The Challenges and benefits of remote coding

The Challenges and benefits of remote coding
La Verne Jones, CPC Director of E&M Services The coding network, llc The Coding Network, LLC 8/13/2017

agenda Introduction to The Coding Network, LLC
Process for Becoming a Remote Coder Notification of Test Results Employee Onboarding Process Independent Contractor Project Manager Workflow Process How Work is Reviewed & Processed Internal Audits Benefits and Challenges of Working Remotely Role of a Coder Coding Areas at High Risk for Compliance The Coding Network, LLC 8/13/2017

TCN is the nation’s leading remote coding service
Each specialty is managed by a national coding expert with years of coding experience in his/her specialty. Our staff of certified coders understand the subtle differences that exist in each specialty. All coders have years of experience coding exclusively for their specialty. Since our 1995 establishment, not a single physician has ever paid a penny for recoupment, fines or penalties for a case coded by TCN. The Coding Network, LLC 8/13/2017

The Coding Network (TCN)
Quality and Affordability THE CODING NETWORK is committed to provide cost effective state-of- the-industry procedural and diagnostic coding support to medical groups, academic practice plans, hospitals, ambulatory, surgery centers, and billing companies throughout the United States. The Coding Network, LLC 8/13/2017

TCN’s Areas of Expertise
PHYSICIAN CODING Ambulatory Surgery Centers Anesthesiology Cardiac Catheterization Colorectal Surgery Emergency Medicine Evaluation and Management Services Gastroenterology General Surgery Gynecology and Gynecologic Oncology Interventionional Radiology Neurosurgery Ophthalmology Orthopedics Otolaryngology – Head and Neck Surgery Pain Management Pathology – Surgical and Anatomic Pediatric Surgery Plastic and Reconstructive Surgery Radiology Surgical Oncology Transplant Surgery Trauma and Burn Urology Vascular Surgery FACILITY CODING Ambulatory Surgical Centers Emergency Medicine Inpatient Records Outpatient Ambulatory Coding The Coding Network, LLC 8/13/2017

When TCN codes for you Provide coverage for absent coders due to illness, vacation or family leave. Eliminate backlogs and/or bottlenecks. Reduce exposure to denials, recoupment and audits. Optimize revenue. Stay on top of coding changes. Comply with all laws and regulations. Receive coding "helpline" access. Receive documentation training. Access to certified experienced coders. Cut overhead by eliminating salaries and benefits. Curtail fixed expenses. Errors and omissions insured. Receive prompt turnaround. The Coding Network, LLC 8/13/2017

Coding Compliance Reviews
The OIG recommends periodic independent reviews to evaluate your coding for accuracy. TCN’s coding specialists examine a sample of your coded medical records to validate the procedural and diagnostic coding. Proper modifier usage and other compliance issues are evaluated and reported. The Coding Network, LLC 8/13/2017

Physician and Staff Training
Physician and staff training onsite at your facility. Extensive physician-specific training to assist in the proper documentation of patient care. All courses are specialty specific and include a syllabus for each participant. The Coding Network, LLC 8/13/2017

LA VERNE JONES, CPC 39 years of experience in practice management settings 13 years as facilitator of procedural and diagnostic coding 13 years experience as practice management consultant of HCFA policies 7 years experience as Compliance Officer The Coding Network, LLC 8/13/2017

Process for becoming a remote coder
Have three years’ experience in a particular specialty to apply for coding position Have five years’ specialty specific experience to apply for an auditor’s position Review openings/needs at Apply for a maximum of your top three specialties Forward resume to The Coding Network Will receive access to specialty specific tests in designated specialties, i.e., Surgical coder – General surgery, E&M coder – Nephrology, Diagnostic Radiology, etc. Must have accuracy rate of 90% or higher Complete tests within 2 weeks The Coding Network, LLC 8/13/2017

Notification of test results
Receive electronic notification of pass/fail Score is not given Individual case results not given Tests scored by members of management team Offered a ten-hour E&M Foundation Course if result is not passing Opportunity to retest after course Some coders pass the Remediation test which allows them to be hired. Others decline the offer. The Coding Network, LLC 8/13/2017

Employee onboarding process
Contacted by Administrative staff to sign Independent Contractor Agreement Provided with list of equipment needs: Computer and Printer Internet Crosscut Paper shredder Current Coding Books Whole Disk Encryption The Coding Network, LLC 8/13/2017

Employee onboarding process ~ Cont’D
Scheduled for Orientation Tools we use – compilation of key documents Operational Workflow Role of Project Manager Policies and Procedures Invoicing Commitment and Communication Targets Quality Assurance Program Education Modules Client specific training with Project Manager The Coding Network, LLC 8/13/2017

Independent contractor
A person who contracts to do work for another person according to his or her own processes and methods; the contractor is not subject to another’s control except for what is specified in a mutually binding agreement for a specific job. Has flexibility in schedule as to when, where and how he/she must work Is responsible for payment of taxes. There are no payroll deductions. Is responsible for tools, materials or other equipment to perform the job Does not receive health benefits or vacation benefits The Coding Network, LLC 8/13/2017

Project manager Acts as liaison between the client and the coder
Is coder’s day to day contact Trains coder on client specific issues Monitors coder productivity (target) The Coding Network, LLC 8/13/2017

Workflow Process Processes may vary from office setting to inpatient setting Efficiencies gained when practice uses EMR rather than paper Typical steps in process are: Patient arrives and necessary paperwork and information is obtained to establish a patient record. Patient care is provided. Physician documents medical record to include all information relevant to patient care on a given DOS. The Coding Network, LLC 8/13/2017

Workflow Process Charge capture-Coding Claims submission to carriers
Option 1: Physician enters CPT, ICD codes and modifiers into the EMR without coder evaluation against the record. Option 2: Physician routes encounter to coder who verifies physician’s codes. May take a look at the record. Option 3: Coder reviews the physician’s documentation to determine the procedure and diagnostic codes supported by the documentation. Greater accuracy should result. Claims submission to carriers Coders may assist in working front-end edits If there are no front end edits, coders may address denials on the back end. The Coding Network, LLC 8/13/2017

Workflow Process Accounts Receivable Management
Monitor and follow up on outstanding accounts. Address claims that have been delayed, denied or never paid Address patient balances Feedback to physicians-often not done Necessary to improve the quality of physician documentation Necessary to minimize compliance risk The Coding Network, LLC 8/13/2017

How work is received and processed
Access to proprietary billing system-EPIC, NextGen, Cerner, etc. Coders review records online and code directly into system Coders have access to entire medical record Records received via secure , FedEx, eBridge or Sharefile Requires completion of individual coding worksheet or completion of Excel spreadsheet for multiple patients Client choice Coders have access to one date of service Is documentation clear on new vs. established patients? The Coding Network, LLC 8/13/2017

Internal audits New coder/new client audits – 15 cases
Requires two scores of 90% or higher accuracy Coder then released to code solo Ongoing quarterly QA’s – 15 cases Requires score of 90% or higher accuracy Educational opportunities if results are not good Possible change in employment status The Coding Network, LLC 8/13/2017

Benefits of working remotely
Flexible hours Teams working at non-regular business hours may accomplish more No micromanagement-someone always looking over your shoulder Must be self-motivated and goal oriented Must maintain self-discipline Improved autonomy Quantifiable production standards Less stress? Better work/life balance The Coding Network, LLC 8/13/2017

Eliminates the cost and time spent commuting Commute time becomes productive time Avoid bumper to bumper traffic Spend less on vehicle maintenance Enjoy surroundings of own home Write off some home expenses such as percentage of internet access, office space, electricity Need for professional wardrobe lessens No need to dress up to go to work Can be very casual Save some outfits in case you travel on business The Coding Network, LLC 8/13/2017

Salaries on par or better than when working in an office Extra income if you are working a full-time job and a part-time job Extended network Specialized staff Greater coverage Exposure to a variety of physician and hospital environments Experience working with different service lines, policies and record types The Coding Network, LLC 8/13/2017

Challenges of working remotely
Self-discipline is important Avoiding distractions-home life, small children Commitment to schedule Need to be task oriented Must be able to manage time Communication becomes more critical and phone calls are only avenues Can’t read body language Coordinating time zones for conference calls More difficult to query physicians from remote locations Ability to teleconference is essential The Coding Network, LLC 8/13/2017

Life/Work boundaries with family and friends gets blurry They know you are home Takes time to adjust to fact that although you are home, you are at work. You have a job. Not knowing when to shut down Work always present in home, sometimes causing one to work more hours-Are you truly off? Define your work schedule and stick to it. Help may not be immediately available Working late at night while manager is asleep in different time zone The Coding Network, LLC 8/13/2017

Dedicated work space-not the dining room table HIPPA compliant-privacy and security Locked file cabinets Stricter productivity standards Employer knows temptations and distractions coder may encounter Management of health benefits and tax status Social aspect of being in office is missing-no sharing stories over lunch or breaks Solitary workplace Do you need interaction with others? The Coding Network, LLC 8/13/2017

Role of a coder Read a patient’s medical chart and analyze it, determining the patient's diagnoses and any procedures performed. Categorize those diagnoses and procedures according to appropriate classification systems, assigning a specific numeric or alphanumeric code and/or modifier to each diagnosis or procedure. Check NCCI edits or other payer edits for unbundling rules, code specific rules, regulatory issues, etc. Often serves as a resource person for physicians, administrators, and other allied health providers for information on documentation, regulations, reimbursement, and data collection The Coding Network, LLC 8/13/2017

Coding for services in healthcare settings
Physician services –Professional fee(Profee) Work performed by physicians, suppliers, and other non-institutional providers for both outpatient and inpatient services. Services submitted on CMS- 1500(paper) or 837-P(electronic) Hospital services or institutional services-Facility fee Services performed by hospitals, skilled nursing facilities, and other institutions for outpatient and inpatient services, including the use of equipment and supplies, laboratory services, radiology services, technical staff, space and other charges. Services submitted on UB-04(paper) or 837-I(electronic) The Coding Network, LLC 8/13/2017

Coding Resources CPT(Current Procedural Terminology)
ICD-10-CM(International Classification of Diseases, Clinical Modification) HCPCS(Health Care Financing Administration Common Procedure Coding System) DRG(Diagnosis-Related Grouping) The Coding Network, LLC 8/13/2017

Increased Complexity of Coding
The expansion of prospective payment systems to multiple healthcare settings, each with specific reporting requirements Expanded coding rules due to new reporting requirements, such as the Health Information Technology for Economic and Clinical Health Act (HITECH), Correct Coding Initiative, payer-specific coverage policies, MIPS The increased need for improved data collection and data maintenance as organizations integrate, use, and rely upon more data from disparate data sources Increased scrutiny for erroneous or fraudulent claims, leaving little tolerance for coding or billing errors The financial pressure to send (or “drop”) a bill or claim to an insurance company as efficiently as possible due to the impact on an organization’s accounts receivable Advancements in medical care, which require that coding professionals continuously advance their understanding of various clinical subjects such as anatomy, physiology, pathophysiology, and pharmacology AHIMA The Coding Network, LLC 8/13/2017

Coding Areas at High Risk for
Non-Compliance The Coding Network, LLC 8/13/2017

Areas of Audit Focus Specific to Coding and Documentation-Office of Inspector General(OIG)
Appropriate billing of Transitional Care Management Services Appropriate billing of Chronic Care Management Services Medical necessity of physician home visits Medical necessity of prolonged services Appropriateness of anesthesia non-covered services Correct use of modifiers to report anesthesia personally performed services The Coding Network, LLC 8/13/2017

Areas of Audit Focus Specific to Coding and Documentation-Recovery Audit Contractor(RAC)
Inappropriate billing of Home health E&M codes during inpatient stay Improper payments for endomyocardial biopsies and right heart catheterizations that were not distinct services Excessive units of hospital services Visits to patients in swing bed Hospital discharge day management service Office visits billed for hospital inpatients New patient visits Global surgery-pre and post-operative visits The Coding Network, LLC 8/13/2017

Areas of Audit Focus Specific to Coding and Documentation-Recovery Audit Contractor(RAC)
Drugs and biologicals-units exceed the only FDA approved dose Automated Trastuzumab(Herceptin), J0355-Multi-dose vial wastage billed with JW modifier The Coding Network, LLC 8/13/2017

CERT Review: Five Error Categories
No documentation Insufficient documentation Medically unnecessary service Incorrect coding Other *Any improperly documented service can fall into one of these categories. The Coding Network, LLC 8/13/2017

Coding Errors To Which Any Provider May Be Subject-Low Hanging Fruit
Documentation that does not support level of E&M service-upcoding and downcoding Lack of medical necessity for a service Coding for noncovered services Inappropriate unbundling of services Incorrect use of modifier 25 Incorrect use of modifier 59 Cloned documentation ICD-10 codes not supported by documentation Incident to services Split/shared visits The Coding Network, LLC 8/13/2017

Coding Errors To Which Any Provider May Be Subject-Low Hanging Fruit
Teaching physician attestations Podiatry services Nursing home services The Coding Network, LLC 8/13/2017

How to Mitigate Physician Risk
Be clear on the rules of documentation, whether E&M, operative reports, diagnostic services, etc. Employ coders who are knowledgeable in their field, having kept abreast of coding changes which occur annually Allow coders to review and assign codes to your documentation before claims are submitted Be receptive to questions and feedback from coders Provide valuable clinical insight to coders to allow them to make better code selections Audit your documentation and coding every six months to determine accuracy of both The Coding Network, LLC 8/13/2017

Gray Areas Within E&M Coding
The Coding Network, LLC 8/13/2017

Medical necessity Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during or as soon as practicable after it is provided in order to maintain an accurate medical record. (Section of the Medicare Claims Processing Manual.) The Coding Network, LLC 8/13/2017

Medical necessity Medical necessity cannot be quantified using a points system. Determining the medically necessary LOS involves many factors and is not the same from patient to patient and day to day. Medical necessity is determined through a culmination of vital factors, including, but not limited to: Clinical judgment Standards of practice Why the patient needs to be seen (chief complaint), Any acute exacerbations/onsets of medical conditions or injuries, The stability/acuity of the patient, Multiple medical co-morbidities, And the management of the patient for that specific DOS. The Coding Network, LLC 8/13/2017

Medical necessity Other Considerations:
How often patient was seen for same problem and what was done during those visits How many diagnoses? Acuity? Duration? Severity of problem(s) assessed Complexity of documented comorbidities that clearly influenced physician work The Coding Network, LLC 8/13/2017

Noridian The Noridian Part B Medical Review (MR) Department has noticed, during prepayment medical review, the provider community is using a quantification method to code their claims. The amount of data contained in the medical record should not be the controlling factor for determining the level of service (LOS). It is neither acceptable nor appropriate to include additional information in the medical record for the sole purpose of meeting the billing requirements for a specific Current Procedural Terminology (CPT) ® code. Providers may include any and all data that they deem appropriate in their patient's notes. However, per Medicare regulations, providers are required to bill only for the elements that are medically reasonable and necessary for the treatment of the patient. The Coding Network, LLC 8/13/2017

Medical necessity Physician Perspective Is there a new problem?
What has happened or changed? Any contributing factors? Any system changes? Exam findings? Testing or workup needed? How critical is the situation? Payer Perspective Nature of the presenting problem? Pertinent ROS Appropriate Exam Frequency of visits Diagnostic workup Plan Coder Perspective Is there a Chief Complaint? Is there HPI, ROS, PFSH? What is the level of exam? What is the assessment and plan? The Coding Network, LLC 8/13/2017

NATURE OF PRESENTING PROBLEM
Presenting Problems Minimal Self Limited or Minor Low Moderate High CPT assigns a type of presenting problem to each level of service The Coding Network, LLC 8/13/2017

Medical Necessity is Not the same as Medical Decision Making.
One more reminder Medical Necessity is Not the same as Medical Decision Making. The Coding Network, LLC 8/13/2017

Chief Complaint A chief complaint is a required element for all E/M services. A trend noted by Part B MR (Noridian) The MDM does not correlate to the chief complaint. One such example would be the HPI supports a follow-up visit for renal functions tests, hypertension, and reflux. The medical management of that patient is then a Physical Therapy referral for low back pain, with no mention of medical management of the issues that brought the patient to the clinic. The documentation did not support complaints of low back pain. Part B MR has also noted that the plan of care simply lists the medical diagnoses of the patient, with no mention of changes to the plan of care if any, or continuation of current treatment regimens. It is difficult to determine the medical necessity of a visit when the documentation lacks important information, or when the documentation does not support medical management of the patient's chief complaint. The Coding Network, LLC 8/13/2017

Chief Complaint If the CC is not clearly stated, the reason for the visit must be easily inferred from the notes. Example: “patient complaining of headache, productive cough and drainage”. Question: Can the CC be used as part of the History of Present Illness (HPI)? Answer: Any descriptive statements made within the chief complaint can be used as part of the HPI. Question: Is a simple statement of “follow-up” or “Here for follow-up” considered as an appropriate CC? Answer: No. “Follow-up” requires documentation in the note that easily infers to the CC. When the CC is listed as a “follow-up” for a chronic or previously existing condition(s), the condition(s) must also be indicated (e.g. diabetes). The Coding Network, LLC 8/13/2017

History Components — HPI
HPI Tips for Each Visit: HPI should clearly show development of problem since last visit. A new problem should be clearly identifiable as a new issue. Conditions and diagnoses the patient presents with at a given appointment should correlate throughout the note starting with HPI, physical exam (if applicable), assessment & plan Noridian E/M Workshop August 2014: Q. An RN or NP obtained the HPI and documents it. The physician then goes over the information with the patient to verify it, can the MD say, "I verified the HPI with the patient. Please see RN/NP documentation above?” A. If that scenario takes place, the information will not be accepted if reviewed. The MD must gather and document the HPI himself. The ROS and PFSH can be recorded by other staff and the physician then reviews and confirms the information. The Coding Network, LLC 8/13/2017

Ancillary Staff Documentation
Per CMS, only the physician or non-physician practitioner (NPP) who is conducting the evaluation and management (E&M) visit can perform the history of present illness (HPI) and chief complaint (CC). This is physician work and shall not be relegated to ancillary staff. Noridian Healthcare Solutions reminds providers that E&M codes are valued as including all elements of work to be performed by the physician or nonphysician practitioner when “physician” criteria are met. Although ancillary staff may question the patient regarding the CC, that does not meet criteria for documentation of the HPI. The information gathered by ancillary staff (i.e. Registered Nurse, Licensed Practical Nurse, Medical Assistant) may be used as preliminary information but needs to be confirmed and completed by the physician. The Coding Network, LLC 8/13/2017

Ancillary Staff Documentation
Reviewing information obtained by ancillary staff and writing a declarative sentence does not suffice for the history of present illness (HPI). An example of unacceptable HPI documentation would be “I have reviewed the HPI and agree with above.” html The Coding Network, LLC 8/13/2017

HPI Location: If the documentation includes a body system and the location can be easily inferred you may use it as the location HPI. Example: Follow-up visit for pneumonia: inferred to the lungs as location (use this as location only if needed for the 4th HPI or it’s the only HPI) Associated Signs and Symptoms: Although Associated Signs and Symptoms are generally positive findings, a pertinent negative finding may also be used. Example: Patient presents with Chest pain with no shortness of breath Modifying Factors: The negative or positive impact of the modifying factor must also be documented. Example: Shoulder pain “relieved” after taking Motrin. The Coding Network, LLC 8/13/2017

HPI versus ros Can you use the same element or statement for both HPI and ROS? Although some carriers may allow this practice, many carriers do not. Novitas: “ROS inquiries are questions concerning the system(s) directly related to the problem(s) identified in the HPI. Therefore, it is not considered "double dipping" to use the system(s) addressed in the HPI for ROS credit.” WPS: “A clearly documented medical record would prevent the need to "double-dip" for HPI and ROS, but WPS Medicare, in rare circumstances, could accept counting one statement in both areas if necessary.” The Coding Network, LLC 8/13/2017

History Components—PFSH
PFSH Components: Past history: Medications and/or patient’s past experiences with illnesses, operations, injuries and treatments Family history: A review of medical events in the patient’s family, including diseases that are hereditary or present a risk factor for the patient. Social history: An age appropriate review of past and current activities Past, Family, and Social History: Documentation in all three history areas is required in comprehensive levels of service for new outpatient encounters, initial hospital encounters, and initial skilled nursing facility encounters. History areas given as unremarkable or non-contributory can be considered insufficient information by many payors. CMS recommends giving greater clarity as to the information reviewed, with pertinence to the patient’s conditions or complaint, and found to be negative. The Coding Network, LLC 8/13/2017

Non Contributory (PFSH)
Use of “non-contributory” as the sole notation in regards to all or part of PFSH (e.g., “Family History – non-contributory”) should not be credited. If the PFSH or a portion of the PFSH is reviewed by the physician and deemed non-contributory, a statement is required in the documentation to qualify it for a complete or partial PFSH. Example: “Reviewed PFSH, non-contributory to current condition” (or a similar statement indicating that the history was in fact reviewed) Example: “Family History non-contributory to heart disease” Do not allow the following statements: Family History: “reviewed and non-contributory” without mention of the current condition “Family History reviewed and negative” “Family History none” The Coding Network, LLC 8/13/2017

Review of SystemS What can and cannot be used in ROS (Diabetes, HTN, etc)? The ROS should not be documentation of actual or historical diagnosis (e.g. Diabetes, HTN). That would be Past History information. Allergies: Depending on documentation, allergies can fall under different categories: “She’s allergic to medical latex & gets a rash - should fall under ROS (sign and/or symptom is documented) “She’s allergic to medical latex” - should fall under Past Medical History (No sign and/or symptom is documented) Be aware of ROS statements being subjective Patient is teary eyed, is an objective statement (exam) The Coding Network, LLC 8/13/2017

Complete ROS The E/M documentation guidelines state that “for a complete ROS those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation such as “all other systems were reviewed and are negative” is permissible. Variations of language may also be acceptable if they clearly imply the same.” In the absence of such a notation at least ten systems must be individually documented The following are examples of allowed statements: All other systems have been reviewed and are negative. A complete ROS is negative. Palmetto GBA: It is acceptable to use the statement 'All others Negative' and ‘No other complaints' as long as the pertinent systems/symptoms/problems were addressed and documented. Novitas, Noridian, WPS, NGS, Cahaba, First Coast Service Options all accept “All others Negative” if the pertinent positive and negatives are documented. The Coding Network, LLC 8/13/2017

Non Contributory (ROS)
Examples of phrases/documentation that are generally not allowed: “Other ROS non-contributory” “All ROS negative” (without documenting the pertinent positive and/or negative responses related to the presenting problem) “The rest of the ROS is negative” “No other complaints” The Coding Network, LLC 8/13/2017

Non Contributory (ROS)
Who allows “Non Contributory?” Novitas: There may be circumstances where the term "noncontributory" may be appropriate documentation when referring to the ROS and/or family history sections of the history component of an E/M service. Under the E/M documentation guidelines, it is noted that, "those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented." The use of the term "noncontributory" may be permissible documentation when referring to the remaining negative review of systems. The term "noncontributory" may also be appropriate documentation when referring to a patient's family history during an E/M visit, if the family history is not pertinent to the presenting problem. Noridian and Palmetto GBA do NOT accept the use of “non contributory” The Coding Network, LLC 8/13/2017

Exam Can you combine Body Areas & Organ Systems?
CAN BE COMBINED CANNOT BE COMBINED FOR ANY LEVEL OF EXAM WPS (J5 and J8) Palmetto GBA (JM and Railroad) NGS (JK) Noridian (JE and JF) Cahaba (JJ) Novitas Counting Body Areas or Organ Systems in the 95 Exam Guidelines Comprehensive exam requires that only organ systems are counted (8+). The Coding Network, LLC 8/13/2017

Exam Elements Exam statements counted in “Body Areas”
“Neck Supple” is counted under Body Area (Neck) “Abdomen benign or Abdomen obese” is counted under Body Area (Abdomen) Extremities You may give credit for the musculoskeletal system when components such as (joints, ROM, gait, instability…etc.) are listed under the extremity section of the exam The Coding Network, LLC 8/13/2017

Exam Elements Exam statements counted in “Organ Systems”
Jaundice will default to the GI. Sclera is icteric defaults to GI. Cyanosis generally defaults to either Cardiovascular or Respiratory. Cyanosis due to an injury would default to Musculoskeletal. Edema defaults to Cardiovascular (even if documented under the extremity section) unless the cause of the edema is stated as a Musculoskeletal problem. Clubbing defaults to Cardiovascular or Respiratory. Alert and Oriented X3 defaults to Psych or Neuro depending on the presenting problem. Alert and Oriented defaults to Psych. Alert defaults to Constitutional. No acute distress (NAD) defaults to Constitutional. No JVD is counted in cardiovascular. The Coding Network, LLC 8/13/2017

95 Exam: What is a Detailed Exam?
Criteria to determine Expanded Problem Focused Exam (EPF) vs. Detailed exam for E&M Guidelines. Expanded Problem Focused Exam is defined as “A limited examination of the affected body area or organ system and other symptomatic or related organ system(s)” Detailed Exam is defined as “An extended examination of the affected body area or organ system and other symptomatic or related organ system(s)” The Coding Network, LLC 8/13/2017

Detailed Exam: 95 Guidelines
Since the 1995 Documentation Guidelines do not clearly define what an extended exam of the affected body area includes, it may be necessary to develop internal coding guidelines to create consistency with all your providers and coders. For Example: Documentation of 2-7 Body areas (BA) or Organ systems (OS), with a minimum of 3 elements from the affected body area(s) or organ system(s) is necessary to get to the Detailed level. The Coding Network, LLC 8/13/2017

Medicare Carriers’ 95 Exam Guidelines
Palmetto GBA More detail' refers to the extent of the exam. The level of detail involved in an exam is a clinical judgment based on the documentation for each individual medical record. There is an expectation that the exam will be more involved, and therefore more documentation would be submitted for a detailed exam. The documentation for a detailed exam would consist of at least two findings for at least two body areas or two organ systems. ~FAQs~EM%20Help%20Center~8EELQD7181 CGS More detail consists of at least 2 findings for at least 2 “body areas” or “organ systems.” The Coding Network, LLC 8/13/2017

Medicare Carriers 95 Exam Guidelines
Novitas Solutions (JH and JL) Follows the 4x4 rule (4 elements examined in 4 body areas or 4 organ systems) for determining if the exam is detailed in a 1995 exam. There is an additional caveat that states clinical judgment can be used in lieu of the 4 x 4 exam in determining a detailed exam. trlstate=3zdgp109t_33&_afrLoop= #! Some Carriers 2-4 (Expanded) and 5-7 (Detailed) NGS Suggesting 2-5 (Expanded) and 6-7 (Detailed) The Coding Network, LLC 8/13/2017

1995 detailed exam Which criteria to apply TCN Standard: Detailed Exam
Follow any specific guidelines used by the client’s Medicare carrier. Use this for Medicare patients only unless directed otherwise by the client 2) Consult client profile for their definition of a detailed examination. 3) Use TCN standard. TCN Standard: Detailed Exam When not otherwise defined, follow TCN standard which is 2x2 2 elements 2 systems Look for detail in two systems, one of which is the system related to the chief complaint. Be subjective but consistent for that client. The Coding Network, LLC 8/13/2017

Example of Detailed Exam
Constitutional: Well–nourished, well-developed patient who ambulates without difficulty. BP: 120/68, HR 79-T, Wt. 268 lbs. Head: Atraumatic, normocephalic Neck: Thyroid is normal size without tenderness or masses. Jugular veins exhibit normal jugular venous pressure, normal hepatojugular reflux Respiratory: Breathing is unlabored. Auscultation of lungs: Normal breath sounds Cardiovascular: Palpitation of heart: Normal PMI. Auscultation of heart: normal rhythm, systolic flow murmur present. Peripheral vascular system: Carotid arteries: normal pulses bilaterally, no bruits. Extremities: no edema present. Skin: Inspection: No rashes present, abnormal discoloration noted. Palpation: No abnormalities, masses or tenderness on palpation. The Coding Network, LLC 8/13/2017

Medical Decision Making
This is arguably the most important of the three key components because the Medical Decision- Making ( MDM ) reflects the intensity of the cognitive labor performed by the physician. Medical decision making drives medical necessity and, therefore, should be one of the two components that drives the level of service for established patient services and the basis for leveling any E/M service. TCN’s position More so than history or exam, medical decision making represents the actual value of a physician’s work. Start with medical decision making and work “backward” from the presenting problem(s). Note that CPT and CMS do not require that MDM be one of the two key components for the level of service for an established patient. The Coding Network, LLC 8/13/2017

Number of Diagnoses/Management Options
A new/established problem is defined as “new to the provider” or “established to the provider” New Problem –additional work-up planned The term “work-up” is meant as any additional testing services that may be performed (during a future visit) that will assist the physician in determining a condition or extent of a condition that would help him effectively manage the patient. Labs, Radiology, etc. Consultation (requesting advise/opinion of another physician) is considered additional workup Decision for surgery/procedure: Diagnostic work-up Therapeutic not a work-up Palmetto GBA states “Additional Work-up” consists of any diagnostic testing, lab testing etc. and may be performed at the time of the visit.—Important for ED setting. The Coding Network, LLC 8/13/2017

High Risk Examples One or more chronic illnesses with severe exacerbation (High Risk). Examples: “Patient with COPD comes in with Respiratory Failure” “Patient with Asthma comes in with Severe Exacerbation” “CAD with severe dehydration and disorientation” Acute or Chronic illness or injury that may pose a threat to life or bodily function (High Risk). Examples: “Organ System Failure (ESRD)” “Diabetic Ketoacidosis” “CVA with Altered Mental Status” The Coding Network, LLC 8/13/2017

Identified Risk Factors?
Elective Major surgery With no identified risk factors (Moderate risk) With identified risk factors (High risk) – These risk factors are above and beyond the risk of the procedure/surgery – Physician must mention the additional factor as a heightened risk i.e. Diabetes, COPD/Emphysema, etc Patient has increased risk due to diabetes and COPD. The Coding Network, LLC 8/13/2017

Medication Management: Low, Moderate or High?
Prescription Drug Management (Moderate Risk) New prescriptions and Management of current medications Documentation of management must be clear (i.e. “patient hypertension stable on the current medication”) When determining Rx management with drugs that are OTC (Low Risk) versus Prescription Drug Management the dosage of the medication must be considered risk to the patient must be considered physician documentation stating increased risk of OTC must be considered The Coding Network, LLC 8/13/2017

Drug Therapy Requiring Intensive Monitoring for Toxicity
Drug level monitoring may be required: Administration of cytotoxic chemotherapy is always considered high risk under management options when monitoring of blood cell counts is used as a surrogate for toxicity. Drugs that have a narrow therapeutic window and a low therapeutic index may exhibit toxicity at concentrations close to the upper limit of the therapeutic range and may require intensive clinical monitoring. The Table of Risk lists drug therapy that requires intensive monitoring for toxicity as a high risk management option. Following is a slide that has a list of drugs that may require monitoring for toxicity; it is not an all-exclusive list. On medical review, to consider therapy with one of these drugs as a high risk management option, documentation is expected in the medical record of drug levels obtained at appropriate intervals. The Coding Network, LLC 8/13/2017

Documentation Documentation needs to show monitoring:
Monitor labs; either reviewing past labs or ordering new labs to monitor for toxicities of a high risk drug. Provider may monitor toxicity through examination (rather than labs). The provider must document in the exam what specifically they are looking for to evaluate for toxicity. The route of medication will determine if drugs are high risk (po vs. IV): PO Vanco is not high risk vs. IV Vanco is high risk. IV Heparin is high risk. Fentanyl IV is high risk. Dilaudid is high risk. SQ Heparin is not high risk. The Coding Network, LLC 8/13/2017

The table below lists examples of drugs that may need to have drug levels monitored for toxicity
DRUG CATEGORY DRUGS IN THE CATEGORY TREATMENT USE Cardiac drugs Digoxin, digitoxin, quinidine, procainamide and amiodarone Congestive heart failure, angina and arrhythmias Antibiotics Aminoglycosides (gentamicin, tobramycin, amikacin) Vancomycin and Chloramphenicol Infections with bacteria that are resistant to less toxic antibiotics Antiepileptics Phenobarbital, phenytoin, valproic acid, carbamazepine, ethosuximide, sometimes gabapentin and lamotrigine Epilepsy, prevention of seizures and sometimes to stabilize moods Bronchodilators Theophylline and caffeine Asthma, Chronic obstructive pulmonary disorder (COPD) and neonatal apnea Immunosuppressants Cyclosporine, tacrolimus, sirolimus, mycophenolate mofetil and azathioprine Prevent rejection of transplanted organs and autoimmune disorders Anti-cancer drugs All cytotoxic agents Multiple malignancies Psychiatric drugs Lithium, valproic acid and some antidepressants such as imipramine, amitriptyline, nortriptyline, doxepin and desipramine Bipolar disorder (manic depression) and depression Protease inhibitors Indinavir, ritonavir, lopinavir, saquinavir, atazanavir and nelfinavir HIV/AIDS The Coding Network, LLC 8/13/2017

Time-Based Billing Counseling/Coordination of Care:
Documentation should reflect the following three components: – Total time – Counseling time – Content of counseling or coordination of care The note must specify the nature of the counseling in order for the level of service to be based on time. Phrases such as "counseled patient on the following topics" or “we discussed…" are recommended when documenting by time and to meet CMS criteria. When time based coding for level of service, counseling/coordination of care must dominate more than 50% of the total encounter time. Time statement variable. Can be coded by time: I spent 25 minutes with the patient, greater than 50% of the time was spent discussing her new diagnosis of irritable bowel syndrome, conservative treatment options and reassurance. Cannot be coded by time: A long discussion was held with the patient as to his underlying diagnosis. Course of treatment plan from conservative management to lesion excision was discussed with the patient. The Coding Network, LLC 8/13/2017

Counseling and Coordination of Care
Example of C&CC Patient returns for MRI results and discussion of treatment regarding her breast cancer. We discussed the role of chemotherapy and benefits of the current clinical trials. Patient understands side effects and consents to start treatment next week. Spent a total of 20 minutes with the patient, over half of which was counseling on treatment options. 99213 based on time. Established Patient Times: • = 5 • = 10 • = 15 • = 25 • = 40 The Coding Network, LLC 8/13/2017

Discharge Services Discharge Services: CMS Discharge Q&A:
99238 Discharge Day Management under 30 minutes 99239 Discharge Day Management over 30 minutes Time MUST be included in the medical record to justify 99239 Face-to-face care must be documented in the discharge summary for the date the discharge service is billed. CMS Discharge Q&A: Q. What information does the physician need to show in the medical record to support a face-to-face visit for the discharge management? Several of our physicians indicate "stable", "stable and improved, "no vomiting, tolerating diet.“ Would these statements show a face-to-face service? A. No, the statements listed could have been obtained from a nursing note or chart. They do not support a face-to-face service. The medical record should show notations on an exam if one was performed, or other observations that could have only been obtained if the physician were present. Some examples could include, "patient is stable and states she is feeling well and wants to go home," or "reviewed plan with patient and he had no questions.” The Coding Network, LLC 8/13/2017

Shared/Split Visits with Mid-levels
CMS Regulation on SPLIT/SHARED E/M SERVICE Medically Necessary Encounter A split/shared E/M visit is defined as a medically necessary encounter with a patient where the physician and a qualified non-physician practitioner (NPP) each personally perform a substantive portion of an E/M visit face- to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer. The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital, office and non facility clinic visits (incident-to), and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to critical care services, or procedures. A split/shared E/M visit cannot be reported in the SNF/NF settings. Due to consultation codes no longer being accepted by CMS, they are no longer a part of the SS exclusions.. even if a consultation is performed and billed under the CPT codes. The Coding Network, LLC 8/13/2017

Questions?? The Coding Network, LLC 8/13/2017

The Coding Network, LLC www.codingnetwork.com
8/13/2017

The Challenges and benefits of remote coding

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