coding, Auditing Compliance and Reimbursement Consulting Tampa, FL
John F. Bishop, PA, CPC, CPMA, CGSC, CPRC AAPA National Chair Reimbursement Work Group Principle, John Bishop and Associates, LLC Private Consultant Tampa, Florida
Get managed care and private carrier companies to recognize and pay for NPPs services Bill properly for a shared visit Supervision requirements Identify what physician supervision rules apply to NPPs performing diagnostic tests List the modifiers to use for NPPs Discover whether NPPs can perform consults “Incident to” – one more time! Skilled Nursing Facility billing for NPP’s
If you didn’t write it down-you didn’t do it If you did write it down but incorrectly-you didn’t do it If you can’t produce a dictated copy of whatever you said you did (OR, ER,ASC)-you didn’t do it If you didn’t do it, don’t bill it. That’s called FRAUD!! If you can’t justify the medical necessity of what you dictated or wrote down-you didn’t do it If you code it incorrectly-you still didn’t do it If you did code it correctly-just maybe you’ll get paid! If you did get paid, doesn’t mean you get to keep it!! If you did get paid, be prepared to give it back!!
Physician-owned distributors of spinal implants Physicians: Place of service errors in ASC and outpatient locations Evaluation and Management Services: Trends in Coding of Claims ◦ We will review E&M claims to identify trends in coding of E&M services from E&M services during Global Surgery periods E&M services: Use of modifiers during global surgical periods*****
E&M services: ◦ We will review multiple E&M services for the same providers and beneficiaries to identify EHR documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across all services, Medicare requires providers to select the code for the service based upon the content of the services and have documentation to support the level of service reported.
“Incident to” Services-medical necessity, documentation, quality of care. Determine whether payment for such services had a higher error rate than that for non-incident to services. We will also assess CMS’s ability to monitor services billed as “incident to.” Medicare Part B pays for certain services billed by physicians that are performed by nonphysicians incident-to a physician office visit. They found that over half of services in 24 hours were being performed by nonphysicians. Also found unqualified nonphysicians performed 21% of the services that physician did not perform personally. Incident-to services represent a program vulnerability in that they do not appear in claims data and can be identified only by reviewing the medical record.
Excessive dosages…monitoring high volume, high cost drugs for acceptable therapeutic levels for patient condition Wound Care Services “Incident to” Services-medical necessity, documentation, quality of care Physical Therapy and OT providers Place of Service Errors-services provided in ASC and outpatient locations E/M during global surgery periods Consults Home Calls
Services by Social Workers Medicare payments for Interventional Pain Management procedures Geographic areas with high utilization of Ultrasound services Geographic areas with high density of Independent Diagnostic Testing Facilities Psychiatric Services – inpatient setting Polysomnography reimbursement – ◦ Medical necessity Violation of assignment rules-improper balance billing Business relationships with Advance Imaging Service in Physician office
10. Debridement Coding - Errors in coding surgical debridement versus active wound care management. 9. Duplicate Billing - Filing claims more than once for the same service. 8. Stark Violations - Physicians referring patient to services in which they have a financial interest or in which a family member has a financial interest. 7. Pharmaceutical Coding in Physician Offices - Incorrect use of codes or units in billing of injections. 6. Social Work Services in Facilities - Some clinical social worker services provided to inpatients in hospitals or skilled nursing facilities cannot be billed under Part B.
5. Psychiatric Services - Over utilization of psychiatric services provided in outpatient setting. 4. Medical Necessity - Documentation not supporting the level of service provided in the outpatient setting. 3. E/M Billed During Global Periods - Use of modifier -24 in billing services that should have been included in the global package. 2. Place of Service Errors - Physicians performing services in ASCs or outpatient facilities but when billing applying a place of service code indicating the service was performed in the physician office. 1. Incident-to Errors - Physician assistants and nurse practitioners performing services for a physician but not following billing-specific guidelines related to the physician's relationship to the patient and the physician's presence in the office.
Allowed by state and federal laws to provide physician services and procedures and direct bill (Medicare/Medicaid/Tricare) Physician Assistants-PA’s Nurse Practitioners-NP’s Clinical Nurse Specialists-CNS’s CRNA’s
Medicare usually defers to state laws Scope of Practice Hospitals CANNOT bill for those considered auxilliary personnel services (on payroll) Require UPIN/PIN File CMS form # 855-Medicare Part B Services must be considered Physician Services Hospital based NPP’s charges may be billed IF NOT INCLUDED ON THE COST REPORT
Must have national certification/license Must have state license/registration Must have hospital (s) privileges If employed by hospital, must still have a supervising physician of record (most states) ◦ PA’s tied to physicians by law ◦ NP’s may be independent in some states Reimbursement is totally dependent upon carrier discretion and interpretation!! Must be considered Revenue generators****
NPP ’ s can get reimbursed for seeing patients in the office Physician must be in Office suite MD must maintain direct supervision MD does not have to see patient NPP can see established, (not new patient or new problem) for “ incident to ” Bill in MD ’ s PIN number-100% reimbursed If No MD — NPP bills 85% with NPP PIN NPP can see new patient or new problem-just bill under NPP NPI number
Only Medicare Part B Not commercial carriers or Medicaid Bill at 100% of physician fee schedule in physician ’ s provider number Must be established patient Service must be within Physician ’ s plan of care- (not a new problem) Physician must be in office suite ARNP/PA must be employee/leased back to practice
The physician was directly involved in the patients care Services were provided in an office setting The patient was not new, nor had new conditions You expect 100% of the allowed fee schedule
There was general supervision (physician NOT in office) The patient had a new or exacerbated condition (NPP deviated from plan of care) Expect to receive 85% of the allowed fee schedule Think of NPPs as Revenue Generators!!
Medicare usually defers to state laws Scope of Practice Hospitals CANNOT bill for those considered auxilliary personnel services (on payroll) Require UPIN/PIN/NPI File CMS form # 855-Medicare Part B Services must be considered Physician Services Hospital based NPP’s charges may be billed IF NOT INCLUDED ON THE COST REPORT
CMS defines 3 levels ◦ General (level 1) – procedure is furnished under physician’s overall direction and control (ie, is available by telephone or beeper)-does NOT need to be present ◦ Direct** (level 2) – physician must be physically present in office suite (laboratory suite) and immediately available to furnish assistance and direction throughout the performance of the procedure ◦ Personal supervision** (level 3) - physician must be in attendance in the room during procedure ** Apply equally to all places of service (office/clinic and hospital facility)
Level 1 - Most diagnostic pulmonary function tests require general supervision Level 2 – Direct supervision involves ◦ administering an inhaled medication 94060, 94070, ◦ Breathing unusual gas mixture-carbon dioxide Low percentage oxygen-94450, 94452, And exercise 94621, 94680, ◦ Pulmonary stress testing only requires level 1 supervision
Office/Clinic when physician is not on site-85% of physician’s fee schedule All services PA is legally authorized to provide that would have been covered if provided personally by a physician in Office/Clinic when physician is on site Physician must be in the suite of offices for 100% of physician’s fee schedule Home visit/ House Call- 85% of physician’s fee schedule Skilled Nursing Facility & Nursing Facility ◦ 85% of physician’s fee schedule Hospital-85% of physician’s fee schedule First assisting at surgery in all settings- 85% of physician’s first assist fee schedule Federally Certified Rural Health Clinics- Cost-based reimbursement. HMO- Reimbursement is on capitation basis. All services contracted for as part of an HMO contract Using carrier guidelines for "incident to" services.
“Direct” Supervision Doctor must see all new Medicare patients and established patients with exacerbations or new conditions 100% of physician fee schedule Must indicate point of doctor’s involvement Doctor should sign all notes “General” Supervision Doctor doesn’t have to see new patients or exacerbated or new conditions 85% of physician fee schedule Not required
Indirectly-MD time is freed up for other uses-office, surgery, hospital rounds, golf course, home, family/children, exercise, reading MD efficiency, accuracy and skills MD bill all carriers for NPP services MD can set a base salary plus give performance bonus based on either productivity, percentage of their monthly A/R or overall practice A/R Prescription writing (DEA) Work for your practice (not Hospital) NPPs are Revenue Generators
PAs Cardiology $109,030 Dermatology $107,727 ED $103,489 Surgery $102,760 Hospital based $97,680 House Calls $94,383 Orthopaedics $91,491 Family Practice $90,528 Pediatrics $86,894 Oncology $85,851 Academia $95,215 NPs Oncology $98,327 - $90,574 ED - $104,549 Hospital - $93,943 Surg. Specialties - $91,511 Women’s Health- $76,483 Gerontology-$93,668 Cardiology-$100,881 Int. Med-$88,287 Family Practice- $86,518 Academia- $80,400
Burn Wound Dressing changes under anesthesia 1 st Assist in the OR VAC changes Compartment measurements-Wick catheter ALL Central lines, Triple lumens, A-line, Hickman’s, Ports, Use of US and Fluoro w/interp I&D’s, NG tubes under guidance, Intubation, Trach’s Consults Admission H&P Daily subsequent visits (not related to Burn injury) Counseling and Coordination of care Joint injections/aspirations Discharge summaries $$$
Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407intensive, greater than 10 minutes INCLUDES: Administration and analysis of a health risk assessment (99420) Face-to-face services for new and established patients based on time increments of 15 to 60 minutes Issues such as a healthy diet, exercise, alcohol and drug abuse Services provided by a physician or other qualified healthcare professional for the purpose of promoting health and reducing illness and injury
EXCLUDES: Counseling and risk factor reduction interventions included in preventive medicine services ( ) Counseling services provided to patient groups with existing symptoms or illness (99078) Code also distinct evaluation and management services when performed in addition Do not report with heath and behavioral services provided on the same day ( )
Surgery Day-Surgical Assisting ◦ THR (27130) x 3=37.70 x 36.07=$ x 13.6% = $580.87**** ◦ TKR (27447) x 2=40.38 x36.07=$ x 13.6% = $415.02**** ◦ Arthroscopy, knee Menisectomy 29881x3:16.38 x 36.07=$ x 13.6% = $249.49**** TOTAL generated $ TOTAL paid $1,
Office Day-Dr. in office (“Incident To”) ◦ PA schedule 40 patients 30 follow-up = 99213=1.70 x 36.07=$ 10 new pt/new problems=99204=3.93 x 36.07=$ (85%) 5 Trigger points injected= 20550=1.49 x 36.07=$ 3 Large joint injections=20610=1.94 x 36.07=$ 2 Med. Joints injected=20605=1.50 x 36.07=$ TOTAL $ ◦ ALL charges go under supervising physician’s billing number except new patients. Then they go under PA’s NPI number (expect 85% return) 37
If more than 50% of visit is spent in counseling the patient Document total visit and counseling time Document what was discussed Can use time as overriding factor on those categories where time is a factor Must make sense for the diagnosis/reason for visit
Prolonged Services ◦ Office 30 minutes to 1 hour additional time (above the time designated for the “base” visit code) each additional 30 minutes additional time (above the time designated for the “base” visit code and after the first hour of additional time (99354) Prolonged Services ◦ Office 30 minutes to 1 hour additional time (above the time designated for the “base” visit code) each additional 30 minutes additional time (above the time designated for the “base” visit code and after the first hour of additional time (99354) Do Not Use Alone – Add-on Code**
Prolonged Services ◦ Hospital 30 minutes to 1 hour additional time (above the time designated for the “base” visit code) each additional 30 minutes additional time (above the time designated for the “base” visit code and after the first hour of additional time (99356) Prolonged Services ◦ Hospital 30 minutes to 1 hour additional time (above the time designated for the “base” visit code) each additional 30 minutes additional time (above the time designated for the “base” visit code and after the first hour of additional time (99356) Do Not Use Alone – Add-on Code**
NPPs are highly educated licensed health care providers Federal and State agencies do not find it credible that an NPP would refrain from providing health care services or making their own observations to solely report the work of a physician NPPs can (and should) be better utilized!! They are revenue generators!!!
Medicare only allows coverage for services and items which are “medically reasonable and necessary” for treatment/diagnosis of a patient. ◦ Medical necessity may be determined according to several factors including the following: Items or services provided to the patient must be appropriate for that patient’s treatment/diagnosis Documentation (When identified as required or when requested) supports the medical need. The frequency of service or dispensing of an item is within the accepted standards of medical practice.
Working diagnosis must match the ICD-9 description Close doesn’t count Do not up-code Fraud Do not down-code Fraud Do not not code-???? Don’t code from the index Always verify and check the book! Then run it through your CCI and NCCI edits 60-70% of first denials come from wrong/not specific/ ICD-9
Fracture coding in ICD-10-CM requires: ◦ documentation of site, ◦ laterality, ◦ type of fracture, ◦ whether it is displaced or nondisplaced, ◦ and the stage of healing (or encounter), which includes open fracture classification. This resource is to assist in the understanding of the classification system utilized in ICD-10-CM for open fractures.
The procedure for evaluation and management of open fractures is basically a set of principles that involve initial management and subsequent surgical interventions. The purpose of any fracture classification system in the clinical setting is to allow communication that infers fracture morphology and treatment parameters.
Grade I: wound less than 1 cm with minimal soft tissue injury; wound bed is clean; bone injury is simple with minimal comminution; with intramedullary nailing, average time to union is 21–28 weeks Grade II: wound is greater than 1 cm with moderate soft tissue injury; wound bed is moderately contaminated; fracture contains moderate comminution; with intramedullary nailing, average time to union is 26–28 weeks Grade III: The following fracture types automatically results in classification as type III: segmental fracture with displacement fracture with diaphyseal segmental loss; fracture with associated vascular injury requiring repair; farmyard injuries or highly contaminated wounds; high velocity gun shot wound; fracture caused by crushing force from fast moving vehicle;
Grade IIIA fracture: wound less than 10 cm with crushed tissue and contamination; soft tissue coverage of bone is usually possible; with intramedullary nailing, average time to union is 30–35 weeks; Grade IIIB fracture: wound greater than 10 cm with crushed tissue and contamination; soft tissue is inadequate and requires regional or free flap; with intramedullary nailing, average time to union is 30–35 weeks; It is important to educate providers on the use of this scale for the specific documentation necessary in ICD-10-CM. This will ensure that proper code assignment can be made without multiple queries to the provider.
Primary localized osteoarthrosis, lower leg Generalized osteoarthrosis, unspecified site M17.0 Bilateral primary osteoarthritis of knee M17.10 Unilateral primary osteoarthritis, unspecified knee M17.11 Unilateral primary osteoarthritis, right knee M17.12Unilateral primary osteoarthritis, left knee M15.0 arthritis of multiple sites bilateral involvement of single joint (M16-M19)
ICD-9-CM Pain in joint; ankle and foot, Ankle joint, Digits [toes], Metatarsus, Phalanges, foot, Tarsus, Other joints in foot ICD-10-CM M Pain in right ankle M Pain in left ankle M Pain in unspecified ankle M Pain in right foot M Pain in left foot M Pain in unspecified foot M Pain in right toe(s) M Pain in left toe(s) M Pain in unspecified toe(s)
ICD-9-CM Bicipital tenosynovitis ICD-10-CM M Other synovitis and tenosynovitis, right shoulder M Other synovitis and tenosynovitis, left shoulder M Other synovitis and tenosynovitis, unspecified shoulder ICD-9-CM Pain in limb ICD-10-CM M Pain in right arm M Pain in left arm M Pain in arm, unspecified M Pain in right leg M Pain in left leg M Pain in leg, unspecified M Pain in unspecified limb
Chapter 19 Injury, Poisoning and certain other consequences of External causes What ICD-9 looked like: What ICD-10 looks like: T24.309A- unspecified site T D-left thigh, subsequent visit T24.321A-right knee T24.332S-sequela left lower leg
First Surgical Assisting
Physician bills 25% of CPT Medicare-PA’s can charge. 85% x 16% = 13.6% of surgeon’s fee Medicaid-same 3rd party-either 100% 75% Reimbursement depends on IF a surgeon assistant is required/allowed and NO Resident is available Check each carrier reimbursement schedule for all reimbursable cases
If physician-modifier-80 Minimal assistance-modifier-81 In teaching institution-modifier-82 (Resident not available) Medicare-PA/NP-modifier AS Blue Cross/Blue Shield doesn’t recognize Non- physician PIN codes-state specific
If physician-modifier-80 Minimal assistance-modifier-81 In teaching institution-modifier-82 (Resident not available) Medicare-PA/NP-modifier AS Blue Cross/Blue Shield doesn’t recognize Non-physician PIN codes-state specific
CarrierReimburseBill under MD 1 st AssistModifier Aetna100%Yes12%80-81 Assurant Health 100%Yes20%80-81 BC/BS100%Yes13.6%AS Cigna100%Yes13.6%AS GHI100%Yes13%AS Humana100%Yes10-20%AS School Insurance of FL 100%Yes Pasco Co-13.6% AS or 80 United Healthcare 100%Yes14%AS
The PA and the physician must work for the same employer. The regulation applies only to E/M services delivered in the hospital and not to procedures. The physician must provide some face-to-face portion of the E/M services on same day. Simply reviewing or signing the patient’s chart is not sufficient. “Incident to” billing has never applied to the hospital setting – and still does not apply Bill 100% under physician PIN
Medical Nutrition Therapy Medical Genetics/Counseling Services Education/training for Self management established pts using standardized guidelines (CHF, Coumadin, Genetics, Immune, Transplant Svc) Home Services (E&M) Home Health procedures (Postnatal, Resp. Tx, Hemodialysis Preventive Medicine-Counseling, Risk factor reduction , with modifier –GT to signify Teleconsultation via interactive video/audio → Non face-to-face Telephone E&M 98969→ Online ( ) E&M assessment and management
CPT code G0447, a 15-minute face-to-face behavioral counseling for obesity, has been assigned total non-facility RVUs of The 2011 conversion factor is $ Screening and counseling coverage is effective as of the decision date, so when contractors are ready to process the claims, physicians will be able to submit claims for service back to the date of coverage, according to the spokeswoman. Patients with Medicare will not be charged for the screening or counseling, according to CMS. Screening for obesity and counseling for eligible beneficiaries by primary care providers are covered under this new benefit. For a beneficiary who screens positive for obesity with a body mass index greater than 30, the benefit includes one face-to-face counseling visit each week for 1 month and one face-to-face counseling visit every other week for an additional 5 months, according to CMS. The beneficiary may receive one face-to-face counseling visit every month for an additional 6 months (for a total of 12 months of counseling) if he or she has achieved a weight reduction of at least 6.6 pounds during the first 6 months of counseling.
Why is the patient being seen? Does the level of visit make sense? Does the documentation support the level indicated? Could it support a different (higher or lower) level of E&M? Too much, too little or just right? Has Medical Necessity been met? Is this visit justifiable? Is this visit defensible from an outside audit or worse, an ALJ hearing?
Teach your doctors, PA’s and other providers to understand what medical necessity is from the payer’s perspective, NOT the provider’ s Teach them what is required for documentation per payer Teach them to dictate/write the proper justification-OP note, procedure note, lab/radiology orders, etc…. Finally, don’t bill it, if it’s not documented and justifiable.
NPP’s very cost effective NPP’s accepted just about every clinical environment NPP’s billing and reimbursement has improved significantly NPP’s will be around for quite a while! Reimbursement is totally dependent upon carrier discretion and interpretation!! Must be considered Revenue generators**** Learn how to get them reimbursed!!