Presentation on theme: "Woodland Hills AAPC Medicare Seminar"— Presentation transcript:
1 Woodland Hills AAPC Medicare Seminar Presented byKathy A. MontoyaSenior Provider Relations RepresentativePalmetto GBA
2 The information provided in this presentation was current as of May 1, Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at
3 ObjectivesTo enhance the knowledge base of Medicare coverage and billing guidelinesTo decrease the National Paid Claims Error RateTo protect the Medicare Trust FundTo ensure the delivery of quality care to our Medicare beneficiaries
7 Jurisdiction E Awarded Announced September 20, 2012Noridian Administrative Services (NAS)
8 Jurisdiction E Noridian launched JE website April 16, 2013 https://www.noridianmedicare.com/je/Outlines implementation timelinePresents calendar of transition eventsStates physical presence in California
10 Implementation Dates Noridian will be the MAC for Jurisdiction E: Part A – August 26, 2013Part B –September 16, 2013The implementation dates for Jurisdiction E are 8/26/13 for Part A and 9/16/13 for Part B.May 2013
11 Communication Resources Noridian will use a number of communication resources to reach out to providers. These include: review slide..Website/Listserv:Contact provider organizations/associationsMeet and Greet meetings with providersMailings to providersWeb based provider workshops/ACTsMay 2013
12 Listserv2 For providers not registered with J1 prior to March 1, 2013 Go to: https://www.noridianmedicare.com and select “ Newsletter Sign Up” at the bottom of the left hand navigation menu.Instructions listed in Listserv article on JE websiteMay 2013
13 Key Website ItemsContact Informationphone numbers and mailing addressesimplementation questionsCurrent news and relevant changesIVRSchedule of EventsAs a follow-up to the previous slide, the key website items available to providers includes:Contact Informationphone numbers and mailing addressesimplementation questionsCurrent news and relevant changesIVRSchedule of EventsCutover datesPayment cyclesFAQsEDI – with a focus on vendors and direct submittersAnd Provider PortalMay 2013
14 Key Website Items Cutover dates Payment cycles FAQs EDI - focus on vendors and direct submittersProvider PortalAs a follow-up to the previous slide, the key website items available to providers includes:Contact Informationphone numbers and mailing addressesimplementation questionsCurrent news and relevant changesIVRSchedule of EventsCutover datesPayment cyclesFAQsEDI – with a focus on vendors and direct submittersAnd Provider PortalMay 2013
15 Contact InformationSingle Toll-free number after JE ImplementationProvider Contact Center (PCC)Electronic Data Interchange Support Services (EDISS)Telephone ReopeningsProvider EnrollmentUser SecurityMay 2013
16 Contact InformationQuestions regarding implementationto orCall Implementation Hotline atHot Line available 8:00 am to 5:00 pm (PT), Monday-FridayMay 2013
17 WelcomeNoridian is proud to be your Medicare Administrative Contractor (MAC) for Jurisdiction E (JE) – formerly Jurisdiction 1. They look forward to working with you in the near future to serve your Medicare needs.
18 New CostsWe are going to start with the revisions to the Medicare deductibles and coinsurances. NEW COSTS
19 2013 Part B Deductible and Coinsurance Rates 20% of eligible chargesThe 2012 Medicare Part B deductible is changed to $The patients responsibility for most services remains 20% for most services.Reminder: It is recommended that you do not bill the patient for the deductible until you receive the RA. The deductible is applied against the first claim processed for payment and not the first service rendered for the calendar year.19
20 2013 Part A Deductible and Co-Pays 1st 60 days of hospitalization$296 co-payDays 61-90$592 co-payDays 91 – 150 Lifetime Reserve$148 co-paySNF daysMedicare Part A pays for inpatient hospital, skilled nursing facility, hospice, and certain home health care services. The $1,184 deductible for 2013, paid by the beneficiary when admitted as a hospital inpatient. Beneficiaries must pay an additional $296 per day for days 61 through 90 in 2010, and $592 for lifetime reserve days. Daily coinsurance for the 21st through 100th day in a skilled nursing facility will be $148 in 2013.
21 2013 Part B Premiums Income Parameters for Part B Premiums Premium/MthlyIndividual IncomeCombined Income (Married)$104.90< $85,000< $170,000$146.90$85, to $107,000$170, to $214,000$209.80$107, to $160,000$214, to $320,000$272.70$160, to $214,000$320, to $428,000$335.70$214, >$428, >For 2013, the Part B premium will still be based on the income of the beneficiary. With the minimum being $ per month.Clear slide(note to speaker in the past two years there were hold harmless premium freeze for the lower level of income – 2013 that has been done away with.)21
22 2013 Part A Premium Fewer than 30 quarters 30 to 39 Quarters $ per month30 to 39 Quarters$ per monthApproximately 99 percent of Medicare beneficiaries do not have to pay a premium for Part A services because they have at least 40 quarters of Medicare-covered employment (or are the spouse or widow(er) of such a person). However, other seniors and certain people under age 65 with disabilities who have fewer than 30 quarters of coverage may obtain Part A coverage by paying a monthly premium set according to a statutory formula. This premium will be $441. per month for 2013. A reduced premium applies in the case of individuals with 30 to 39 quarters of coverage, who will pay a premium of $243 in 2013.
24 Payment Reduction April 1, 2013 The Budget Control Act of 2011Requires Federal spending reductions, sequestrationThe American Taxpayer Relief Act of 2012 postponed sequestration for two monthsPresident Obama issued a sequestration order on March 1, 2013The Budget Control Act of 2011 requires, among other things, mandatory across-the-board reductions in Federal spending, also known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for two months. As required by law, President Obama issued a sequestration order on March 1, The Administration continues to urge Congress to take prompt action to address the current budget uncertainty and the economic hardships imposed by sequestration.
25 Payment Reduction April 1, 2013 Medicare FFS claimsPart B - dates-of-service ≥ April 1, 2013Part A - dates-of-discharge ≥ April 1, 2013Two percent reductionCR7825In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a two percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME Competitive Bidding Program, will be reduced by two percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013.
26 Transitional Care Management Services (TMC) New codes and 99496Established patientModerate to high complexity medical decision making
27 Transitional Care Management Services (TMC) Transition period from an inpatient setting (IP, LTC, SNF, rehab) to the patient’s community settingTMC begins on date of discharge + 29 daysOne face-to-face visit combined with non FTF services provided by physician or clinical staff
28 Transitional Care Management Services (TMC) Medical decision making/date of the first face-to-face visit are used to select the code99495 TMC serviceCommunication with patient/caregiver within 2 business daysModerate complexityFace to face within 14 calendar days of discharge
29 Transitional Care Management Services (TMC) 99496 TMC serviceCommunication with patient/caregiver within 2 business daysHigh complexityFace to face with 7 calendar days of discharge
30 Transitional Care Management Service (TMC) Date of Service = 30th dayPlace of Service = POS for face to face visitWhat if patient dies during the 30 day periodBill E/M code onlyHere are answers to the many questions we have been getting regarding sequestration.
31 Psychiatry Initial Psychiatric Evaluation 90801 and 90802 were deleted Distinction made between service by MD and one by non physician
32 Psychiatry – New Codes90782 = Initial evaluation with physician services90791 = Initial evaluation done by a non physician90785 = New add on code for interactive complexity
33 Multiple Procedure Payment Reduction (MPPRs) CR7848Effective January 1, 2013Reduction to Technical Component (TC)Diagnostic CardiovascularOphthalmology proceduresMultiple Procedure Payment Reduction (MPPR) on the Technical Component (TC) of Diagnostic Cardiovascular and Ophthalmology ProceduresRelated Change Request (CR) #: CR Effective Date: January 1, Implementation Date: January 7, 2013Medicare is expanding the Multiple Procedure Payment Reduction (MPPR) policy by applying MPPRs to the Technical Component (TC) of diagnostic cardiovascular and ophthalmology procedures. Make sure that your billing staff is aware of these changes.Background Section 3134 of the Affordable Care Act added Section 1848(c)(2)(K) of the Social Security Act (the Act), which specifies that the Secretary of Health and Human Services (the Secretary), shall identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service. As a further step in implementing this provision, Medicare is expanding the MPPR policy by applying MPPRs to the TC of diagnostic cardiovascular and ophthalmology procedures.
34 Multiple Procedure Payment Reduction Multiple services to same patient, same dateAffected codesRemittance AdviceAdjustment Reason Code 59The MPPRs on diagnostic cardiovascular and ophthalmology procedures apply when multiple services are furnished to the same patient on the same day. The MPPRs apply independently to cardiovascular and ophthalmology services. The MPPRs apply to TC-only services, and to the TC of global services.The complete lists of codes subject to the MPPRs on diagnostic cardiovascular and ophthalmology procedures are in Attachments 1 and 2 of CR 7848 respectively. CR 7848 is available at on the Centers for Medicare & Medicaid Services (CMS) website.When payments are reduced due to the MPPR, you will receive a Claim Adjustment Reason Code of 59 (Processed based on multiple or concurrent procedure rules. (For example, multiple surgery or diagnostic imaging, concurrent anesthesia) Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present, and Group Code CO (Contractual Obligation).
35 Multiple Procedure Payment Reduction Cardiovascular ServicesSame physician, or multiple physicians in same groupFull TC payment with highest valueSubsequent TC paid at 75%.For cardiovascular services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice (e.g., same Group National Provider Identifier (NPI))) to the same patient on the same day.
36 Multiple Procedure Payment Reduction Ophthalmology servicesSame physician, or multiple physicians in same groupFull TC payment with highest valueSubsequent TC paid at 80%For ophthalmology services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice (e.g., same Group NPI)) to the same patient on the same day.1.0.19
37 MPPRs Cardiovascular Payment Reduction Example Sample Cardiovascular Payment ReductionCode 78452Code 93306Total CurrantTotal 2013 PaymentPayment CalculationPC$77.00$65.00$142.00No reductionTC$427.00$148.00$575.00$538.00$427 + (.75 x $148)Global$504.00$213.00$717.00$680.00$142 + $427 + (.75 x $148)Example clear slide78452 myocardial perfusion imaging, tomographic (SPECT), Multiple studies at rest and stress93306 Echocardiography, transthoracic, real time with image
38 MPPRs Ophthalmology Payment Reduction Example Sample Ophthalmology Payment ReductionCode 92235Code 92250Total CurrantTotal 2013 PaymentPayment CalculationPC$46.00$23.00$69.00No reductionTC$92.00$53.00$145.00$134.40$92 + (.80 x $53)Global$138.00$76.00$214.00$203.40$69 + $92 + (.80 x $53)Example clear slide92235 Fluorescein Angiography with interpretation and report includes multiframe imaging92250 Fundus photography with interpretation and report
39 CR7260 Health Insurance Claim Number (HICN) and Name Mismatch Effective October 1, 2012Claims will reject MA 130 and MA61Take information exactly as shown on Medicare cardWe have seen increased calls resulting from Change Request 7260 that went into effect on October 1, With this change, Medicare contractors will reject a claim with ANSI reason code MA130 and MA61 when the beneficiary name and Health Insurance Claim Number (HICN) do not match information listed in the Common Working File (CWF) record for that beneficiary. Providers should ensure they report the beneficiary’s name and Medicare HICN exactly as they appear on their Medicare card.
40 John D. Doe MEDICARE HEALTH INSURANCE JOHN D. DOE 123-45-6789A MALE SOCIAL SECURITY ACTNAME OF BENEFICIARYJOHN D. DOEMEDICARE CLAIM NUMBER SEXWhen an individual becomes entitled to Medicare, they are issued a health insurance card like the one depicted here.Office staff should regularly request the patients card and picture ID to verify services are furnished to eligible individuals.The following information can be found on the health insurance card;NAMESexMedicare HIC# with an alpha or alphanumeric suffix indicating how patient is entitledParts of Medicare that the patient is entitled to,REMINDER: Use the name exactly how it appears on the HIC card and verify the card once a year… the number may change depending on how the beneficiary is entitled to Medicare.Example- if the beneficiary was getting benefits from a spouse and the spouse passes away… the number’s suffix will change…A MALEIS ENTITLED TO EFFECTIVE DATEHOSPITAL INSURANCE (PART A) /1/98MEDICAL INSURANCE (PART B)John D. DoeSIGNHERE2
42 MPPR increased to 50% from 20% for all settings Multiple Procedure Payment Reduction (MPPR) for Selected Therapy ServicesCR 8206Effective April 1, 2013MPPR increased to 50% from 20% for all settingsApplies to the practice expenseApplies to HCPCS codes on the “always therapy” list
43 2013 Financial Limitation for Outpatient Therapy Services Effective January 1, 20132013 Therapy Cap amounts:$1,900 for OT$1,900 combined PT and SLP
44 2013 Financial Limitation for Outpatient Therapy Services Section 603 of American Taxpayer Relief Act of 2012Outpatient Therapy claims capExtended through DOS December 31, 2013$3,700 for PT and SLP$3,700 for OTManual Review of claims > $3,700
45 Changes for Therapy Services in 2013 Reporting requirementsUse Functional status codesUse Functional Limitation modifiersEvery 10 treatments or 30 calendar days, whichever is earlier
48 Functional Status Codes Three codesCurrent statusGoal statusDischarge status
49 Severity Complexity Modifiers Impairment Limitation RestrictionCH0 % impaired, limited or restrictedCIAt least 1% but less than 20% impaired, limited or restrictedCJAt least 20% but less than 40% impaired, limited or restrictedCKAt least 40% but less than 60% impaired, limited or restrictedCLAt least 60% but less than 80% impaired, limited or restrictedCMAt least 80% but less than 100% impaired, limited or restrictedCN100% impaired, limited or restrictedFor each of the G codes used, a modifier must also be used to report the severity or complexity for that functional measure. The severity modifiers reflect the beneficiary’s percentage of functional impairment as determined by the therapist, physician or NPP furnishing the therapy service.
50 Functional Reporting Use of G codes and modifiers is required At the onset of therapy episode of careAt least once every 10 treatment days
51 Functional ReportingSame date of service that an evaluation/re-evaluation procedureAt the time of discharge from therapy episode of careOn the same date of service the reporting of a functional limitation is ended
52 Claim Reporting Onset of therapy and each reporting period Discharge Report two G codes with modifiersCurrent status, goal statusDischargeCurrent status, discharge status
53 Manual Medical Review CMS Update March 21, 2013 Recovery Auditors (RA) to conduct MMR at $3,700 thresholds (PT and SLP, OT)Prepayment Review Demo – CaliforniaPos-tpayment Review – Nevada, Hawaii
55 Manual Medical Review Prepayment Review California Palmetto GBA to send a Additional Documentation Request (ADR) to providerRequest documentation be sent to the RAThe Recovery Auditor will conduct prepayment reviewWithin 10 business days of receiving documentationWill notify Palmetto of payment decision
56 Manual Medical Review Postpayment Review Hawaii and Nevada Palmetto GBA to send a Additional Documentation Request to the providerRequest documents be sent to the RAThe Recovery Audition will conduct a post payment reviewWill notify Palmetto GBA of the payment decision
57 Ordered and Referred Services Reminders and Updates
58 Phase 1 Ordering/Referring Rejects Affordable Care Act §6405Required Ordering/Referring providers to be enrolled in MedicareName and NPI needed on claimPhase 1Began October 5, 2009Incorrect, Missing information – rejected claimInformational messaging on Remittance AdvicesThe Affordable Care Act, Section 6405, 'Physicians Who Order Items or Services are Required to be Medicare Enrolled Physicians or Eligible Professionals,' requires physicians or other eligible professionals to be enrolled in the Medicare Program to order or refer items or services for Medicare beneficiaries.. Also, effective January 1, 1992, a physician or supplier that bills Medicare for a service or item must show the name and unique identifier of the attending physician on the claim if that service or item was the result of an order or referral. Effective May 23, 2008, the unique identifier was determined to be the National Provider Identifier (NPI). The Centers for Medicare & Medicaid Services (CMS) has implemented edits on ordering and referring providers when they are required to be identified in Part B, DME and Part A HHA claims from Medicare providers or suppliers who furnished items or services as a result of orders or referrals.Phase 1: Informational messaging: Began October 5, 2009, to alert the billing provider that the identification of the ordering/referring provider is missing, incomplete, or invalid, or that the ordering/referring provider is not eligible to order or refer. The informational message on an adjustment claim that did not pass the edits indicated the claim/service lacked information that was needed for adjudication
59 New Edit Phase 2Planned Effective/Implementation May 1, DelayedClaims will be denied when Ordering/Referring provider neededProvider not enrolled in MedicareNo NPI on claimWrong specialty for service/supplyDenied as Non-coveredEffective May 1, 2013, Medicare will deny claims for all covered Medicare Part B, durable medical equipment, orthotics, and supplies (DMEPOS), and Part A home health agency (HHA) services when the ordering or referring provider is not enrolled in Medicare or the claim does not list the national provider identification (NPI) number for the ordering or referring provider.
60 Denial Reason CodesN264 = Missing/incomplete/invalid ordering provider nameN265 = Missing/incomplete/invalid ordering provider primary identifierClaims will be denied with the reason codes listed above
61 New Edit Resources SE1305 CRs 6421, 6417, 6696, 6856 Ensure your in PECOSLook up your NPIClear slideProviders should check their NPI in the CMS listing to ensure that they are in PECOS and that their name and numb er are listed correctly
62 Order or Referral Must Include Specific services requestedCPT/HCPCS codeIndicate preventive or diagnosticUse appropriate gender specific codes if applicableWhen ordering or referring a patient provide the performing provider with enough information to determined medical necessity.An order or referral should include:Specific services requested. Indicate the appropriate CPT/HCPCS for the service. Remember to include the code that represents either the covered preventive or diagnostic service that you want done. Watch out for gender specific codes.
63 Order or Referral Must Include Applicable ICD-9-CM codeScreening versus diagnostic codesSign or symptomsPatient diagnosisUse appropriate gender specific codes if applicable.Applicable ICD-9-CM code. Include the ICD-9-CM code that best reflects the reasoning you are requesting the service (ig: screening or the signs, symptoms or patient diagnosis if known). Utilize the proper code for screening versus diagnostic and watch out for gender specific codes.
64 Order or Referral Must Include Ordering/Referring Provider’s Name and NPI numberOrdering/Referring Provider’s signature if necessaryPlan of Care if applicableYour name and National Provider Identification Number (NPI).Your signature on the order/referral if necessary.Plan of Care is applicable
65 Reporting Ordering/ Referring Information Don’t use nicknamesDon’t enter credentials (Dr.)First name first, Second name secondJohn SmithUse individual not group informationMake sure your claims are properly completed.Do not use 'nicknames' on the claim, as their use could cause the claim to fail the editsDo not enter a credential (e.g., 'Dr.') in a name fieldOn paper claims (CMS-1500), in item 17, you should enter the Ordering/Referring Provider's first name first, and last name second (e.g., John Smith)Ensure that the name and the NPI you enter for the Ordering/Referring Provider belong to a physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner who generated the order or referral
68 Documentation Important for Billing Important for Audits
69 Basic Coverage Rule Social Security Act in Section 1862 (A) 1 No payment for expenses not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body memberOne of the basic rules of Medicare is outlined in the Social Security Act in Section 1862 (A) 1. It states;‘Notwithstanding any other provision of this title, no payment may be made under part A or part B for any expenses incurred for items or services which, except for items and services described in a succeeding subparagraph, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.’
70 855 I, Section 15, Bullet 4Abide by Medicare laws, regulations and program instructionsProvider must knowClaim payment based uponClaimUnderlying transactionSupplier’s compliance with conditions of participationIn the 855 I, Section 15, bullet number four it states:‘I agree to abide by the Medicare laws, regulations and program instructions that apply to me or to the organization listed in Section 4A of this application. The Medicare laws, regulations, and program instructions are available through the fee-for-service contractor. I understand that payment of a claim by Medicare is conditioned upon the claim and the underlying transaction complying with such laws, regulations, and program instructions (including, but not limited to, the Federal anti-kickback statute and the Stark law), and on the supplier’s compliance with all applicable conditions of participation in Medicare.’
71 Medicare Audits They happen Be prepared Create thorough documentation Read request carefullyUse Medicare Self Help toolsLearn from mistakesYou can survive an audit by simply following these rules:Be preparedCreate thorough documentationRead request carefullyUse Medicare Self Help toolsLearn from mistakes
72 Medicare Audits Medical Review of Palmetto GBA Comprehensive Error Rate Testing (CERT) programRecovery Audit Contractors (RACs)Zone Program Integrity Contractors (ZPICs)Provider must respond to any applicable party working under the direction of the CMS (CERT, RAC, and MAC etc.).An audit/request for documentation can happen at any time. There are four different audit entities being utilized by Medicare to measure if the submission of claims is done accurately and if the payment of the claim was done correctly. The Medical Review department of Palmetto GBA, the Comprehensive Error Rate Testing (CERT) program, the Recovery Audit Contractors (RACs) and Zone Program Integrity Contractors (ZPICs) address fraud, waste and abuse issues through auditing and analyzing records.
73 Audits Pre-payment or post payment Documentation Follow industry, specialty, CMS and Palmetto GBA guidelines
74 Additional Documentation Request (ADR) Outlines requested informationIndicates date of service(s)Outlines timeline for return of documentsProvides return addressRead request carefullyOutlines requested informationIndicates date of service(s)Outlines timeline for return of documentsProvides return addressRespond promptly
75 Use Medicare Self Help Tools And Articles CERT sectionArticles sectionADR ChecklistsUse Medicare Self Help toolsCERT sectionArticles sectionADR Checklists
76 Learn From Mistakes Review results Medical review audits CERT and RAC auditsOffice of Inspector General (OIG)Learn from mistakesInformation on past Medical review auditsInformation on past CERT and RAC auditsInformation on the Office of Inspector General (OIG) website at regarding areas of concern regarding claim submission
77 Code of Federal Regulations 42 CFR 424.5 (a) (6) Sufficient information. The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
78 Medical Record Documentation Thorough proper documentationVerifies service/level providedKey to audit successEnsures payment for services renderedProtects patients and providerCreate thorough documentationKey to audit successEnsures payment for services renderedProtects patients and providerSubmit claims only for services you can substantiate with medical records
79 Documentation Should Paint a Picture CHOOSE A NORMAN ROCKWELL OR ANDREW WYETH PAINTINGNOT A JACKSON POLLOCK OR VASILY KANDINSKY PICTURE
80 Medical Record Documentation Evaluate, plan and monitorCommunication, coordination and continuityClaims payment and reviewUtilization and quality evaluationsResearch and educationMedical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates;the ability of the physician and other health care professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her health care over time;communication and continuity of care among physicians and other health care professionals involved in the patient's care;accurate and timely claims review and payment;appropriate utilization review and quality of care evaluations; andcollection of data that may be useful for research and education.
81 Principles of Documentation Complete and legibleTranscribe if necessaryReason for encounterRelevant historyPhysical examinationThe principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E & M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E & M services.1. The medical record should be complete and legible.When responding to an Additional Documentation Request (ADR) submit both a copy of the applicable medical records and a transcription of the information. In doing this you will avoid any incorrect interpretation of the data.2. The documentation of each patient encounter should include:reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;
82 Principles of Documentation Diagnostic testRationale for orderingResultsAssessment, clinical impression or diagnosisPlan for careDate and legible signaturediagnostic test rationale for ordering and/or results;assessment, clinical impression or diagnosis;plan for care; anddate and legible identity of the observer.
83 Principles of Documentation Past and present diagnosesIdentify health risk factorsPatient's progressResponse to and changes in treatmentRevision of diagnosisSupport CPT and ICD-9-CM code selection. Past and present diagnoses should be accessible to the treating and/or consulting physician.5. Appropriate health risk factors should be identified.6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.
84 General Documentation Tips Patient name on each page and date of serviceTemplates/forms OK, but must be individualizedComputerized notes OK, but must be individualized
85 General Documentation Tips Document time when coding is based on time (face to face)Must be legible, when in doubt transcribeEach entry must be signed (first, middle, last) with credentialsSignature log O.K. to useElectronic signature O.K. to use
86 Illegibility Read by others for treatment/care Proof of services renderedIllegibility leads to denials‘If it isn’t documented it didn’t happed’Auditors cannot use inference in evaluation of recordsIllegibilityIllegibility is a very serious issue with medical documents submitted in the J1 region. The medical chart is read by a number of health care workers who need to be able to identify procedures, medicines, patient progress, etc. The proof of what is being done for the patient lies exclusively within the pages of the patient’s chart. If the information is illegible, the chart does not communicate valuable information about the services.If the auditors and medical review staff cannot read the documents, they cannot evaluate the medical need and necessity of the service. Therefore, the claim will be denied.Remember an important rule of Medicare which state, ‘If it isn’t documented it didn’t happed.’ The inability of auditors to read your medical record is equivalent to not having any medical records at all.At one time, medical review staff would read as much of the record as they could and then apply inference to complete the picture of what the provider did for the patient. Now CMS has prohibited the use of inference in the evaluation of the medical record contents.
87 Missing Provider Signatures Acceptable signature requiredEach entryFirst, middle and last nameInclude credentialsDateUse signature log or attestation statement(CR) 6698Missing Provider SignaturesA large number of claims are denied due to missing signatures. Each entry in the patient’s medical record requires the acceptable signature, including credentials and the date of the person writing the note. The only acceptable way to do this is to write your first, middle and last name, followed by your credential positioned at the end. The signature must also be clearly visible after each entry. If the provider signature is a scrawl and impossible to change, the provider will have to use a signature log or prepare an attestation statement to submit to the auditors for document review.A signature log is a paper that has the provider’s signature along with his/her printed or typed first, middle and last name and credentialAn attestation statement is a small paragraph that states the acceptance of the claim information as being correct, that the provider did see the patient and performed that service on that particular date of service (DOS)Either process is appropriate to submit to the audit agency. Without a legal visible signature on the chart paperwork, the claim will be denied.CMS released Change Request (CR) 6698 in May of 2010, which required all documents be legible, signatures present and visible. This requirement is reflected in the ADR letter below that states if the signature of the provider is questionable, submit an attestation statement. It also states that claims will be denied if required signatures are illegible. CR6698 is located on the CMS Web site at
88 Insufficient Documentation Documentation should answerWhat was wrong?How was it manifested?What did it look like?What was the procedure to fix it?What was the plan of careInsufficient DocumentationNot providing sufficient documentation is another reason that claims are being denied after the audit review of the medical records. In order to prove the patient contact was both reasonable and necessary, the medical records from the provider must clearly portray the whole story of the visit and answer the following questions:What was wrong?How was it manifested?What did it look like?What was the procedure to fix it?What was the plan of care (including expectations or results with time frames identified)?
89 Insufficient Documentation Paint picture of need for serviceVague statements not detailed enough‘Status quo’, ‘no change’ or ‘patient stable’Give detailsIn your medical record document try to paint the whole picture of the patient’s needs for medical intervention as succinctly and specific as possible. There can be no gaps in the information provided. Entering ‘status quo’, ‘no change’ or ‘patient stable’ does not provide enough information to fully document the encounter with the patient and may result in a denial of the claim. Specific and detailed entries are more appropriate. For example, explain ‘no change’ by adding information about the ‘what’ there was, not a change to and then explain why.Claims are placed into the category of insufficient documentation when the medical documentation submitted does not include pertinent patient facts (e.g., the patient’s overall condition, diagnosis and extent of services performed).Some vendors have stated to providers that using their chart template for medical entries will provide the highest odds of getting paid for claims submitted. As a result, providers may mark all the boxes or mark negative or positive in the template, but no narration is present in their charts.A provider may also check all the boxes which indicate that a comprehensive review of systems or comprehensive physical examination was done. That is only relevant if the chief complaint warranted that level of service. However, checking all the boxes does not guarantee the provider of getting a high level evaluation and management (E & M) code paid. There would have to be some documentation that substantiates the need for a complete or comprehensive service. The ICD 9‐CM code billed or the chief complaint stated guides the decision of how involved the service must be.
90 Insufficient Documentation Medical documentation submitted does not include pertinent patient facts (e.g., patient’s overall condition, diagnosis, extent of services performed)Use narrative with chart templatesDocument need for a complete or comprehensive servicesIn your medical record document try to paint the whole picture of the patient’s needs for medical intervention as succinctly and specific as possible. There can be no gaps in the information provided. Entering ‘status quo’, ‘no change’ or ‘patient stable’ does not provide enough information to fully document the encounter with the patient and may result in a denial of the claim. Specific and detailed entries are more appropriate. For example, explain ‘no change’ by adding information about the ‘what’ there was, not a change to and then explain why.Claims are placed into the category of insufficient documentation when the medical documentation submitted does not include pertinent patient facts (e.g., the patient’s overall condition, diagnosis and extent of services performed).Some vendors have stated to providers that using their chart template for medical entries will provide the highest odds of getting paid for claims submitted. As a result, providers may mark all the boxes or mark negative or positive in the template, but no narration is present in their charts.A provider may also check all the boxes which indicate that a comprehensive review of systems or comprehensive physical examination was done. That is only relevant if the chief complaint warranted that level of service. However, checking all the boxes does not guarantee the provider of getting a high level evaluation and management (E & M) code paid. There would have to be some documentation that substantiates the need for a complete or comprehensive service. The ICD 9‐CM code billed or the chief complaint stated guides the decision of how involved the service must be.
91 Incorrect Date Of Service Incorrect date of service receivedRead ADR letter carefullyCheck before respondingSend multiple dates if askedIncorrect Date of Service of Documents Returned for Medical ReviewAnother common error noted by Palmetto GBA and the CERT and RAC contractors is the receipt of medical records containing the incorrect date of service. For example, if the ADR asks for patient notes for January 12, 2012, that is what you should send. Sending in notes for another date of service, other than January 12, 2012, would not be appropriate and would result in a denial of the claim.
92 Missing Patient Name Missing patient name on documentation Check copies before mailingBoth sidesBeware of photocopiesAbsence of the Patient Name on the Medical RecordAnother error that can cause a denial is the absence of a patient name on documentation. Many charts have dual side sheets. Although the date of service and patient name may be present on the first side, many times the flip side of that sheet has no patient name.
93 New Patient Versus Established Patient Denials Not seen within the previous three yearsFrom physician or physician group practice (same physician specialty)Hospital services countNew Patient versus Established PatientA ‘new patient’ is a patient who has not received any professional services, such as evaluation and management (E & M) service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years.For example, if a professional component of a previous procedure is billed in a three-year time period (e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed) then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test (e.g., reading of an X-ray or electrocardiography (EKG), etc.) in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.If a patient has been seen in the hospital (e.g., CPT code (subsequent hospital care) by a specialty 06), the face-to-face service requirement has been met for that specialty in that same group practice. When that patient is seen in follow-up for the first time in the office by a new member of the same group, he/she is considered to be an established patient, not a new patient.The following denial may appear on your Remittance Advice if multiple initial visits are billed:M13 – Only one initial visit is covered per specialty per medical group
94 Combined Billing Physicians in same group, different specialties Bill and paid regardless of groupCombined Billing Physicians in the same group practice, but who are in different specialties, may bill and be paid without regard to their membership in the same group. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one E/M (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that levelTwo office visits submitted for the same beneficiary, same physician/same specialty in same group on the same day are not payable. Palmetto GBA will deny the second visit submitted. This applies to CPT codes A review would be necessary for Palmetto GBA to consider a second office visit on the same date of service. On review, the provider must clearly indicate the visits were for unrelated problems in the office/outpatient setting, which could not have been provided during the same encounter.E/M services provided on the same day in sites other than the nursing facility will be bundled into the initial nursing facility care code. Hospital and observation services are not included.
95 Combined Billing Physician in same group, same specialties Bill and paid as single physicianOnly one E/M per dayUnless unrelated problemsSelect E/M level to incorporate allCombined Billing Physicians in the same group practice, but who are in different specialties, may bill and be paid without regard to their membership in the same group. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one E/M (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one E/M service may be reported unless the E/M services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that levelTwo office visits submitted for the same beneficiary, same physician/same specialty in same group on the same day are not payable. Palmetto GBA will deny the second visit submitted. This applies to CPT codes A review would be necessary for Palmetto GBA to consider a second office visit on the same date of service. On review, the provider must clearly indicate the visits were for unrelated problems in the office/outpatient setting, which could not have been provided during the same encounter.E/M services provided on the same day in sites other than the nursing facility will be bundled into the initial nursing facility care code. Hospital and observation services are not included.
96 Documenting Services Comments Field – NTE 02 Provide explanation of multiple physician treatmentIdentify subspecialty if applicableSend documentation when requested or for appealsShow need for1+ visits per dayOn electronic claims the documentation record could be used to explain why treatment was needed by a different provider in the same group or to specify the subspecialty of the provider when more than one service has been billed by multiple providers in the same groupAttachments (e.g., signed office notes, signed progress notes, etc.) for paper claims must identify the patient’s name, Health Insurance Claim number, date of service and other pertinent information (e.g., subspecialty of the billing provider):Attachments must be a full page (8 ½ x 11)On appeal, signed medical records (e.g., progress notes, history and physical notes, office notes, etc.) may be sent as evidence to show why more than one visit was submitted on the same date either by similar providers from different groups or different providers with different subspecialties from the same groupOn appeal, the identification of the providers’ subspecialty, when more than one provider from the same group is billing for E/M services to the same patient on the same date, can be helpful in explaining why multiple providers were needed
97 E & M Guidelines“1995 Documentation Guidelines for Evaluation and Management Services”“1997 Documentation Guidelines for Evaluation and Management Services.”Use either setUse only one per E & M serviceTwo sets of official E & M guidelines are available: “1995 Documentation Guidelines for Evaluation and Management Services” and “1997 Documentation Guidelines for Evaluation and Management Services.” Use these guidelines to learn more about the specific steps for determining the levels for the key components and their respective elements.Neither set of guidelines is better. A physician or practitioner may use either set of guidelines to determine the appropriate level of code for the E & M service provided.For each separate E & M service, you must use only one set of E & M guidelines throughout the code determination process. Mixing or combining of the two sets of guidelines for a single E & M encounter is not acceptable.The “1997 Documentation Guidelines for Evaluation and Management Services” provide more detail on the examination component and the expected/recommended types of examination that should be completed for the respective levels.
98 E & M Guideline Resources IOM , Chapter 12, §30.6CMS “Evaluation and Management Services Guide”Listed below are resources available from CMS. Please see your Medicare Contractor’s website for additional resources.CMS Internet-Only Manuals, “Medicare Claims Processing Manual” (Publication ), Chapter 12, Section 30.6 at on the CMS website.CMS “Evaluation and Management Services Guide,” 1995 Guidelines, and 1997 Guidelines at on the CMS website.
99 Also available at the CMS website listed above is the ‘Evaluation and Management Services Guide.’ This guide is an excellent tool that can be used the supplement the information outlined in the documents mentioned above.The Evaluation and Management Service Guide, as well as the 1995 and 1997 Documentation Guidelines for Evaluation and Management Service are invaluable tools. We suggest that you bookmark the URL/website page listed above or save it as a favorite in your browser. Not only are these documents useful in billing and coding but they are essential tools for use by physicians and other clinical staff in the proper documentation of the services that they perform.
100 E & M Services Grouped by categories and subcategories Setting Type of service3 to 5 levels of serviceE & M services are grouped into several different categories and subcategories of services based on the setting (e.g., hospital or physician’s office) and type of service (e.g., initial or subsequent care). Within each category or subcategory of service, there are 3 to 5 levels of services that are specific to the category or subcategory of service. From April 2009 to May 2010, E & M professional services accounted for an estimated $28 billion in Part B payments on a national level. Based on the recent data from the CERT program, 8.4% of those E & M payments were identified as being billed at the wrong code level – either too high or too low. The careful selection of the level of service is important in the proper billing of claims to the Medicare program.
101 Components of E/M Services Chief complaintHistoryExamDecision making
102 Components of E/M Services CounselingCoordination of careNature of presenting problemTime
114 Common E/M Documentation Errors Missing documentationBeneficiary’s nameDate of ServiceRendering physician’s/NPP’s signatureSupporting documentation (referred to ROS, PFSH, or orders)Minimum documentation requirements not met (down coded)
115 Common E/M Documentation Errors Medical necessity/reasonableness was not establishedIllegible documentationBilled in error (per physician/NPP)Cloned records
116 Common E/M Documentation Errors The chief complaint/reason for visit was not clearly documentedBilled higher level servicesExtensive PFSH was documented for lower-level services
117 Common E/M Documentation Errors Complete PFSH was missingNew patient or initial servicesExpansive ROS was documented for lower-level servicesMissing ROS for the system(s) related to the presenting problem or system(s) related to the presenting problem were “negative”
118 Common E/M Documentation Errors Documented diagnoses under ROSExtensive examination was documented for lower level servicesUnable to determine if diagnosis/problem is stable or worsening
119 Common E/M Documentation Errors The assessment contained a list of diagnoses/problems that were not addressed during the encounterDocumented “labs reviewed” without further informationUnable to determine if the physician/NPP independently reviewed image, tracing, or specimen
120 Common E/M Documentation Errors Didn’t summarize old records/history from othersAncillary staff/scribe documentation requirements were not metCounseling/coordination of care missing time/documentationIncident to requirements were not met
122 Medical Record Amendments General Medicare requirementsAfter medical records are sign & datedAdditional information can be added in form of an appropriate Amendment or addendumsOn rare occasions & not used as common practiceAfter the medical record entries have been dated and signed, additional information may be added to a medical record in the form of an appropriate addendum. Addenda should only be necessary on rare occasions and should not be used in a common practice of documenting services performed. Amending medical records to meet policy guidelines is inappropriate.
123 Accepted as an Appropriate Addendum to Medical Records Must be added timely within a few days/one weekMust contain individualized, patient-specific clinical information for each date of service amended.Blanket statements, declarations or attestations not acceptedPalmetto GBA has identified the following criteria that will be accepted as an appropriate addendum to medical records:The addendum must be added to the medical record in a timely manner within a few days of the original entry.The addendum must contain individualized, patient-specific clinical information for each date of service amended. We do not accept blanket statements, declarations or attestations..
124 Accepted as an Appropriate Addendum to Medical Records Should be chronological in recordsMust be legible, signed and datedShould address additional, clinically relevant informationNot added to meet regulatory requirementsNot added to support downcoded claimThe addendum should be chronological in the original medical records. If the addendum is voluminous, you may refer in the progress notes to the addendum information found elsewhere in the records.Each addendum must be legible, signed and dated by the person making the entry.The addendum should address additional, clinically relevant information; not information just to meet regulatory requirements or to later validate a CPT code that was initially down coded due to lack of supporting documentation
125 Making Corrections to the Medical Record Follow legal requirementsNever write over, erase, or obliterate an entryDraw a single line through incorrect informationWrite correction near deletionAll information should still be legibleShould be signed and datedWhen making a correction to the medical record, legal requirements must be followed. Never write over, erase, or obliterate an entry to the medical record. A single line should be drawn through the incorrect information, and the correction should be written near the deletion. The incorrect information should still be legible. The practitioner should sign and date the deletion. A correction can also be made by submitting the original record and adding the correction(s) as an addendum, preferably typed, with a full explanation of why the record was in error. The practitioner should sign and date the correction.
126 Making Corrections to the Medical Record A correction can also be made by submitting the original record and adding the correction(s) as an addendum, preferably typedA full explanation of why the record was in errorPractitioner should sign and date the correction