Coding Strategies To Increase Revenue

1. E&M and Critical Care Coding

3. New Standard E&M Training Packet for Physicianshttp://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

4. FAQ’s on Palmetto Website*

5. Signatures No Patient Name, Date of Service or an Acceptable Provider Signature in the Medical Record Each medical record shall contain sufficient, accurate information to identify the patient and date that the service was provided.  All pages of the medical record must be marked with the patient’s name and date of service.    The medical record must include the physician’s signature on all documentation.  Medicare requires a legible identity for services provided/ordered.  Palmetto GBA must clearly be able to tell who rendered the service and who wrote the notes.  The Palmetto GBA website includes specific examples of acceptable/unacceptable signatures.  Under the Articles section, select “General” to find the article, Medicare Part B Medical Records: Signature Requirements-Acceptable & Unacceptable Practices under general guidelines.

6. Medicare Part B – acceptable and unacceptable Medicare Requirements for Valid SignaturesAcceptable methods of signing records/test orders and findings include:  Handwritten signatures or initials Electronic signatures:  Digitized signature – an electronic image of an individual’s handwritten signature reproduced in its identical form using a pen tablet.   Electronic signatures usually contain date and timestamps and include printed statements, e.g., “electronically signed by,” or “verified/reviewed by,” followed by the practitioner’s name and preferably a professional designation.  Note: The responsibility and authorship related to the signature should be clearly defined in the record. See below example.    Electronically Signed By:  John Doe, M.D.  08/01/2008 @ 06:26 A  Digital signature – an electronic method of a written signature that is typically generated by special encrypted software that allows for sole usage. Unacceptable Signatures Signature “stamps” alone in medical records are NO longer recognized as valid authentication for Medicare signature purposes and may result in payment denials by Medicare.    Reports or any records that are dictated and/or transcribed, but do not include valid signatures “finalizing and approving” the documents are not acceptable for reimbursement purposes.  Corresponding claims for these services will be denied. 

7. Overarching CMS guideline “….Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code…..Chapter 12, Section 30.6.1A Medical necessity is not necessarily synonymous with “medical decision-making” Does presenting problem (stable diabetes managed by diet ) warrant a comprehensive history and exam obtained on established patient ? Patient seen every 6 months for diabetes and complete PFS history and ROS and exam obtained and documented which increased code above MDM? Patient who was ‘lost to follow up’ and now returns 2 years later for evaluation of stable diabetes. Complete PFS history and ROS and exam obtained and documented which increased code above MDM? Difficult for non-clinical ‘auditor’ to judge this except in extreme cases or if a pattern exists (performing a comprehensive History or exam on every established patient) Things auditors may want to consider: ‘weigh’ medical decision making higher than history and exam for established problems to . review presenting problems definition (See CPT manual) and CPT vignettes to help guide medical necessity.

8. Critical Care

9. Medical Necessity and Definition – per CMS transmittal 1530, effective 7/7/08 Conforms with CPT definition and adds: “critical care encompasses both treatment of vital organ failure and prevention of further life threatening deterioration of the patient’s condition. Therefore, although critical care may be delivered in a moment of crisis or upon being called to the patient’s bedside emergently, this is not a requirement for providing critical care service. The treatment and management of the patient’s condition, while not necessarily emergent, shall be required, based on the threat of imminent deterioration (i.e. the patient shall be critically ill or injured at the time of the physician’s visit) Providing care to a critically ill patient should not automatically be coded as critical care. While more than one physician may provide CC services, each physician must be managing one or more critical illness(es) in whole or in part.

10. Medical Necessity Metfor Critical Care services per transmittal 81 y.o. admitted to ICU following AAA resection. Two days after surgery, he requires fluids and pressors to maintain adequate perfusion and arterial pressures. He remains ventilator dependent. Documentation of Critical Care service: “Patient developed hypotension and hypoxia. I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs and oxygen. I reviewed the resident’s documentation and I agree with the resident’s assessment and plan of care”

11. Medical Necessity Metfor Critical Care services per transmittal 67 y.o. 3 days S/P mitral valve repair develops petechiae, hypotension, hypoxia requiring respiratory and circulatory support. 70 y.o. admitted for RLL pneumococcal pneumonia with a history of COPD becomes hypoxic and hypotensive for 2 days after admission. 68 y.o. admitted for acute anterior wall MI continues to have symptomatic ventricular tachycardia that is marginally responsive to antiarrhythmic therapy.

12. Medical Necessity – Not metfor Critical Care services per transmittal Daily management of a patient on chronic ventilator therapy does not meet the criteria for critical care unless the critical care is separately identifiable from the chronic long term management of the ventilator dependence. Management of dialysis or care related to dialysis for a patient receiving ESRD hemodialysis does not meet the criteria unless separately identifiable from the chronic long term management. (i.e. management of seizures or pericardial tamponade related to renal failure). A history or physical exam performed by one group partner for another group partner in order for the second partner to make a medical decision would not represent critical care services. Staff addendum to resident’s note of daily visit (Hx, exam, assessment, plan) would not represent critical care services. May not report critical care for patients based on a ‘per shift’ basis.

13. Full Attention Definition Time spent: evaluating, providing care and managing the critically ill or injured patient’s care. at the immediate bedside or elsewhere on the unit or floor so long as the physician is immediately available. Physician/provider devotes the full attention and therefore cannot provide services to any other patient during the same period of time. Can be provided by APN or PA according to scope of practice including the requirements for collaboration and supervision.

14. Example “Mrs. X is critically ill with hypotension, respiratory failure, vent dependence, pleural effusion, hyponatremia, and p/c malnutrition. She also has a c dif and UTIs. I administered hextend 500 cc this am and increased norepinephrine prior to her trach fo hypotension. I also monitored her on CPAP trials this morning and suspended trial due to increase WOB and hypotension. Since she has returned from her trach I have reduced norepinepherine, restarted tube feeds, d/c propofol, stop lasix infusion and converted to intermittent IV dose. Total CCT – 40 min, not including procedures” Comments Note describes the critical care services performed (what was done), why and the time spent doing it. The note itself implies ‘full attention’ was given without having to state it. Time is documented properly

15. Example “Mrs. X is critically ill with the above problems (many listed). I will reduce PEEP to 8 as tolerated today. Will titrate norepi for MPA > 65. I will consult CTS for trach. Will add ducolax suppository and change amio to PO. Need to discuss the need for 4 antibiotics w/ ID service given the negative BAL. Will continue diuresis to improve lung function. TCC = 55 min.” Comments The note describes critical care that will be done, but has not yet been done. Auditor’s potential question: Did the time get counted or documented based on what was done or in anticipation of what was to be done? Ideas to improve note. Make later addendum/addition to note: “I spent an aggregate of 55 minutes critical care time performing the above plan”

16. Group Practice Issues Same day critical care by Same Specialty CC physician Initial CC time (99291) must be met by a single physician or qualified NPP. Example: 15” by one physician, 15” by another ? 99291 At least one provider in the group must meet the first 30” time. In can be a single period or cumulative on the single calendar date. Only ONE 99291 for single date by single specialty Subsequent critical care visit time (99292) may represent aggregate time by the same physician/NNP or physicians in the same group practice and specialty. All visits must meet the definition of critical care in order to be combined. Each provider should document his/her own time. Same day critical care by a different CC specialty Each may bill 99291 if the care is unique to his/her specialty. May not bill 99291 if the different specialty is providing ‘staff coverage’ or follow up of the original physician who billed 99291. However, may bill 99292 or a subsequent E&M code.

17. Services by Non-Physician Practitioners SPLIT/SHARED guidelines do not apply to critical care: CC services are reflective of care and management by an individual physician or qualified NNP for the specified reportable period of time. The person who performs the ‘medically necessary’ CC services is the one who bills the service. The initial CC time (99291) must be met by a single physician or qualified NPP. Subsequent (99292) can represent aggregate CC time by those in the same specialty (including NNP) Therefore, each person providing the CC service documents his/her own critical care service. Note: It is possible that a separate E&M service and Critical Care service is provided (and billed) on the same day if it is a separate period of time. What about Subsequent hospital care codes? - No change to shared/split service Both document each one’s portion of the service and the combined notation is used to support the bill. Physician may bill as long as documentation shows he/she performed a ‘face to face’ portion of the service.

18. Performance of other E&M services on the same day If E&M service is provided earlier on the same date by same specialty, and later critical care is provided, both codes may be used. This includes physicians of the same specialty (or services by NNP). Documentation will be required to demonstrate that the services were provided at a separate time during the day. “Simultaneous” critical care by multiple providers may only be billed by one physician/provider. Concurrent care (same date, different time) by different specialties may be coded and should be paid.

19. Global Surgery Critical care by the surgeon is separate, identifiable and above and beyond the usual pre/post operative care associated with the procedure performed. ( 24 modifier) Unrelated to the specific anatomic injury or surgical procedure (800.00 – 959.9 codes is acceptable documentation) When post-operative critical care services (for procedures with a global period) are provided by a physician other than the surgeon, no modifier is required unless all surgical postop care has been officially transferred from the surgeon to the physician performing critical care. Critical care services must meet all the conditions described by Medicare.

20. Counting Time Excludes time spent performing any separately reported procedure. excludes the pre/intra/post-work of procedure Document time performing procedure was not included in critical care time. Time counted may be continuous or intermittent and aggregated in time increments (e.g. 50 min of continuous clock time or 5 ten minute blocks of time spread over a given calendar date). Some providers document/time multiple ‘entries’ into the record and then calculate/summarize aggregate time at the end of the day. Critical care may not be billed on a ‘per shift’ or ‘per day’ basis. Medicare will monitor multiple CC times submitted by a given physician or physician specialty.

21. More Time Guidelines Family discussions/updates Routine daily updates – not to be included in critical care time Time needed to obtain history or discuss treatment options – IS included in crtical care WHEN the patient is unable to participate and the discussion is necessary for determining treatment options. Telephone calls that meet this criteria CAN be included in critical care time. All other discussions, no matter how lengthy, are not included in critical care time. What to document “Patient is unable/incompetent to participate in giving history or making treatment options” “No other source was available to obtain history” “patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family. The medically necessary treatment decisions for which the discussion was needed A summary that supports the medical necessity of the discussion.

22. E&M Coding/Auditing 

23. E&M Documentation Guidelines Two sets of guidelines established by CMS 1995 1997 Providers may use either one or the other. Providers do not have to declare which standard they are using. Therefore auditors are instructed to audit under BOTH sets and allow the providers to use whichever is most beneficial. If Intelicode™ user, application allows using both and selecting either. If paper audit tool, audit using both methods. Use tool’s ‘matrices’ to determine codes once key elements are determined.

24. Review of E&M Category Matrices Which need 3 of 3 key elements? – New, Consults, Initial Which need 2 of 3 key elements? – Established, Subsequent What is MDM for all level 5 services? HIGH What is MDM for all level 4 services? MODERATE How many levels do Initial hospital or Subsequent hospital codes have? 3 For Same day Admit and Discharge codes, how many hours must the patient be in the hospital? At least 8 What is an Interval History and when do I use it? HPI, ROS for Subsequent services

25. E&M Key Elements

26. Chief Complaint –from Palmetto Concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the encounter. CC establishes ‘medical necessity’ Chief complaint may be inferred within the HPI or may be separately documented.

27. Past Medical, Social and Family History “PFSH reviewed and negative” alone is not sufficient (Palmetto FAQ) “because it is unknown what was reviewed” Listing Current Meds – considered past medical history Social History Tobacco, drug use, marital status, living arrangements

28. History and vitals by Ancillary Staff Ancillary staff may document Past, Family, Social history, Review of Systems and vital signs. EMR: Physician STILL must indicate he has confirmed what was obtained by others even if he has ‘taken over’the note . Advise physician to develop and use a ‘macro’ at end of note or elsewhere in note. (“I have confirmed and edited as necessary PFSH and ROS obtained by others”.) Hardcopy: Add phrase and sign it under documentation obtained by others (including questionnaire completed by patients) May use preprinted form with ‘check off’ box

29. HPI In certain instances an office or emergency nurse may document pertinent information regarding the chief complaint/HPI” Should be treated as preliminary information Physician needs to document that he/she has explored the HPI in more detail. (Palmetto – May 2008 educational handouts) Example: “HPI explored in detail with patient and edited as necessary”. Multiple progress notes would also show any edits made by physician. NOTE: Some hospital policies may require physicians to document their own HPI regardless of Palmetto’s policy.

30. History of Present Illness Eight (8) elements we all know well (1995) Status of chronic/inactive diseases (1997) Per Palmetto: only applicable when using 1997 guidelines Per CMS (Coding Answer Book quote from CMS): can also be used with 1995 guidelines and not restricted to the 1997 guidelines For CC, we should follow Palmetto at this time although a request to reassess the guidelines has been submitted. Can there be ‘inferred’ locations? Urinary tract for hematuria Cardiovascular for hypertension If more than 1 complaint, can elements be used for each? Per Palmetto FAQ: Revised 8/08. Confusing; seems to imply using second complaints as associated symptoms or ROS Per CMS query: Yes, one can have multiple locations due to multiple problems Palmetto has not updated this FAQ.

31. HPI elements Timing can also include words such as: Recently, yesterday, sometimes, at night, in the morning. Duration How long usually is a time frame. “Chronic” can also imply duration. More than a week Associated signs/symptoms vs ROS Depends somewhat on where you need it! ROS is usually an ‘answer’ to a question to elicit symptoms that might not otherwise be presented by the patient. Signs/symptoms are usually related to the chief complaint

32. HPI – Status of conditions A list of problems (i.e. problem list) is not sufficient for 1997 guidelines. Need status: DM type 2 well controlled with diet HTN controlled with Toprol Hyperlipidemia – patient attempting to control with dietary changes, however levels still elevated. NOTE: You may still be able to do better by checking the HPI elements against the ‘chief complaint’ (one of the above problems) with remaining problems as associated conditions.

33. Review of SystemsWhat to tell your docs! Medicare’s rule: Review of systems = Review of SYMPTOMS! Diseases listed by system are ‘counted’ as past medical history, not ROS. Documentation Do’s Always document positive and pertinent negative answers to questions. May document ‘remaining ROS negative’ IF all system questions were asked. May refer to previous ROS as unchanged if it is specifically referenced per guidelines. However, this is not recommended as best practice. Documentation Don’ts Don’t use “non-contributory” Remind physicians: ROS should not contradict what is being documented in HPI. Don’t copy and paste a ‘normal’ ROS and then try to edit; this often can be the cause of this problem.

34. History Caveat “If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.” Advise the physician to get whatever the documentation he can from family, records, etc. A patient may not ‘remember/know’ past, social, medical history but may still be able to answer Review of ‘Symptom’ questions. Don’t assume the patient’s condition will pass the ‘auditor’s test’ of what could/could not be obtained re: ROS or HPI elements. Does this mean it counts as a comprehensive history? Not necessarily. What would you have ‘needed’ to do for the service. Usually means code will be determined based on the other 2 elements.

35. 1995 Exam – Body areas and Organ Systems Exam can be documented in two ways: Eight organ systems Constitutional, Eyes, ENT, Cardio, Resp, GI, GU, MSK, Skin, Neurologic, Psychiatric, hematologic, lymphatic. Eight body areas head, neck, chest/breast, abdomen, genitalia/groin, back, each (4) extremity Can body areas and organ systems be mixed and matched? Content is important, not necessarily the ‘headers “Exts: no edema” = only 2 areas per Palmetto “Exts:no edema, no clubbing” = 4 areas per Palmetto .

36. 1995 Exam Issues Limited (EPF) versus Extended (Detailed) exam 2-4? 5-7? Detailed verbiage? 2X2 (at least 2 of bulleted items from 97 guidelines in 2 areas/organ systems) How many to count? “HEENT: negative” Head and Neck – 2 areas Eyes and Ears/Throat – 2 systems “HEENT: PERRLA, conjunctivae clear Eyes only Where to count the exam finding? Neck supple – Neck body area, but which, if any, organ system? Edema – Cardiovascular or lymphatic depending on condition Sinus tenderness – Head or ENT? Endocrine – nothing is listed as exam element but it is an organ system Alert and oriented x 3- neuro

37. 1995 Exam Issues What is a ‘comprehensive single organ system’ exam? Never was defined in 1995 guidelines The 1997 guidelines were established to try to solve this problem! Therefore, there really isn’t a comprehensive single organ system in the 1995 guidelines. Palmetto states that no single organ system exam exists in the 1995 guidelines.

38. 1997 Exam Guidelines Who should use them? Eye Dermatology (maybe) Psychiatry Neurology (maybe) Other specialty exams are unrealistic

39. Medical Decision-Making# of Diagnoses and Management Options Breakdown of problem types Self-limited or minor problem (1 pt) Minor is ill-defined. Perhaps one that is ‘aligned’ with straightforward management options and dx testing options Established problem – improving (1 pt) Established problem-worsening or failing to change as expected (2 pt) New problem- no additional workup (3 pt) New problem – with additional work up (4 pt)

40. New Problem versus Established Problem New problem or an established problem with exacerbation? Documentation is key in this scenario. The physician's/nonphysician-practitioner’s (NPP) documentation must support whether it is a new problem of heartburn, nausea and vomiting, or whether it is an exacerbation of GERD. The medical record should reflect a clear picture of the physician’s/NPP’s view as to whether this is a new problem or not.  (Palmetto) Is a new problem to patient or to new to the provider for it to be considered a new problem for E&M coding? New to PROVIDER (updated from Palmetto’s original policy) Exceptions where it would be considered an established problem: Established patient in a specialty/department that is now seeing a newly hired physician A visit by an on-call or covering physician

41. What is additional workup Additional testing that is performed during the visit resulting in a final diagnosis and completed management decision – NOT additional workup. Any additional testing (including requesting consultation) that is performed after the visit is concluded or scheduled to be performed at a later visit to assist the physician in 1) diagnosing a condition, or 2) determining the extent of a condition for appropriate medical management of the patient. Tests or other diagnostic procedures ordered ‘Provisional’ or unconfirmed diagnosis awaiting further information. Hospitalization Consultation requests

42. Amount and Complexity of Data Summarization of prior records “excerpts of an x-ray report’ that is appropriately cited Order and review of x-ray image Points for both the personal review of the image/film and order for the same radiologic test? YES. Points: 1+2=3 Labs ordered and reviewed Get only 1 point Labs ordered and specimen looked at Order ( 1point) and specimen –(2 points) 2 labs versus 8 labs More points? Palmetto weighs this depending on ‘clinical inference’. Requests for old records Review of records brought to the visit by the patient?

43. Table of Risk – Presenting problem Risk of significant complications, morbidity , and/or mortality associated with the presenting problem. Risk related to the disease process anticipated between the present encounter and the next one. What determines a patient’s condition is ‘mild’ versus ‘severe’ exacerbation? The provider’s documentation must support the conditions/ status of the patient. The medical record should reflect a clear picture of the provider’s view as to if it is mild versus severe (Palmetto – May 2008) What does this mean exactly? Advise physicians to specify using adjectives… Mild, severe, new, worsening, improving, etc. Sometimes the immediacy of the treatment will imply severity.

44. Table of Risk – Diagnostic and Management Options Risk of significant complications, morbidity and or mortality based on the risks associated with the diagnostic procedure(s) and/or the management options selected or agreed to. Based on the risk during and immediately following any procedures or treatment. Medications prescribed versus Monitoring for drug toxicity? Drug must itself be considered ‘toxic’; check against the formulary and Palmetto article 9/30/08 on drugs. Prescription drugs do not have to be ‘changed’ for physician to get credit for prescription management options (moderate). DNR discussion Discussion of living will with well patient does not count.

45. What about Medical Necessity? Compliance concerns about documenting comprehensive H&PE in EMR when ‘not necessary”. Difficult for non-provider to assess this however things to consider: Review ‘Nature of Presenting Problems’ definition in the CPT codebook Minimal, self-limited/minor, low, moderate, high Does the NPP support the extent of H&P that was performed/documented? Review co-morbid conditions that are on the problem list but not specifically documented? Did the physician forget to document his addressing these issues and therefore, the extent of hx and exam is necessary? Review Medical Decision-making Score Does a low MDM support the hx and exam performed?

46. Providing feedback re: Medical Necessity Ask the physician if comprehensive H&P would typically be performed for a patient with the particular condition(s). Listen carefully to insights that may not be apparent in the record. Offer an ‘outside auditor’s view of the documentation to ‘play devil’s advocate’. Avoid giving an impression that you are questioning the physician’s medical expertise or practice. Empathize with the provider when appropriate. Encourage the provider to share several ‘typical patient cases’ with you to review. These can make more sense from a clinical perspective.

47. Using time for selecting code Used when counseling/coordination of care dominates (more than 50%) of the face to face provider encounter (outpatient) and includes “floor time” only in case of inpatient services Medical decision-making and description of coordination of care or counseling should be documented. History and exam not considered for code selection. Document total time w/ patient and percentage of time spent coordinating/counseling. (excludes any time spent on procedures billed) Example: “> 50% of time spent reviewing management options w/pt. Options include: xxxx Total time 60 minutes.” Must include reference to what was discussed or summary of what was discussed. Wording such as “counseling dominated time” is also acceptable. Per Palmetto, they would accept: Spent 60” counseling patient about….” without the reference to percentage of time. But: If Comprehensive H&P is performed and time is documented showing entire time was spent counseling (60 of 60), it appears contradictory.

48. Auditing

49. “Pre-audit” steps Understand each physician’s/provider’s practice How will he/she document? (transcription, EMR, handwritten, pre-printed forms?) Will secretary be transcribing notes? Will anyone be scribing? What kind of ancillary staff will be working with him? Nurse, APN, PA, MA, residents How will others work with him? Shared or split services? Independent? In office setting or HOPS? Post-op or pre-op? What is his specialty as provided to Medicare on the 855 form? What procedures or other services will she/he perform? Where will he/she be performing services? Inpatient, Outpatient, different sites? Educate the physician or provider about E&M documentation and coding. Medicare/Palmetto Materials Tailor to his practice as much as possible. Know when changes occur in his practice (eg. New services, new location, new mid-level agreement).

50. Audit Process Read through the note and familiarize yourself with the case. What category of service: Consult, New, Established, Preventive Enter/write the demographic info including the category of code you have identified. Note: This may be different than the category the physician coded. Work through the note and mark as you go. Enter into the audit tool (Intelicode™ or audit sheet). Enter notes and comments for use in feedback. Compare physician code and reviewer code. Kinds of recommendations: Education re: errors resulting in a coding inaccuracy Is it an ‘underdocumentation’ problem? Is it a coding problem? Education re: ‘best practices’. (example: documentation is minimally acceptable yet there is a better way).

51. Issues related to ‘copy and paste’ in the EMR This is an increasing area of concern by CMS and auditors and surveyors. How to ‘audit’ Review notes prior to and after the current date of service being provided whether by the same provider or a different provider. Look for portions of the note that are exact copy of prior note(s) Consecutive abnormal exam findings that have not been edited. Copies of other provider’s notes (interpretations, HPIs) without separate attribution or separate header (i.e. “excerpts from prior notes”). Inconsistent findings documented in the same note (i.e. normal ROS with abnormal symptoms in HPI) How to provide feedback to provider Medicolegal, coding and patient complaint consequences. Advice on how to use ‘copy & paste’ appropriately (for historical reference and with appropriate citations)