Coding and Documentation for Resident Education

Coding and Documentation for Resident Education
Module 1: Coding Basics Module 2: E/M and Office Coding Module 3: Global Package: Obstetrics and Gynecologic Surgery Jennifer Hamm, MD University of Louisville Marygrace Elson, MD, MME University of Iowa Seine Chiang, MD University of Washington

Educational objectives
At the conclusion of this presentation, participants should be able to: Illustrate how the documentation of a patient encounter is converted into revenue Utilize common coding/billing terms Outline variables that can affect reimbursement Global packages Medicaid/Medicare requirements List common reasons claims are declined

Why do physicians need to know about coding and billing
Why do physicians need to know about coding and billing? Won’t the office staff take care of it? Physicians must… Create an accurate medical record that is compliant with coding terminology and rules. Provide good patient care Minimize liability and fraud issues Develop habits that will translate into time-savings and reimbursement for services. Create accurate medical record that is aligned with coding terminology and rules. Only the physician knows what services were provided and why. Provide good patient care Minimize liability and fraud issues Physician is responsible for the information on every claim that leaves the office Develop habits that will translate into time-savings and reimbursement for services. You can’t bill just for what is done…you only can bill for what is done and documented!

Ramifications of Coding and Compliance
Institutional: Multi-million dollar fines Practice Group: - Increase collections - Decrease claim inquiries and denials Individual: - Compensation and measurement of work performed - Protect against criminal prosecution for fraud For the Patient: -Describes patient conditions and treatment -Allows data tracking of efficacy “Carrot and stick” The “stick” approach has been used extensively for years. If you code incorrectly or fraudulently, you don’t receive payment, or your payment is recouped, or (for governmental payers), you incur fines, penalties, etc. The “carrot” approach is being used more lately and will be used more in the future in conjunction with performance-based compensation. Examples would include additional reimbursement for reducing primary c-section rates, increasing immunization rates, appropriate pap rates, etc. The only way that payers will know that providers are meeting guidelines (and give the carrot) is if it is coded correctly. Data tracking of efficacy—as we move into MACRA and the Quality Payment Process, coding will be required to quantify quality of service

Like a slot machine, you need 3 cherries to get paid:
Correct CPT code for a medically necessary service Correct ICD-10 code to support the CPT code The service is covered by the patient’s policy or contract However, it is not a matter of luck-it is all within your control.

Module 1: Basics of Documentation, Coding and Billing
Jennifer Hamm, MD University of Louisville Marygrace Elson, MD, MME University of Iowa Seine Chiang, MD University of Washington

Module 1 Coding Basics Educational Objectives
Describe documentation principles and their impact on coding/billing Define basic coding terminology and how it impacts billing and reimbursement: ICD-10 International Classification of Diseases, 10th revision CPT Current Procedural Terminology RBRVs (RVUs) Resource-Based Relative Value Scale E/M codes Evaluation and Management HCCs Hierarchical Condition Categories This presentation includes a discussion of both physician and facility coding.

Breaking it down… Patient Encounter Doing the Work Documentation
Accurately recording the Work Coding Converting the Work into numeric code(s) Billing Charging for the Work Payment Receiving reimbursement for the Work Physicians play a primary role in providing the services during the encounter, documenting the services provided, and share the responsibility of coding the encounter with the office billing staff.

Accurately recording the Work Coding Converting the Work into numeric code(s) Billing Charging for the Work Payment Receiving Reimbursement for the Work You have completed the patient encounter. First, let’s talk about documentation—clearly and accurately recording the encounter.

Importance of Documentation
Claims review & payment Continuity of care Records facts, findings & observations Chronological history of patient care Improved coordination of care Information Research/education Medical necessity/risks Improves quality of care Utilization Review Medical Liability

Documentation Principles
The documentation should include: Medical indication for tests Past & present diagnoses Patient’s progress, effective and failed treatments Risk factors Support for intensity & complexity of Medical Decision Making Past diagnoses only apply if these impact the management or the reason the patient is being seen today.

Basic Documentation & Coding
Document: What you did (CPT) Why you did it (ICD-10) and code: What you documented Only the physician knows what services were provided and why. Staff could accurately code off of the documented chart only if the documentation is complete.

All of these terms are used to denote some aspect of your “work” converted to Insurance Payor language ICD-10- diagnosis (Why you provided services) HCC- specific ICD-10 codes that designate greater risks and complexity CPT- services provided. (What you did) RVUs- numeric value assigned to each CPT code that translates into “work” and $.

What is the numerical identification system used to report SERVICES provided to the patient?
ICD-10 (International Classification of Diseases) CPT (Current Procedural Terminology) RBRVS (Resource-Based Relative Value Scale) HCC (Hierarchical Condition Categories) None of the above. Answer is B. CPT

Accurately recording the Work Coding Converting the Work into numeric code(s) Billing Charging for the Work Payment Receiving Reimbursement for the Work “This is what I did”– CPT code “This is why I did it” - ICD 10 diagnostic code and supporting documentation The International Classification of Diseases, 10th revision, was created in 2008 and went live in Some sectors of US Health Care such as small employer-based payers, long term care facilities and nursing homes have continued to use the previous revision, ICD9 which was ratified in 1975. IDC10 is more granular and data-rich than ICD 10 and in particular useful for health care outcomes research.

Converting work into numeric code
You assign the diagnosis(es) and the associated diagnosis code(s) ICD-10 HCCs You select the appropriate code(s) to bill for medical services, based on what you did and documented CPT Code The value of your work is determined by the relative value units (RVUs) of the code(s) you selected

Coding your diagnosis-ICD10
International Classification of Diseases, Tenth Edition Implemented October 1, 2015: 2 component parts ICD-10-CM : For use in all U.S. health care settings Uses 3–7 alpha-numeric characters ~68,000 individual diagnosis codes ICD-10-PCS For use by hospitals to report inpatient services in U.S. ~75,000 individual procedure codes, all with 7 alpha-numeric characters ICD-10-PCS stands for “Procedural Coding System”

ICD-10 replaced ICD-9 Provides greater specificity and clinical information Improved ability to measure health care services Enhanced ability to conduct public health surveillance Captures additional advancements in clinical medicine

ICD-10 reports your diagnosis
ICD-9-CM Spotting complicating pregnancy, antepartum ICD-10-CM O Spotting complicating pregnancy, 1st trimester O Spotting complicating pregnancy, 2nd trimester O Spotting complicating pregnancy, 3rd trimester O Spotting complicating pregnancy, unspecified trimester This slide demonstrates the superiority of ICD10 over the previous ICD9 in terms of granularity of diagnosis. Risk scores is introduced here for learners to become familiar with the terminology. Risk scores are not addressed in these three basic modules otherwise. The ICD-10 code identifies medical necessity for services provided. It also drives the risk scores for payment for hospitals and health systems.

Selecting Diagnoses Codes (ICD)
Document to the highest degree of certainty as ICD codes are assigned accordingly Document and select HCC diagnoses codes when they are evaluated, documented, and impact care at that visit. Suspected, possible, and r/o diagnoses should not be coded. Codes for signs and/or symptoms are assigned when final diagnosis is NOT identified by provider HCC is the Hierarchical Condition Category which provides risk adjustment. Payment to hospitals and health systems is based on RISK rather than an average. At present HCCs are not features of provider payment. HCCs and risk adjustment are mentioned here for vocabulary familiarity.

What is the ICD-10 code for a threatened abortion at 8 weeks of pregnancy?

Code to the Highest Specificity
Threatened AB at 8 wks of pregnancy O Threatened Abortion O Other hemorrhage in early pregnancy O Unspecified hemorrhage in early pregnancy Z3A weeks pregnancy The correct primary code is O20.0, Threatened abortion and secondary diagnosis Z3A.08

Do not code for r/o…such as r/o appendicitis…r/o ectopic
36 yo female presents to ED with c/o 1 day history of RLQ pain, nausea, subjective fevers. LMP 6 weeks ago. What is the best ICD code to select? Appendicitis (K35.80) Ectopic pregnancy (O00.90) RLQ pain (R10.31) Ruptured ovarian cysts (N83.299) Pelvic pain (R10.2) C. RLQ pain Do not code for r/o…such as r/o appendicitis…r/o ectopic

CPT Current Procedural Terminology
CPT codes are numerical identification of services (cognitive, procedural, and/or material) provided to the patient. Preventive Health services Evaluation and Management (E/M) for cognitive services Procedures / Surgeries Global Services : OB, Gynecologic surgeries

Procedural Coding (CPT)
This system uses 5 digit codes to describe the services provided and allows computer processing of claims ie. Endometrial biopsy TAH +/- USO/BSO TAH with Burch

Relative Value Units- RVUs
Used by Medicare and many third party payers to determine reimbursement for medical services Three components Provider Work Practice Expense Professional Liability Features Resource-Based RVUs (RBRVS): Adjustment based on cost of the location (GPCI) Decreases physician practice expense RVUs for facility-based procedures Increases physician practice expense RVUS for office-based services and procedures

Same procedure, differing reimbursement based on location
Example for determining reimbursement for an endometrial biopsy Performed in a Physician’s Office in Wyoming RVUs GPCI Work 1.53 x 1.000 = 1.5300 Practice Expense 1.38 1.3800 Liability 0.19 1.050 0.1995 Total adjusted RVUs (3.1095) x Conversion Factor ($35.89) = $111.60 Practice expense is more in office This example takes you through how physicians can get paid varying amounts for the same procedure based on location due to the GPCI—Geographic Practice Cost Indices—office versus surgical center. Performed in a Surgery Center in Wyoming RVUs GPCI Work 1.53 x 1.000 = 1.5300 Practice Expense 0.78 0.7800 Liability 0.19 1.050 0.1995 Total adjusted RVUs (2.5005) x Conversion Factor ($35.89) = $89.74 Adapted from ACOG Coding Cases 2017

RVU Modifiers and “GPCI”
RVUs are modified based on practice location and the cost of doing business there Geographical Practice Cost Indices (GPCI) are used by Centers for Medicare and Medicaid services (CMS) to determine Modified RVUs The Modified RVU is then used with the current CMS Conversion factor (Dollars per RVU) to determine reimbursement CMS sets rates. CMS has an enormous coverage pool. Commercial insurers may reimburse providers more or less than CMS in order to keep providers in their provider pool. For the purposes of this presentation, we will only discuss CMS reimbursement as CMS “leads” commercial insurers.

Adjusted Total RVUs x current Conversion Factor = REIMBURSEMENT
(Work RVU x Work GPCI) + (Practice Expense RVU x Practice Expense GPCI) + (Professional Liability Expense RVU x Professional Liability GPCI) = ADJUSTED TOTAL RVU Adjusted Total RVUs x current Conversion Factor = REIMBURSEMENT Conversion Factor for 2016= $ Conversion Factor for 2017 = $ RVUS are not the whole story. CMS uses an elaborate formula displayed here for reimbursement which takes into account the expense of practicing in a particular location. This results in an ADJUSTED TOTAL RVU. The adjusted total RVU is then multiplied by the current CONVERSION FACTOR to determine REIMBURSEMENT. CMS.gov

2017 GPCI- some examples Locality Name Work GPCI Practice Expense GPCI
Malpractice GPCI San Francisco, CA 1.077 1.357 0.439 Colorado 1.000 1.015 1.066 Miami, FL 1.031 2.528 Chicago, IL 1.012 1.036 1.972 Iowa 0.902 0.458 Kentucky 0.876 0.807 NYC Suburbs/Long Island 1.044 1.207 2.182 As one can see from this chart the Practice Expense GPCI for San Francisco is high reflecting higher property values/rents. Practice expsnse GPCI’s are lower for locations where the cost of doing business is lower. Malpractice GPCIs are higher in areas where malpractice premiums are higher which reflects the local malpractice “climate” but also reflects locations where there are caps in place for malpractice suits. For example, the malpractice GPCI for San Fransciso reflects the California Medical Injury Compensation Reform Act (MICRA), which was passed in Among other things, MICRA places a $250,000 cap on non-economic damages in medical malpractice cases (pain and suffering.) (Geographic Practice Cost Indices)

Same procedure, differing reimbursement based on geography
Example for determining reimbursement for an endometrial biopsy Performed in a Physician’s Office in Kentucky RVUs GPCI Work 1.53 x 1.000 = 1.5300 Practice Expense 1.38 0.876 1.2089 Liability 0.19 0.807 0.1533 Total adjusted RVUs (2.8922) x Conversion Factor ($35.89) = $103.80 Cost of providing the service is more in Chicago This example takes you through how physician’s can get paid varying amounts for the same procedure based on location due to the GCPI. Performed in Physician’s Office in Chicago RVUs GPCI Work 1.53 x 1.012 = 1.5484 Practice Expense 1.38 1.036 1.4297 Liability 0.19 1.972 0.3747 Total adjusted RVUs (3.3528) x Conversion Factor ($35.89) = $120.33 Adapted from ACOG Coding Cases 2017

RVU tables for every procedure
This chart, from ACOG, contains the procedures most frequently reported by Ob/Gyns. It is abridged from information available at the CMS website. The CMS website contains RVU information on every procedural code. ACOG abridged chart

Documentation Strategy
Document to the highest level of specificity All diagnoses must include assessment/plan Avoid “h/o” or “s/p” for active disease: implies past condition Use linking terms: “due to” or “secondary to” For each diagnosis, Indicate “treatment plan” such as “refer to…”, “observation… Indicate “assessment” such as “stable”, “worsening”, “not responsive to …” Why documentation matters or MAKING documentation matter to physicians

Coding Strategy Code to highest level of specificity
Only code confirmed diagnosis or diagnoses Code the presenting signs and/or symptoms. ONLY if diagnosis is not yet confirmed Not acceptable if signs/symptoms integral to diagnosis Code all conditions managed on that visit Code all conditions that co-exist at time of encounter that impact visit diagnosis: Select HCC codes if appropriate HCC is the Hierarchical Condition Category which provides risk adjustment. Payment to hospitals and health systems is based on RISK rather than an average. At present HCCs are not features of provider payment. HCCs and risk adjustment are mentioned here for vocabulary familiarity.

How can I find all this information??
Professional Organizations AMA ACOG Governmental Agencies Centers for Medicare and Medicaid Services- CMS (cms.gov) Medicare Books, Computer Programs, Mobile Phone Apps Conferences ACOG CODING WORKSHOPS!!!! CMS- Centers for Medicare and Medicaid (cms.gov)

Module 2: Evaluation and Management (E/M) Coding
Jennifer Hamm, MD University of Louisville Marygrace Elson, MD, MME University of Iowa Seine Chiang, MD University of Washington

Module 2 Evaluation and Management (E/M): Educational Objectives
Define the types of E/M services Discuss key elements of the E/M service E/M Modifiers Clinical cases for practice

Common OBG “Services” (CPT)
Preventive Services (not a problem visit) Wellness visit; no chief complaint Counseling A.k.a. “Billing for time” Evaluation and Management (E/M) codes MUST have a chief concern and an HPI Services rendered for diagnosis/treatment of a “problem” Procedures Global package: OB, Gyn surgeries This module primarily discusses E/M coding and billing as well as RVU modifiers, and the nuts and bolts of converting provider work into reimbursement. E/M services can also be billed on time, if criteria are met.

Who is a NEW patient? New Patient
Has not been seen by same specialty and subspecialty member of your group in past 3 years E/M must meet all 3 key components (History, Exam, Medical decision-making) or be based on time. Established Patient Seen by same specialty and subspecialty member of your group in past 3 years E/M must meet 2 of 3 key components (History, Exam, Decision-making) or be based on time. CPT’s definition is “the same specialty AND subspecialty.” Some payers, however, do not differentiate between different subspecialties, and some compliance offices therefore will have their providers only count a patient as “new” if not seen by a partner in the same specialty in last three years, but doing so is not consistent with CPT guidelines.

Preventive Services Encompasses services when age-appropriate comprehensive history and exam with counseling and risk-factor reduction are provided. This is not a problem-oriented visit and does not involve a CC and HPI NEW and ESTABLISHED also applies to preventive visits Codes: Established patient New patient These next 2 types of E&M services (Preventive and Counseling) will be discussed only briefly.

Medicare Screening Services
Medicare does not cover preventive services reported with the preventive services CPT codes. Medicare will cover selected screening services, such as screening pelvic and breast exam (G0101) and collection of pap smear (Q0091) part of Preventive services: Every 2 years for Low Risk patients Annually for High Risk patients The remaining fee (minus Medicare’s coverage) should billed to the patient.

Medicare Screening Services
Ms. Smith is seen for her annual gyn exam. Her last pap smear was 5 years ago, and she now has Medicare coverage and is 65 y.o. Medicare’s allowable* is: $ for G0101 (Pelvic and breast exam) $ for Q0091 (Collection of Pap smear) Your fee for Ms. Smith’s annual exam is $300 *2017 Medicare allowable

To whom do you bill the preventive services
To whom do you bill the preventive services? How would you submit this bill?

Medicare Reimbursement
Paid by ICD Code CPT Code Allowed Amt G0101 Q0091 $39.12* $45.58* Medicare Z12.4 Ms. Jones Z01.419/Z01.411 99387 $215.30** Total Amount Received $300.00 *2017 Medicare allowable **Not covered by Medicare, amt billed will vary by group

Rules on Time with E/M codes
Time determines the E/M level only where counseling or coordination of care dominates >50% of the encounter. Documentation should include: - Total amount of time spent by MD - Amount of time spent in counseling - Summarized content of encounter - Clear medical necessity Note that there are times associated with many of these E&M codes. You may upcode to a higher E&M level based on time spent by the MD, face-to-face with the patient. For example, a patient presents with vaginitis and a quick speculum exam and wet prep was performed - all of which took 5-10 minutes. Trichomonas vaginitis was diagnosed and this married patient barrages you with many questions regarding this sexually transmitted disease. Based on your history, exam, and decision-making, you might normally bill an E&M level 3, established patient. However, you spent an additional 25 minutes face-to-face counseling this patient regarding this STD and you document the history, exam, assessment and plan, and that you spent 25 minutes out of 35 minutes face-to-face counseling this patient on trichomonas, cause, treatment, etc. , and thus upcode to an E&M level 4, established patient.

Evaluation and Management (E/M) Services Codes
Services provided in the diagnosis and treatment of illness, disease, and symptoms (ICD-10, HCCs). Divided into broad categories: -office visits, hospital visits, consultations Subcategorized as: -new vs. established patient -initial vs subsequent hospital visits.

Outpatient vs. Inpatient
A patient is considered an outpatient until inpatient admission to a health care facility occurs. Do not report Observation services if patient is admitted to inpatient status on the same calendar day. For example, you admit a patient to 23 hour observation status but 6 hours later, it becomes obvious that the patient will need prolonged hospitalization. You change her observation status to “Admission”. You should bill for hospital admission, not for both observation and admission. The physician must align the patient status with the hospital status of the patient.

Choosing The Correct E/M Code
Location where services are rendered Type of service Chief complaint Components of History documented- HPI, ROS, Past, Family, and Social History (PFSH) Components of Examination Medical Decision-making +/- Time, counseling, coordination of care

What type of E/M service is Dr. B providing?
1. Ms. Smith is seen by Dr. B in his office, diagnosed with PID, and admitted to the hospital that same day. 2. Dr. B is asked by the ER physician to see Ms. Smith in the ER and she is admitted to the hospital with PID that same day. 3. For the past 5 yrs, Mrs. Jones was followed by Dr. C, a Gyn Oncologist, and is now NED. She is now seen by Dr. B, a gynecologist not in Dr. C’s group, for vaginitis. 1. Inpatient Admission 2. Inpatient Admission , not outpatient consultation New patient, office visit (The physician must align the inpatient or outpatient status with the hospital status. )

E/M Coding Key areas of documentation History
New Patient- must meet 3 of 3 Established Patient- need 2 of 3 Key areas of documentation History Chief Complaint, History of Present Illness Past Medical History, Allergies, Medications, Social History, Family History, Review of Systems Physical Examination Examination of up to 14 organ systems Medical Decision-Making Differential diagnosis, Complexity of case

Chart outlines documentation requirements in order to bill a given level of E/M code for an established patient. Two of the three key components- history, exam, and medical decision making- are required for ESTABLISHED patients. The numbers at the top of the columns are the E/M “Levels.” is a return Level I, is a return Level II, etc.

The importance of a ROS 1.24 RVU 3.05 RVU =$45.74 =$112.51
99201 99202 99203 99204 99205 HISTORY CC Required HPI 1-3 elements > 4 elements OR > 3 chronic or Inactive conditions ROS N/A 1 system 2-9 systems 10-14 systems PFSH 1 element 3 elements PHYSICAL EXAMINATION 1995 1 System 2-4 systems 5-7 systems > 8 systems 1997 1-5 elements 6-11 elements > 12 elements Comprehensive MEDICAL DECISION MAKING Level SF Low Moderate High TIME Face-to-face 10 min 20 min. 30 min. 45 min. 60 min You forget to document an ROS, you automatically go to a Level I MAX for a new patient For a NEW patient: You forget to document an ROS, you automatically go to a 99201 1.24 RVU 3.05 RVU =$45.74 =$112.51

E/M Services and RVUs E/M Level New Est Level I 1.24 0.57 Level II
2.11 1.23 Level III 3.05 2.06 Level IV 4.63 3.03 Level V 5.83 4.08 Table displays the relative value units (RVUs) assigned to different level of E/M service for new and established patients. These are the same value regardless of practice location. (2017) Value for office-based services

Counseling Only Visit Codes (99401-99404)
Preventive counseling when provided at a separate encounter from the comprehensive history and exam in the absence of problems, signs, and symptoms. Visit is 100% counseling. Not to be used when counseling on results, prognosis, management, risk factor reduction Must document approximate amount of time spent in discussion. For OB/GYN, examples would be pre-pregnancy counseling (diet, exercise, etc.) in the absence of any infertility issue, a follow-up discussion of STI/pregnancy prevention for a non-sexually active teenager, etc. If the patient has a known disease or problem and you perform risk factor reduction or counseling which relates to the known disease / problem, then you should use Problem-oriented E&M codes and bill the level of visit based on the time spent face-to-face counseling the patient. Again, you must document the approximate amount of time spent in discussion. Ie. Weight loss and smoking cessation in a Type II diabetic who smokes 2 ppd.

Consultations Types: Outpatient Initial Inpatient
Criteria to bill Consult: document request by an appropriate source for opinion regarding a specific problem AND consultant’s written opinion back to requesting provider. Note that in order to bill a consult one MUST send a written opinion back to the requesting provider.

What Type of E/M Service is Dr. B providing?
1. After diagnosing her pregnancy, Mrs. Gravid was sent by her internist Dr. A to Dr. B, an OB/Gyn. 2. Ms. Diabeta is pregnant and sent by her OB/Gyn to Dr. B, an internist, for evaluation of IDDM at his office. 1. Referral for pregnancy care - Global OB 2. Outpatient consultation

Principles of Documenting E/M Services
Documentation must be complete and legible! Key Components: History Examination Level of Medical Decision- making Contributing Factors: Nature of Presenting Problem Counseling Coordination of Care We have already talked about the role of time and counseling and how, in certain clinical situations, it can increase your level of service.

What is the correct E/M code?
CC: Postmenopausal Bleeding HPI: 63 yo established patient with new onset of painless vaginal bleeding x 3 days. Not on HRT. No recent trauma to area. No SUI, melena, or other changes in bowels or appetite. ROS: See above HPI. All other systems reviewed with the pt and is unchanged from her visit with me 2 months ago PMFSHx reviewed and is unchanged from her last visit. Exam= elements Medical Decision-making = Moderate HPI 4+ signs and symptoms or 99215 Exam 6+ elements Decision-making Since this is an established patient, you need to meet only 2 out of 3 criteria - HPI and Decision-making documentation justifies billing , problem-oriented office visit, E&M level 3, established patient.

E/M Documentation Guidelines
The CC, ROS, and PFSH may be recorded separately OR included in the HPI. The ROS and/or PFSH obtained during the prior encounter does not have to be re-recorded if it is clear that physician reviewed and updated The ROS and/or PFSH may be recorded by the ancillary staff or on a form by the patient, but review by the physician must be documented. It is not recommended that the CC/ROS/PFSH be included in the HPI.

How do I keep it straight???
A good form or well-constructed template can be your friend… Encourage proper documentation Ensure appropriate reimbursement Improve efficiency Place commonly used diagnosis and/or CPT and E/M codes in one area This is true with paper charts and EMR

Clear and accurate documentation
Important for many reasons Improve patient care, safety, and team communication Remind yourself and others in your practice of current findings, past treatments, and overall plan Support your billing and decrease risk if you are audited Maximize return on your hard work

E/M Codes- Helpful tools
Pocket Reference Cards Apps Many practices have pocket reference cards for providers. Practices utilizing billing functions within the electronic medical record may have prompts to help select the proper code. The AMA has a free smartphone app which can be helpful.

I got it….What? There’s more??
There are still several more things you need to know… Global Periods and Packages Variables that can affect your reimbursement Multiple procedures Bilateral Procedures Asst Surgeon Fees Modifiers

Module 3 Global Package Obstetrics and Gynecologic Surgery: Educational Objectives
Describe “Global Package” Define components of a global surgical package, operative report documentation, and Modifiers Define components of the global obstetrics package. Review general coding rules for Obstetrics Coding for antepartum, delivery, and postpartum services

Multiple Procedures You are paid 100% for the 1st procedure and 50% for each procedure thereafter Know total RVUs for each procedure to determine which procedure to list as Primary. Ie. TAH A&P with vaginal enterocele repair (29.09 RVUs) (25.94 RVUs)

Global Periods Defined as the period of time for which one may not bill related office visits/consultations For Medicare this is either 0 days (minor surgeries) 10 days (minor surgeries) 90 days (major surgeries) Preoperative visits- Visits made after the decision to operate is made, beginning with the day before surgery for major procedures and the day of surgery for minor procedures Intraoperative services- a usual and necessary part of a surgical procedure Complications following surgery- all additional medical or surgical services required of the surgeon during the postoperative period of surgery because of complications which do not require an additional trip to the operating room How do I know which one has what??

Check that RVU table again!
Xxx- global code doesn’t apply. Used for nonsurgical codes (e/m codes) MMM- global code doesn’t apply. Uncomplicated maternity care ZZZ- global code doesn’t apply. Used for codes that are part of another service (add-on codes)

Post-op complications and the global fee
The global fee generally covers all additional medical or surgical services required of the surgeon during the postoperative period of surgery because of complications which do not require an additional trip to the operating room

What is the CPT code(s) for TVH, RSO, enterocele repair, and Burch colpo-urethropexy?
Using the available CPT books or the Superbills in your notebook, figure out the following:

Options: 58263 TVH,enterocele repair,USO/BSO 51840-51 Burch
58267 TVH, Burch Vaginal enterocele repair 58260 TVH, USO/BSO, Burch and Enterocele Since all of these codes describe the procedures performed, which one would you use on your claim and why? The last option is considered "Unbundling" and your claim will be denied.

Best Answer: 58263 TVH, USO, enterocele (28.09 RVU)
Burch (50% of RVU)

Unilateral vs bilateral
What if you do a bilateral procedure? Most procedures in Ob-Gyn pay the same for unilateral and bilateral procedures, however, there are some exceptions Salpingostomy (58770)- considered a unilateral code If you do both sides- reimbursed at 150% How do I know which ones are “unilateral” codes?

Bilateral Procedures Xxx- global code doesn’t apply. Used for nonsurgical codes (e/m codes) MMM- global code doesn’t apply. Uncomplicated maternity care ZZZ- global code doesn’t apply. Used for codes that are part of another service (add-on codes)

Co-surgeon vs Assistant
What if my partner helps me?? Some procedures allow for payment of co-surgeons or assistants Co-surgeons each receive 62.5% of allowable amount Asst surgeon receives 16% of allowable amount Primary surgeon still receives 100% How do I know if an assistant is allowed??

Check the RVU table- again
An asst surgeon is SAME specialty A co-surgeon is DIFFERENT boarded specialty “Maybe” requires documentation of medical necessity for both surgeons Yes- will be paid Maybe- may be paid if medical necessity for asst is documented No- not paid

Modifiers Used to describe special circumstances, such as:
Unusual events A service that was: provided more than once prolonged unrelated to the original surgery or procedure mandated by a 3rd party carrier A service/procedure with both a professional & technical component.

E/M Modifiers -22 Procedure requiring significantly more work than typical -24 Unrelated E/M service during postop period -25 Significant, separately identifiable E/M service on same day of procedure -26 Professional component only -32 Mandated services -52 Reduced services or procedure -57 E/M service that resulted in decision for surgery on day of or day before surgery A list of common modifiers- great to know!

E/M and Procedure Same Visit
Generally insurers will not pay for an office visit and a procedure on the same day unless you apply a modifier Modifier -25 applies to a “significant, separately identifiable Evaluation and Management service by the same provider on the day of a procedure” Example: A patient is seen for abnormal uterine bleeding, you evaluate, and you perform an endometrial biopsy procedure at the same visit.

Procedure Only Visit If the patient presents for procedure only, you should NOT bill an E/M code in addition to the CPT procedural code. Example: a colposcopy following an abnormal cervical cytology at a preventive visit

ICD-10 Coding Cases - OB 1. Class B Type I diabetic at 25 weeks hospitalized for blood glucose control yo Gravida 3, Para 2, delivered vaginally at 39 weeks without complications yo delivered vaginally at 38 weeks over 3rd degree perineal laceration yo Para 1 breastfeeding mother, seen 3 weeks postpartum with right breast mastitis without abscess Go to the Tabular List under Complications of pregnancy, childbirth, and the puerperium in your ICD manual. O Pre-existing type 1 diabetes mellitus, in pregnancy, second trimester (O = 2nd trimester) E10.65 Type 1 diabetes with hyperglycemia Z3A weeks gestation of pregnancy There is no specific code for elderly multigravida in childbirth. Therefore, you simply use the code that is available. O09.523 Z37.0 single live birth Z3A.39 O70.20 Third degree perineal laceration during delivery, unspecified (Documentation should indicate 3rd degree laceration type (category I, II, or III) to get more specific diagnosis code—O70.2-. Z3A.38 NOTE you cannot code O80 if you are using another “O” diagnosis code Correct procedures are: and O91.23 Nonpurulent mastitis associated with lactation This would be reported with an E/M service with a 24 modifier.

Obstetric Ultrasound CPT codes for ultrasound, BPP, NST have both a Professional and Technical component When these tests are performed in the physician’s office, the global (combined) service is reported (No Modifier) When these tests are performed in the hospital, the facility bills for the Technical component only (-TC) and the MD bills for the interpretation (-26) To bill for ultrasound services, there must be a report, documented findings, and notation of interpretation by physician. Refer to the CPT manual for instructions on reporting ultrasound for multiples.

Global Obstetric Package
The services normally provided in uncomplicated maternity cases include antepartum care, delivery, and postpartum care. Vaginal delivery Cesarean delivery VBAC C/S after failed TOLAC (trial of labor after Cesarean) This definition of Global Obstetric Package is from the AMA’s CPT guidelines. Low risk obstetric care and delivery is an example of a “bundle” where a single CPT code covers the routine care and delivery. Physicians and hospitals will be expected to manage the care in a cost effective manner that is high quality with excellent outcomes. Under CPT rules, antepartum, delivery, and postpartum care for routine SVD, Forceps, C/S, VBAC, and C/S after failed trial of labor should be billed as a single CPT code. The component services should not be “unbundled” as separate components for billing. “Unbundling” occurs when multiple CPT codes are billed for the component parts of a procedure when there is a single CPT code available that includes (“bundles”) the components. “Unbundling”- coding separately for procedures that should have been “bundled” is a frequent cause of claims denials.

Billing Global OB Package- Carrier Variation
After Delivery By Trimester For each service (either all on one claim after delivery, per trimester, or as they occur) Realize that not all carriers will follow CPT or CMS guidelines. When you contract with the different insurance carriers, you should have in writing how the carrier would like you to bill for obstetrics services. Some want you to bill for the entire obstetric package only after the patient delivers, and others want you to bill for services every trimester. The next couple of slides pertain to the AMA’s CPT guidelines for obstetrics coding and billing.

Global OB Package- Included Antepartum Services
Initial and subsequent history and exams Monthly visits up to 28 weeks (5-6) Biweekly visits to 36 weeks (4) Weekly visits until delivery (3-5) Any services normally provided in uncomplicated pregnancies up to 13 visits. After 13 visits, services may be billable separately after delivery. The RVUs for global OB care is based on 13 visits. When more than 13 visits are provided, these may sometimes be reported separately, after the delivery. This is not always true. If the physician sees the patient for additional visits for pregnancy related risk factors but no complications develop, typically only the global package is reported and reimbursed.

Global OB Package- Excluded Antepartum Services
Initial E/M service during which the pregnancy is diagnosed Maternal or fetal Ultrasound ( , ) Antenatal fetal testing ie. NST, BPP Inpatient admission or subsequent visits for pregnancy complications (that occur more than 1 calendar day before the delivery date) External cephalic version It is acceptable to bill for these services, in addition to the Global obstetric package. The first obstetric visit is time consuming, in terms of history taking, examination, medical decision-making and counseling/risk assessment. However, the initial OB visit was valued into the Global OB package as a established patient visit, or a new patient visits when the global OB code values were initially established. The diagnosis of pregnancy can be reported as a problem E & M visit using ICD=10 diagnosis codes from the Z32.0- ( Encounter for pregnancy test and childbirth and childcare instruction) code section for the “Confirmation of Pregnancy” visit. This is typically a low level visit to confirm the pregnancy. She is scheduled and brought back later to initiate the antepartum visit. If any of the comprehensive work that is part of the initial OB visit is performed and documented, this is considered the start of the global package.

Antepartum Care- Unrelated Visits
Necessary visits for conditions unrelated to pregnancy should be reported using E/M visit codes with appropriate ICD-10 codes. Bill for these services at the time they are rendered. Medical services which are provided that are unrelated to pregnancy should be billed separately and additionally at the time they are rendered, using problem-oriented E&M codes with appropriate supporting ICD codes. Example, patient is seen with URI symptoms.

Antepartum Care- Complicated vs High Risk
Complicated Antepartum If the total # of antepartum visits exceed 13 due to a pregnancy complication, report additional visits with E/M visit codes High Risk Pregnancy If the total # of visits exceed 13 due to a prior poor obstetric outcome and no complication occurs, only global OB should be billed. Note that there is a significant difference between a pregnancy that is complicated by a specific problem versus a pregnancy deemed “high risk” because of a prior poor obstetric outcome. For example: a patient with a history of a 25 week preterm delivery racks up 18 antenatal visits due to your vigilance and efforts to prevent another preterm delivery. If she subsequently does not have preterm labor or other antenatal problems with this pregnancy, the extra 5 visits should not be billed in addition to the global OB fee. However, if she does develop preterm labor or other antenatal problems with this pregnancy, you are justified in billing for the extra 5 visits using problem-oriented E&M codes with the appropriate ICD code to define medical necessity for those additional medical services. The ACOG coding course is now making a distinction between “at risk” ( the patient should be more closely monitored due to some past issue) and “high risk” ( the patient has a condition that requires closer monitoring)

Antepartum Care Only Patient transfers obstetric care to another practice Patient care is transferred to another MD (MFM) during the antepartum period Patient is delivered by another MD not associated with your practice. Patient’s pregnancy ends prior to viability. Patient changes insurance during pregnancy Here are some clinical scenarios where the patient may receive antenatal services from your practice but not be delivered by your practice.

Antepartum Care Only 1-3 visits Use E/M visit codes
4-6 visits unit 7+ visits unit In these instances, outlined on the previous slide, you should bill for the antepartum visits as noted in the CPT rules above, and not use the Global OB code(s).

Delivery Included Services
Admission history and exam Management of labor +/- induction, insertion of cervical dilator on day of delivery, simple cerclage removal. Delivery: vaginal, C/S, forceps, vacuum. Delivery of placenta +/- manual removal Episiotomy and repair.

Delivery Excluded Services
Additional services in L&D management which are not normally provided and which were not rendered more than 1 calendar day before delivery External cephalic version. Insertion of cervical dilators on a day other than day of delivery.

Delivery & Postpartum Care Postpartum Services Only: 5.31 RVUs
Global OB Delivery Only Delivery & Postpartum Care Delivery ICD 10 RVUs Vaginal Delivery 59400 60.28 59409 23.58 59410 30.10 Cesarean Section 59510 66.91 59514 26.58 59515 36.59 VBAC 59610 63.45 59612 26.61 59614 33.09 C/S after failed TOLAC 59618 67.81 59620 27.16 59622 37.27 These RVUs were taken from the Medicare 2017 Update. The codes in the last two columns are the CPT codes that you should use if you provided the delivery and postpartum services only (no antenatal visits). Postpartum Services Only: 5.31 RVUs

Postpartum Services Included services:
-Routine inpatient care immediately after delivery and -Routine outpatient visit(s) after delivery Excluded services: -Treatment of postpartum complications or other conditions unrelated to the pregnancy Medical services for the diagnosis and treatment of postpartum complications that are not “normal” or “typical” (ie. breast abscess, episiotomy breakdown) or other conditions unrelated to the pregnancy (ie. DVT, pyelonephritis) should be billed as problem-oriented E&M services, in addition to the Global OB / Postpartum fee.

Common Obstetric Modifiers
-22 Increased services -24 Unrelated E&M service during postop period -25 Significant separately identifiable E&M service on the same day of a procedure -26 Professional component only -51 Multiple procedures

What are the CPT codes for:
1. Antepartum services + Delivery of Twin A vaginally and Twin B C/S+ Postpartum services? 2. Antepartum services + delivery of Twin A and Twin B by C/S for transverse lie+ Postpartum services? 1. Twin B Global OB package for C/S ( RVUs) Twin A (+/-51 modifier) Vaginal delivery only (½ of RVUs) Twin A and B (must include operative report and letter justifying why you deserve more compensation than the standard Global OB package for C/S - because you delivered two infants by C/S. It is appropriate to provide an additional amount ( a percentage of the intraservice work) you feel is justified by the medical necessity based on the additional physician work performed during the delivery. Payers are rarely paying extra for twin Cesarean deliveries, since you provided antepartum service, a single Cesarean incision, and postpartum service for a single patient, unless specific information is provided about the delivery complexity or complications.

Like a slot machine, you need 3 cherries to get paid:
Correct CPT code for a medically necessary service Correct ICD-10 code to support the CPT code The service is covered by the patient’s policy or contract However, it is not a matter of luck-it is all within your control.

Why didn’t I get paid? Poor documentation
Doesn't justify the procedure done Doesn't support the level of service coded CPT or ICD-10 code is invalid or doesn't match Didn’t file the claim in a timely manner Missing or misplaced information on the claim form Patient ID Date of Service Provider name/NPI number mission Provider tax ID missing/incorrect Filing duplicate claim forms Not a covered service

How do I get paid??? Look at the explanation for denial
Fix the problem, if there is one, and resubmit Provide the information they are asking for Resubmit your claim as it stands with a letter requesting reconsideration Include why you did what you did in the letter This can be a lot of work…can take a lot of time…and you may still not get reimbursed Endeavor to do it right the first time Clear documentation Appropriate ICD10 code CPT supported by documentation

Ready to try some cases? HERE WE GO……..
From ACOG Coding Conference Case Examples

Case #1 Chelsea, a G1P0 at 35 weeks 0 days gestation, presents to L&D with decreased fetal movement. Dr. Kensington is called and an NST is ordered. The L&D nurse calls Dr. Kensington with the findings. He asks her to reassure Chelsea and send her home with instructions. The following day he interprets the NST and writes a report. What can he bill for???

Case #1 What is the diagnosis? Can he bill for the triage visit?
Decreased Fetal Movement, Third trimester (O ) 35 weeks gestation (Z3A.35) Can he bill for the triage visit? No, he didn’t see the patient Can he bill for the NST? Yes, because he interpreted it and wrote a report. CPT code Can only bill for the professional component since the hospital owns the machine, it provided the work force to perform the test, and the supplies associated with the test. modifier 26

Case #1 At 39 weeks, Chelsea returns to L&D with possible contractions. The L&D nurse calls Dr. Kensington, who decides to come in to see Chelsea. Dr. Kensington examines Chelsea and reviews the NST. He documents his encounter and the NST interpretation. She is again sent home with instructions. What can he bill for???

Case #1 What is the diagnosis? Can he bill for the triage visit?
False labor after 37 weeks without delivery, (O47.1) 39 weeks gestation (Z3A.39) Can he bill for the triage visit? Yes, because he saw the patient Problem focused exam. Level of service will depend on work performed and documented Can he bill for the NST? Yes, because he interpreted it and wrote a report. CPT code Can only bill for the professional component since the hospital owns the machine, it provided the work force to perform the test, and the supplies associated with the test. modifier 26

Case #2 Tess is a 63 yo female last seen 4 years ago. She is here today with complaints of urinary urgency and frequency, worsening over the last several months. She states that occasionally she can’t make it to the bathroom in time but it then takes her a long time to urinate. She also notes urine loss on coughing or sneezing. She has not discussed the issue with her primary care physician who she sees periodically for hypercholesterolemia and routine exams. ROS- she denies burning on urination, vaginal bleeding, or discharge. She has not experienced loss of bowel control or other GI symptoms. Her weight has remained stable. All other systems negative. PMH- hypercholesterolemia on statin medication. She is not on any other medications

Case #2 Social Hx- She is sexually active. She does not smoke or use alcohol Exam: BP 120/85 HR 85 Wt 125 lb Ht 5’4” Pleasant, cooperative, appears stated age Abdomen- no masses, no tenderness, no HSM Lymphatic- no lymphadenopathy Pelvic- external genitalia without lesions. Urethra and meatus no lesions. Vagina normal appearance. Cervix normal appearance. First degree uterine prolapse. Third degree cystocele and 1st degree rectocele. Bimanual: uterus is small, anterior, mobile, and non-tender. Adnexa without masses or tenderness. Rectal Confirms exam and first degree rectocele noted.

Case #2 What can we bill for??? Impression
Pelvic relaxation with 3rd degree cystocele, and 1st degree uterine prolapse and rectocele Urinary urgency and frequency Possible UTI Mixed incontinence Plan In office urinalysis Return in 2 months for re-exam Pelvic exercise instructions given Consider surgical intervention if symptoms persist/worsen R/B/A discussed with patient. Literature given and informed consent form taken home to read and discuss with family. What can we bill for???

Case #2 Diagnoses? Any Labs? What is our E/M code?
Incomplete uterine prolapse (N81.2) Rectocele(N81.46) Urinary urgency and frequency (R35.0) Mixed incontinence (N39.46) Any Labs? In office UA What is our E/M code? 99203 -New or Established? Sample Superbill New- not seen this practice in last 3 yrs Level 3 visit as history and PE detailed but not comprehensive  Other possible ICD UTI Straining on urination Urinary hesitency New patient- hasn’t been seen in >3 years Why only 99203 -only a detailed history and exam not comprehensive  

Case #3 Hope is a 22 year old established patient with complaints of mild vaginal itching and irritation for the last 3-4 days. Exam- External genitalia mild redness. Vagina-thick, white, curdy discharge. Wet mount- positive candida Assessment: Vaginal Candidiasis Plan: Clotrimazole cream and vaginal inserts x 7 days Return PRN What can we bill for???

Case #3 Diagnoses? Any Labs? What is our E/M code?
Vaginal Candidiasis (B37.3) Any Labs? Wet prep (87220) What is our E/M code? 99212 Sample Superbill Cannot bill higher than level 2. Could have been level 3 w ROS and one additional system of exam, if it is medically necessary to do for this pt/condition    

Case #4 CC: “Growths” on her Vulva
HPI: Anna is a 22 yo female who has been seen on multiple occasions for perineal and vaginal condylomata. Today she comes in with complaints of recurring external lesions and mild vaginal itching. She first noted symptoms about 2 wks ago. She tried an OTC anti-fungal medication without relief. PMH: Previous perineal and vaginal condyloma SH: Sexually active and on oral contraceptives ROS: She denies urinary urgency, frequency, or burning. She denies pain on intercourse. Her last pap smear was 8 months ago and was normal. No vulvar rash, erythema, or ulcer.

Case #4 Assessment: Exam: BP 120/78 Wt 125lb Ht 65 in
GU: several thickened areas of epithelium were noted on the vulva and perianal area. Urethra and meatus no lesions. Cervix clear. Anus no indication of lesions. Vagina: normal appearance with small amount of yellow discharge. Wet mount negative. Assessment: Condylomata

Case #4 Plan: The nature of the lesions and treatment plan were discussed with Anna. Because of her past history, a cervical colposcopy and vaginoscopy will be done. The vulvar lesions will be treated today using topical TCA. She was counseled regarding STDs and the use of condoms. She should return to the office in 1 week for biopsy results.

Case #4 Office Procedure Note:
Acetic acid is applied to the entire vagina and cervix and colposcopy performed. The cervix showed a thin rim of acetowhite epithelium around the ectocervical os as well as faint changes on the left vaginal sidewall. After local anesthesia, biopsies were taken from the 12:00 position on the cervix as well as the vaginal side wall. Silver nitrate was used for hemostasis. The vulvar lesions were treated using topical TCA. The patient tolerated both procedures well without complaints. What can we bill for???

Case #4 Diagnoses? Any Labs? Any Procedures? What is our E/M code?
Condylomata (A63.0) Any Labs? Wet prep (87220) Any Procedures? Colposcopy Cx/Vag, bx (57455) Destruction Vulvar Lesion (56501) What is our E/M code? 99213 -Any Modifiers? 25 and 51 Level 3 E/M for expanded problem-focused history & exam, moderate MDM Modifier -25 for visit plus procedures Modifier-51 for multiple procedures Sample Superbill Example of Billing for E/M PLUS procedures This is a Level 3. HPI is extended—context (multiple occasions), location (perineum and vagina), severity (mild), duration (2 weeks), modifying factors (OTC antifungal ineffective), associated signs and symptoms (itching). The review of systems is limited (GU only). Other possible ICD Vulvar itching Vaginal discharge Vulvar lesion Note: For professional services billing, if you have a definitive diagnosis that includes the symptoms, you do not report the symptoms individually. -modifier 25 for visit plus procedures -modifier 51 for multiple procedures      

Putting it all together--
Patient Encounter Doing the Work Documentation Accurately recording the Work Coding Converting the Work into numeric code(s) Billing Charging for the Work Payment Receiving Reimbursement for the Work

Improving Physician Documentation & Billing Compliance
Interval audits and feedback to physicians regarding their documentation and whether it accurately reflects the work performed and supports the level billed Educational Tools: E/M Templates for Gyn and Antenatal Services Dictation Templates E/M Pocket Cards Technology: computer or PDA software Electronic medical record tools. Linked documentation and billing software

References and Resources
Centers for Medicare & Medicaid Services American College of Obstetricians and Gynecologists Committee on Health Economics and Coding RVU charts Coding Conference 2014 Case Studies (adapted) American Medical Association E/M University Emuniversity.com

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