CERNER MILLENNIUM Clinic Billing Workflow (especially for Primary Care Residents) In primary care resident clinics, where patients are scheduled with the resident & not the attending, this is the workflow for adding visit charges for E&M services & procedures, including modifiers where appropriate. In non-primary care clinics, or any clinic where patients are scheduled under the attending’s name, the attending usually drops the charges, so this workflow may not apply, though there are still things here that are useful to know. This has been prepared for Millennium code level 2015.01.13 & mPage 6.0. Subsequent updates may display cosmetic & functional changes. Use the keyboard or mouse to advance.

Basic Visit Charges This is the workflow when you’re just dropping one visit charge, such as an E&M code, without any modifiers involved. (We’ll discuss modifiers in the next section.)

Residents, like most providers, will often find it easiest to add visit charges via a Quick Orders tab, or mPage. For this example, we’ll click Office Visit Level 3 to add the charge to the checkout cart, then click the checkout cart.

Associate diagnoses as desired (it can be done later if necessary), then click Modify.

Residents will see a Supervising Physician required field Residents will see a Supervising Physician required field. Click in that & search for your supervising attending. (Faculty & midlevels will not see this field.) The next required field is Billing Provider. It is defaulted to Supervising Provider. Unless you receive specific instructions otherwise, do not change this selection.

Date of Service is also a required field; it defaults to the present date & time. You can change the date if you’re documenting the next day; you can probably disregard the time unless it is germane. Click Sign & you’re done placing your visit charge order. Complete & sign your visit note if you haven’t done so already, & you can move on to the next patient.

Visit Charges Requiring Modifiers There are times when a charge order needs to include a Modifier. Discussion of modifiers can get a bit complicated. Most providers just learn the idiosyncrasies of the modifiers needed in their day-to-day work; it is also often helpful to keep a work aid or “cheat sheet” for modifiers most commonly used in your practice.

Visit Charges Requiring Modifiers Common situations in which you may need a modifier: Two or more professional services are performed at the same visit, e.g., a cryo of a skin lesion during a visit also addressing other medical problems. A Medicaid Well Child Check (EPSDT). A series of Medicaid visits to address the same chronic disease, e.g., asthma. (AKA “Interperiodic Visits.”) A resident who sees a Medicare patient.

In the following slides we’ll look at examples of how to use these. Here is a short list of common modifiers (not meant to be all-inclusive): -24 Unrelated E&M during a postop period -25 Unrelated E&M on same day as a procedure -58 Staged procedure (re-excision) during postop period -59 Different procedure on different lesion, same day -79 Unrelated procedure during postop period -EP Medicaid EPSDT; -GA Medicare may deny; patient informed -GY Uncovered Medicare service (e.g., cosmetic) -GC Service performed by resident under teaching physician supervision, Medicare patient -GE Service performed by a resident without the presence of a teaching physician under the primary care exception, Medicare patient In the following slides we’ll look at examples of how to use these.

EP Modifier The EP modifier is used by all providers (not just residents) when seeing a Medicaid patient for a preventive care or “well child” visit, & when seeing such children over multiple visits for chronic disease management.

In this example, we’re doing a well child check on a 4 year old established patient. We see that the insurance is Medicaid, so we know we’ll need the EP modifier. Select the 99392 4 year old established well child charge, then click the checkout cart.

Associate diagnoses (it can be done later if necessary), then click Modify.

Select Supervising Physician & other details as above Select Supervising Physician & other details as above. Then click the CPT Modifier dropdown arrow.

Scroll down to the EP modifier & click on it Scroll down to the EP modifier & click on it. (You could also type EP in the box to jump down to it.)

Click Sign & the charge has been placed.

Another time when you would use the EP modifier is when a pediatric patient requires multiple visits for management of a chronic disease. Medicaid allows patients 14 visits a year, but when children have to be seen multiple times for the same illness, Medicaid allows us to apply the EP modifier to define these as Interperiodic Visits; all of these encounters will only count as one visit against the 14 allowed. Just pick the appropriate E&M code as usual, then add the EP modifier.

GC & GE Modifiers The GC & GE modifiers are used when a resident sees a Medicare patient. The distinction is: GC: Service performed by resident under teaching physician supervision. (Supervising provider sees the patient.) GE: Service performed by a resident without the presence of a teaching physician under the primary care exception. (Supervising provider is available, but did not personally see the patient.

As before, place the order, pick the supervising provider, then use the CPT Modifier dropdown to select GC or GE, then click Sign.

Modifiers for Multiple Charges You may place multiple professional charges on the same encounter. An example would be a visit addressing chronic diseases, but also performing a procedure, like a skin biopsy or an I&D. There are a number of such modifiers, & some tricks to learning how to use them. A short list of common ones includes: 24 Unrelated E&M during a postop period 25 Unrelated E&M on same day as a procedure 58 Staged procedure (re-excision) during postop period 59 Different procedure on different lesion, same day 79 Unrelated procedure during postop period

In this example, we’re placing a 99213 visit charge, but also charging for cryotherapy on a wart. After selecting those charges, we’ll click the Checkout Cart.

Associate diagnoses as appropriate (you can do it at a following step if necessary), then click Modify.

First select the cryo (destruction) & adjust details as necessary. Then select the Level 3 office visit.

The modifier goes on the E&M code The modifier goes on the E&M code. Since the wart cryo is unrelated to the cognitive work that justifies the 99213, we need to add the 25 modifier, Unrelated E&M on same day as a procedure. Scroll down to that, select, then click Sign. Your two charges have been placed with the required modifier.

Adding Multiple Modifiers You may need to place more than one modifier on the same charge. A common example would be a resident who needs to place the GC or GE modifier on a Medicare charge, while also adding a modifier for a procedure. We’ll use a variation of the above example to illustrate.

Let’s repeat the above example, but assume a resident is performing these services on a Medicare patient. Select the 99213 visit charge, then the lesion destruction charge, & then go to the Checkout Cart.

Associate diagnoses as before, then click Modify.

The attending was present in the room for the cryo, so we’ll add the GC modifier to the destruction charge then move on to the office visit charge.

It may be a little tricky to add two modifiers It may be a little tricky to add two modifiers. It can vary a bit depending on what sort of device you’re using, & it often takes two hands. Scroll to the first modifier. Press the Control Key, then click the modifier, 25 in this example.

Continue to hold the Control Key, then use the mouse to scroll to the second modifier. Click on the second modifier, GC in this example. (When you’re adding them with other modifiers, the Medicare & Medicaid modifiers—GC, GE, & EP—come last.)

Both modifiers now display. Click Sign, & your charge with the proper modifiers is complete. If not already done, generate your note, sign, & submit to your attending.

Attending Review The attending can review the charges at the same time the resident’s note is reviewed.

The attending receives the sign-off request for the note in the inbox The attending receives the sign-off request for the note in the inbox. While there are a few different approaches, it is often convenient just to go ahead & open the chart. Here we’ll go straight to the Documentation List. Right-click the request, then use the mouse to navigate to Open Patient Chart | Documentation.

Review the note & sign it off using one of the available methods Review the note & sign it off using one of the available methods. (Note sign-off is reviewed in detail in another demonstration.) To review charges, click Orders.

The encounter charges display.

You can right-click an order to modify, cancel, etc You can right-click an order to modify, cancel, etc. And of course you can add additional charges yourself, or send a message to the resident with a critique of the charges, requesting that the resident modify the charge.