Presentation on theme: "Advanced Evaluation and Management Scorecard Presentation Monmouth-Ocean AAPC Local Chapter April 7, 2011."— Presentation transcript:
Advanced Evaluation and Management Scorecard Presentation Monmouth-Ocean AAPC Local Chapter April 7, 2011
Disclaimer Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. Highmark Medicare Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare program provisions are contained in the relevant laws, regulations, and rulings. Highmark Medicare Services does not permit videotaping or audio recording of training events 2
Highmark Medicare Services Education specific to providers in Medicare Administrative Contractor (MAC) Jurisdiction 12 which includes Maryland, DC Metro, Delaware, New Jersey, and Pennsylvania. If you are not a provider in Jurisdiction 12, please contact your Medicare contractor for specific guidance. 3
Frequently Asked Questions Frequently Asked Questions relating to Evaluation And Management Services are available on our website Questions and answers from previous Webinars are reviewed and posted Visit – https://www.highmarkmedicareservices.com/faq/part b/index.html 4
Objectives Explain the importance of the Comprehensive Error Rate Testing Program and how it relates to today’s Webinar We will use the Scorecard to determine the level of service of three Evaluation and Management case examples – New patient in the Office or other Outpatient setting – Initial Hospital Care – Subsequent Hospital Care Use the Score Card to evaluate your own documentation for your billed E/M services 5
COMPREHENSIVE ERROR RATE TESTING (CERT) PROGRAM 6
National Paid Claims Error Rate The Centers for Medicare and Medicaid Services (CMS) – National Medicare Fee for Service Error Rate for November 2009 Reporting Period is 7.8% – That Error equates to $24.1 Billion Dollars 7
Comprehensive Error Rate Testing (CERT) Information Center Comprehensive Information on the CERT Program Review Common CERT Errors Valuable References Bi Annual Reports Education Articles and Frequently Asked Questions https://www.highmarkmedicareservices.co m/cert/index.html 8
The Diagnosis Common Evaluation and Management (E/M) Errors Errors across entire spectrum of E/M codes Incorrect Coding – Documentation did not support code billed – One or more of the key components Insufficient Documentation – Documentation did not contain a valid physician’s signature – Missing records 9
Signatures Signature Requirements Legible Identifier is IMPORTANT! CMS, Internet Only Manual, Publication 100-8, Chapter 3, Section 126.96.36.199 B – Medicare requires a legible identifier for services provided/ordered. The method used shall be hand written or an electronic signature (stamp signatures are not acceptable) to sign an order or other medical record documentation for medical review purposes. 10
Signatures Examples of Acceptable Handwritten Signatures Legible full signature Legible first initial and last name Illegible signature over a typed or printed name Illegible signature where the letterhead, addressograph or other information on the page indicates the identity of the signature. 11
Signatures Examples of Acceptable Signatures – Illegible signature NOT over a typed/printed name and NOT on letterhead, but the submitted documentation is accompanied by a signature log, or an attestation statement – Initials over a typed or printed name – Unsigned handwritten note where other entries on the same page in the same handwriting are signed. Additional information can be found in the Med Learn Matters article 6698 http://www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf 12
Redeterminations When in doubt Appeal Claims that were denied or cutback Requests must be made in writing and must be filed within 120 days Submit all supporting documentation Redetermination form is available on our Website – Visit https://www.highmarkmedicareservices.com/partb/forms/pdf/partb- redeterm-form.pdf https://www.highmarkmedicareservices.com/partb/forms/pdf/partb- redeterm-form.pdf 13
CERT Information Center Information on the Comprehensive Error Rate Testing (CERT) Program Review Common CERT Errors Valuable References Bi Annual Reports Education Articles and Frequently Asked Questions – https://www.highmarkmedicareservices.com/cert /index.html https://www.highmarkmedicareservices.com/cert /index.html 14
Are You Ready for the Cases? Handout materials contain three blank Scorecards and Medical Record Examples Make sure you have a Pencil or Pen available 15
Example 2 Billed as 99205 Evaluation of increased liver function tests (LFTs) in a patient with a history of a colon cancer. HPI: Back in November of 2001 she had a large adenomatous polyp removed. The pathology report showed an insitu cancer right at the surface of the polyp only. In fact, it was not invasive at all into the stalk. The patient has had several follow-up colonoscopies and each time has had a polyp noted. Recently in the fall of 2003, she had a polyp noted in the transverse colon and it was rather large. It could not be removed by endoscopy so the patient underwent a right hemicolectomy in November of 2003. The pt had some complications after the surgery with a post op ileus and was in the hospital for approximately 22 days. Recent labs indicated an elevated serum glutamate pyruvate transaminase (SGPT). However none of the other LFTs were elevated. She had an appointment to see us as well as an ultrasound of the abdomen but the ultrasound is not going to be until June 8th. The pt relates no history of abdominal pain. No nausea, vomiting, discolored urine. She does not really feel ill at all.
PMH: Other than positive for the polyp and the colon cancer, has had vascular surgery back in 1998. MEDS: Pravachol, Lotrel, Metoprolol, Leutein, Garlic, Caltrate, Contrum Silver, Bayer and as needed Bumatane. ALLERGIES: Denies any known allergies. SOCIAL HISTORY: Does not smoke. Rarely drinks alcohol. No recreational drug use. FAMILY HISTORY: Widowed with 2 children. Had 2 brothers – one died of heart disease at 49 and one died of heart disease at 76. Mother died of unknown causes and father died at 72 with heart disease. ROS: Weight gain, high BP. Denied any gastrointestinal (GI) symptoms. No genitourinary (GU) symptoms. No pulmonary symptoms. No neurologic symptoms.
PE: Very pleasant elderly woman in no acute distress. VITAL SIGNS: Height 5’3”, Weight 201, BP 162/74, Temp 96.6, Pulse 78, Resp 20 HEENT: Normocephalic, conjunctiva are pink. Moist mucus membranes CHEST: Clear to auscultation HEART: Regular rate and rhythm with a grade 2/6 systolic murmur. ABDOMEN: Soft. I could not appreciate any hepatomegaly or splenomegaly. EXTREMITIES: Has diminished pulses in both legs. NEURO: No focal deficits SKIN: Healed abdominal incision. LAB: Most recent lab study showed an serum glutamine oxaloacetic transaminase (SGOT) of 47 and SGPT of 37. Electrolytes were normal. Blood count from 5/25/04 normal. White blood count (WBC) of 6.8, hemoglobin (HGB) 13.0 and platelets 174
IMPRESSION: The pt has a very mild transaminitis the differential of which could be just normal variant secondary to medication, secondary to intrinsic liver disease or extrinsic to metastatic colon cancer. History (Hx) of Stage I colon cancer three years ago with no evidence of recurrence. Hx of polyps Hx of peripheral artery disease, quite significant Hypercholesterolemia RECOMMENDATIONS: Obviously we need to visualize the liver with an ultrasound of the abdomen. At the same time we will have her get some blood work including repeat LFT on the same day as the ultrasound and also get a carcinoembryonic antigen (CEA). Unlikely that this represents metastatic cancer but we certainly will check. Will see her after and if there is anything to follow-up on, we will. If not, release her back to her primary doctor.
Example 1 - Billed as 99214 A 69 year old woman was seen in my office in follow-up to hospital stay (5/22-6/11) for a blood clot in left leg. She complains of still having leg pain. She is currently on Coumadin, and needs to be monitored, but wants home therapy. Claims it is too difficult for her to get to this office. I am recommending referring her to VNA Home Health for evaluation. VNA will conduct PT and pro-times to begin 6/19. She should continue with oxycodone for leg pain, Lipitor for cholesterol and Lisinopril for BP. No known allergies. She is alert and active, in no apparent distress. Chest clear to auscultation anterior and posterior. No wheezes, rubs or rhonchi. BP 133/63, HR 76 b/min. Heart regular rate and rhythm, without ribs, murmur or gallop. Extremities without edema. Left lower extremity more swollen than right. Upper anterior tibial area is an erythematous warm area. It is not indurated, and not terribly painful. Claims this is not where it hurts when she walks.
Example 1 - Billed as 99214 (Cont) Assessment Benign essential hypertension Thrombophlebitis of left tibial vein Hypercholesterolemia Orders Lipitor 10MG oral Oxycodone HCI 5 MG oral Discontinue Acetaminophen-Codeine 30 MG oral Atenolol 100 MG oral Lisinopril 20-25 MG oral Plan Referral to VNA Home Health for home PT and pro-times.
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