Presentation on theme: "Review for Provider Reappointments"— Presentation transcript:
1 Review for Provider Reappointments Coding and ComplianceReview for Provider Reappointments
2 Course ObjectivesThe purpose of this course and its follow-up test is to provide physicians and other clinicians, who are being re-credentialed by UNC Hospitals, with important information on three issues…
3 Course ObjectivesWhy coding and compliance is important to you and your practiceKeys to correctly coding hospital and office visits - Evaluation and Management (E&M) ServicesTeaching physician (TP) rules. In order to bill for services when working with residents and fellows, the teaching physician must abide by federal and state laws and regulations
4 Why coding and compliance is important to you and your practice
5 ReimbursementProviding good care while billing accurately and confidently requires:Doing only what is medically necessaryDocumenting what you doBilling what you documentUnderstanding and applying coding and compliance conventions can improve the level of reimbursement for UNC Physician practices as well as the quality of the medical record documentation.
6 Why ComplianceGood documentation and billing practices make for good patient careOffice of Inspector General (OIG), Health & Human ServicesRoutine error rate testing and auditing programsDocumentation is an integral part of patient care, aiding in communicating with other providers and in research as well as recording your management and the patient’s progress. Good documentation practices will also protect you from costly recoupments by government or other payers. The Centers for Medicare and Medicaid services have several big programs for ferreting out error, fraud or abuse. Medicare contractors for Part A and Part B are required to conduct error rate testing and auditing. Third parties are contracted to find problems and are paid a percentage of the over or underpayments they find. The OIG for the Department of Health and Human Services has its own audit and recovery agenda. Other inquiries are the result of patient or health care employee complaints. Knowing the standards for billing and documenting services will give you confidence to bill appropriately and fairly.6
7 Why ComplianceResidents are paid through the hospital by Part A Medicare. Medicare pays a portion of the residents’ salaries based on the proportionate share of Medicare at the teaching hospitalTeaching physicians (TP) are paid by Part B Medicare on a fee-for-service basisThe government, through Medicare, will pay for both resident and TP services if both participate. If the TP does not participate in a given patient service the TP cannot bill
8 Why ComplianceTwo problems have caused a majority of refunds and penalties:The TP billed and he/she may have been present and participated in the care, but TP presence was not documentedThe documentation in the note did not support the level of service billed
9 Keys to correctly coding hospital and office visits - Evaluation and Management (E&M) Services
10 Choose the Outpatient Category Outpatient E&M CategoriesConsultationNewEstablished
11 Use of Consultation Codes Outpatient Consult Codes:Use when expert opinion or advice is requested by an appropriate source involved in that patient’s careDoes not include patients “referred for management of a condition” or self-referredUse outpatient consultation codes only one time per request, subsequent visits are established patient visitsA consulting physician may initiate diagnostic and/or therapeutic services at the same visit and the initial visit remains a consultationWritten or verbal request must be documented in the rendering physician’s note and the consultant’s opinion communicated by written report to the requesting physician. The shared medical record is sufficient communication for providers in the UNC system
12 Documenting Consultations Documentation of a consultation request must be clearly stated in the note:WRONG: Mr. Patient referred by Dr. Jones for management of GERD symptoms.RIGHT: “Mr. Patient is seen in consultation at the request of Dr. Jones for evaluation of abdominal pain.”Please be sure to include the referring provider is the in the referring provider field. This will help in communicating (by) a letter to the provider that requested a consult. A letter can be sent to the requesting provider through the communications tab in Epic.Ask TR how to communicate in EPIC to a referring provider
13 New Patient New Patient CPT codes: 99201-99205 Has not received any professional evaluation and management (E&M) services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years, including inpatient, outpatient or emergency roomA patient would still be considered “new” if a diagnostic procedure was billed without an E&M visit charge
14 Established Patient Established Patient CPT codes: 99212-99215 Has received an E&M service from the division within the past three years including inpatient, emergency room or inpatient or outpatient consultations
15 Visit ComponentsConsults and new patient visits must include all three of the following components – established patient visits must include any two of the three:HistoryHistory of present illness Documenting HistoryReview of systems History examplePast family and social historyPhysical examination Physical Exam1997 Single Organ ExamsMedical decision MakingDiagnosis and management options Documenting MDMAmount and complexity of data reviewedOverall risk Risk TableClick these links for more information
16 Visit LevelsBilling at a higher level than actually provided and/or documented is one of the two chief issues contributing to CMS fraud allegation settlementsThere is a laminated, pocket-sized physician’s coding card that may be a valuable guide to correct coding. To request a copy of this card please callQuestions on correct coding and compliance issues should be directed to the Compliance Auditors atClick on this link for documentation requirements at various E&M levels of service
17 Visit levels – based on time Document the total time of the visitOver 50 % of an outpatient visit must be spent in face-to-face counseling and treatment planning and so documented. For Medicare patients, count only face time between the Teaching Physician and the patientFor inpatient count total for the day of counseling, coordination of care and time on floor in care of the patient
18 Visit levels – based on time (con’t) The note must include a description of the counseling and treatment planningThe physician’s coding card contains minimum time requirements for each visit levelNote that the minimum times are different for each of the three categories of visits: consults, new patient and established patientClick on this link for additional time-based billing information
19 Modifier 25Append a modifier 25 to an E&M code if a significant, separately identifiable E&M service is performed by the same physician on the same day as a procedure or other serviceThe patient’s condition must require E&M services above and beyond what would normally be performed in the provision of the procedureThe necessity for the E&M service may be prompted by the same diagnosis as the procedureA new patient E&M service is considered separate from the same day surgery or procedure—no 25 modifier needed
20 Modifier 25For an established patient, if the E&M service results in the initial decision to perform a minor procedure (0-10 days global period) on the same day and medical necessity indicates an E&M service beyond what is considered normal protocol for the procedure, the 25 modifier is appropriateTo determine the correct level of E&M service to submit, identify services unrelated to the procedure and use as E&M elementsClearly mark the encounter form to indicate that a 25 modifier should be attached to the E&M
21 Modifier 59Modifier 59 (distinct procedural service) is being split into 4 new modifiers accepted by Medicare effective 1/1/2015. The new modifiers are:-XE: Separate encounter (services that are separate because they take place during separate encounters)-XS: Separate structure (Performed on different anatomic organs, structures or sites)-XP: Separate practitioner (services are distinct because different practitioners perform them)-XU: Unusual non-overlapping services (services that are distinct because they do not overlap the usual components of the main service)Beginning with date of service 1/1/2015, if you assign a modifier, also assign the corresponding “X” modifier. The system will make sure that the correct modifier gets to the correct insurance carrier.
22 3. Teaching physician (TP) rules—supervision of residents and billing Medicare and Medicaid
23 Medicare TP Attestation Requirement The 11/22/02 revisions to the regulations provide that, for E&M services, the TP does not have to duplicate any resident documentationThe TP must be present during the key portions of the service and personally document his or her presence.The resident note alone, the TP note alone or a combination of the two may be used to support the level of service billedDocumentation by a resident of the presence and participation of the TP is not sufficientDocumentation may be dictated and typed, or a computer statement initiated by the TP
24 Medical Student Involvement in E&M Services and the Requirements Any contribution and participation of a medical student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth in this section for teaching physician billing.Students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history. The teaching physician may not refer to a student’s documentation of physical exam findings or medical decision making in his or her personal note.
25 Medical Student Involvement in E&M Services and the Requirements If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.These requirements can be found at the below link.
26 Medicare’s Examples of Unacceptable TP notes "Agree with above." followed by legible countersignature or identity;"Rounded, Reviewed, Agree." followed by legible countersignature or identity;"Discussed with resident. Agree." followed by legible countersignature or identity;"Seen and agree." followed by legible countersignature or identity;"Patient seen and evaluated." followed by legible countersignature or identity; andA legible countersignature or identity alone.The preceding six and similar statements do not make it clear that the TP was present, evaluated the patient, and/or had any involvement with the plan of care.
27 Medicare Exception for Primary Care CMS does not require direct patient contact for primary care, lower-level visits provided by residents with more than six months training working in approved primary care programsApproved primary care centers at UNC:Family MedicineGeneral/Internal MedicineGeneral PediatricsWomen’s Primary HealthMed Geriatrics
28 Medicare Primary Care Exception TP may supervise up to 4 residents on an immediately available basisResidents must have completed 6 months trainingTP must review each patient case w/resident during or right after visitTP must document his/her contemporaneous discussion of the patient’s condition with the residentOnly E&M codes , may be billedTP may see and evaluate a patient in a primary care exception clinic and bill a higher level of service
29 Medicare Supervision Guidelines for Procedures Performed with Residents TP must be present during critical and key portions & immediately available throughout surgical procedures and endoscopic operations:TP decides what portions are keyIf present entire time, the resident’s note can attest to thatIf present for key portions only, TP must document extent of involvementTwo overlapping surgeries:Key portions must happen at different timesMust be available to return to either
30 Medicare Supervision Guidelines for Procedures Performed with Residents Minor procedures of <5 minutesMust be present the entire timeEndoscopies (other than surgical operations)TP must be present for entire viewing, including insertion and removal
31 Medicare Supervision Guidelines for Supervision of Specific Procedures Radiology/Diagnostic TestsImage and resident interpretation must be reviewed by TP to be billableTP may sign acknowledging agreement or edit: a co-signature only is insufficientPsychiatryTP presence requirement met by concurrent observation of the service by video or one-way mirrorMust be present for entire period of time billed if psychotherapy code is used
32 Medicare Supervision Guidelines for Specific Procedures Time-based procedures billed on TP time onlyCritical careHospital discharge day managementProlonged servicesCare plan oversightE&M counseling/coordination of careSpecific complex or high-risk procedures require continual personal TP supervisionInterventional radiologic/cardiologic codesCardiac cath, stress tests, transesophageal echocardiogram
33 Medicare Supervision Guidelines for Critical Care Only the teaching physician time may be counted toward critical care time. A combination of the TPs documentation and the residents documenting may support the critical care service.The teaching physician medical record documentation must provide the following information: time the teaching physician spent providing critical care, that the patient was critically ill during the time the teaching physician saw the patient, what made the patient critically ill; and the nature of the treatment and management provided by the teaching physician. The medical review criteria are the same for the teaching physician as well as for all physicians.This attestation will meet the TP requirements for billing to Medicare.“Patient is critical with ______. I spent ___ minutes while the patient was in this condition providing ______. I reviewed the residents documentation and I agree with the residents assessment and plan of care.”
34 Medicaid Requirements Medicaid requires that the TP be "immediately available" to the resident and patient and use "direct supervision" for procedures. Direct supervision does not necessarily mean that the TP must be present in the room when the service is performed. The degree of supervision is the responsibility of the TP and is based on the skill, level of training and experience of the resident as well as the complexity and severity of the patient's condition. Written documentation in the medical record for Medicaid patients must clearly designate the supervising physician and be signed by that physician.
35 The Hospitals’ financial health is important to you Short stays have been a recent focus of government auditors and large refunds have been required due to insufficient documentation of medical necessity for an inpatient admission.Leaving patients in observation who should be admitted results in lost revenue to UNC Hospitals.Only physicians can make a decision to admit as an inpatient, place in observation status or extended recoveryOnly physicians can change the patient status. Clinical Care Management (CCM) staff assist in determining the appropriate status
36 Summing Up Billing Status Planned vs unplannedMedical necessity required?Billable?EXR(Extended Recovery)PlannedNoOBS(Observation)UnplannedYesSomeINP(Inpatient)Either
37 Eliminating Confusion (and Revenue Loss) Problems with the “Admit” wordInterpreted as inpatient intent to CMSMeans “Place Patient in Bed” at UNCHDoes not define a billing statusGenerally causes confusionCan cause CMS retractionsAvoid an order contradiction in notes“Will admit to Obs”“Will place on Inpatient Observation”
38 The Importance of the H&P Admitting team documentation required for billing status determinationInpatient medical necessity is established by a review of criteria and documented intent/risk by the admitting teamBilling status begins when the order is placedDelay in H&P or admit note with intentDelay in Billing Status OrderUn-billable days==
39 School of Medicine Compliance Office 919-843-8638 Where To Get HelpUNC FP Professional Charges (code inpatient services and some outpatient procedures)School of Medicine Compliance OfficeHeather Scott, CPC, Compliance OfficerDana Sheffield, CPC, Compliance Review AnalystTracy Rentner, FNP,CPC, Compliance AuditorConfidential Help LineAMA CPT Manual