Coding and Compliance Review for Provider Reappointments

Course Objectives The purpose of this course and its follow-up test is to provide physicians and other clinicians, who are being re-appointed by UNC Hospitals, with important information on three issues…

Course Objectives 1.Why coding and compliance is important to you and your practice 2.Keys to correctly coding hospital and office visits - Evaluation and Management (E&M) Services 3.Teaching 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

1.Why coding and compliance is important to you and your practice

Reimbursement Doing only what is medically necessary Documenting what you do Billing what you document Understanding and applying coding and compliance conventions can improve the level of reimbursement for UNC Faculty Physician practices as well as the quality of the medical record documentation. Providing good care while billing accurately and confidently requires:

 UNC SOM Compliance Why Compliance Good documentation and billing practices make for good patient care Office of Inspector General (OIG), Health & Human Services Routine and probe audits by CMS contractors and third parties

Why Compliance Residents 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 hospital Teaching physicians (TP) are paid by Part B Medicare on a fee-for-service basis The 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 may not bill.

Why Compliance Two 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 documented The documentation in the note did not support the level of service billed

2.Keys to correctly coding hospital and office visits - Evaluation and Management (E&M) Services

Choose the Outpatient Category Outpatient E&M Categories Consultation New Established

Use of Consultation Codes Outpatient consult codes: , inpatient consult codes Use when expert opinion or advice is requested by an appropriate source involved in that patient’s care Does not include patients “referred for management of a condition” or self-referred Use outpatient consultation codes only one time per request, subsequent visits are established patient visits

Use of Consultation Codes A consulting physician may initiate diagnostic and/or therapeutic services at the same visit and the initial visit remains a consultation Written 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 Medicare has not recognized consultation codes since 2010, but Epic translates the consultation codes to the appropriate E&M category and level for Medicare. Providers retain Relative Value Units (RVUs) associated with the consult for productivity measures. Please continue to bill consultation codes for all payers when provided and documented.

Documenting Consultations Documentation of a consultation request must be clearly stated in the note: WRONG: Mr. Patient was 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 in the in the referring provider field. This will help in communicating a letter to the provider that requested a consult. A letter can be sent to the requesting provider through the communications tab in Epic.

New Patient CPT codes: 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 room A patient would still be considered “new” if a diagnostic procedure was billed without an E&M visit charge New Patient

Established Patient CPT codes: Has received an E&M service from the division within the past three years including inpatient, emergency room or inpatient or outpatient consultations Established Patient

Visit Components Consults and new patient visits must include all three of the following components – established patient visits must include any two of the three: History History of present illness Documenting History Documenting History Review of systems History example History example Past family and social history Physical examination 1995 Physical Exam 1995 Physical Exam 1997 Single Organ Exams Medical decision Making Diagnosis and management options Documenting MDM Documenting MDM Amount and complexity of data reviewed Overall risk Risk Table Risk Table Click these links for more information

Visit Levels Billing at a higher level than actually provided and/or documented is one of the two chief issues contributing to CMS fraud allegation settlements There 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 call Questions on correct coding and compliance issues should be directed to the Compliance Auditors at Click on this link for documentation requirements at various E&M levels of servicedocumentation requirements at various E&M levels of service

Visit levels – based on time Document the total time of the visit Over 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 to face time between the Teaching Physician and the patient For inpatient count total for the day of counseling, coordination of care and time on floor in care of the patient

Visit levels – based on time (con’t) The note must include a description of the counseling and treatment planning The physician’s coding card contains minimum time requirements for each visit level Note that the minimum times are different for each of the three categories of visits: consults, new patient and established patient Click on this link for additional time-based billing informationadditional time-based billing information

Append 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 service The patient’s condition must require E&M services above and beyond what would normally be performed in the provision of the procedure The necessity for the E&M service may be prompted by the same diagnosis as the procedure A new patient E&M service is considered separate from the same day surgery or procedure—no 25 modifier needed Modifier 25

For 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 appropriate To determine the correct level of E&M service to submit, identify services unrelated to the procedure and use as E&M elements The modifier 25 should be appended in the modifier field on the level of service in Epic. Modifier 25

Modifier 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 -59 modifier, also assign the corresponding “X” modifier. The system will make sure that the correct modifier gets to the correct insurance carrier. Modifier 59

3. Teaching physician (TP) rules—supervision of residents and billing Medicare and Medicaid

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 documentation The 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 billed Documentation by a resident of the presence and participation of the TP is not sufficient Documentation may be dictated and typed, or a computer statement initiated by the TP

Medical Student Involvement in E&M Services and Documentation Requirements 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. 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) must be performed in the physical presence of a teaching physician or a resident. The teaching physician or resident must verify and redocument the history of present illness, perform and redocument the physical exam and medical decision making. These regulations are found: and-Guidance/Guidance/Transmittals/downloads/R2303CP.pdf and-Guidance/Guidance/Transmittals/downloads/R2303CP.pdf

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 programs Approved primary care centers at UNC: Family Medicine General/Internal Medicine General Pediatrics Women’s Primary Health Med Geriatrics For Add’l Information: Primary Care ExceptionPrimary Care Exception

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 key If present entire time, the resident’s note can attest to that If present for key portions only, TP must document extent of involvement Two overlapping surgeries: Key portions must happen at different times Must be available to return to either

Minor procedures of <5 minutes Must be present the entire time Endoscopies (other than surgical operations) TP must be present for entire viewing, including insertion and removal Medicare Supervision Guidelines for Procedures Performed with Residents

Radiology/Diagnostic Tests Image and resident interpretation must be reviewed by TP to be billable TP may sign acknowledging agreement or edit: a co-signature only is insufficient Psychiatry TP presence requirement met by concurrent observation of the service by video or one-way mirror Must be present for entire period of time billed if psychotherapy code is used Medicare Supervision Guidelines for Supervision of Specific Procedures

Time-based procedures billed on TP time only Critical care Hospital discharge day management Prolonged services Care plan oversight E&M counseling/coordination of care Specific complex or high-risk procedures require continual personal TP supervision Interventional radiologic/cardiologic codes Cardiac cath, stress tests, transesophageal echocardiogram Medicare Supervision Guidelines for Specific Procedures

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.” Medicare Supervision Guidelines for Critical Care

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.

Where To Get Help UNC FP Professional Coders—code inpatient services and some outpatient procedures. (See your division manager for your coder’s name.) School of Medicine Compliance Office Heather Scott, CPC, Compliance Officer Dana Sheffield, CPC, Compliance Review Analyst Tracy Rentner, FNP, CPC, Compliance Consultant Confidential Help Line AMA CPT Manual