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Moving Targets: Coding Advice To Take You From The Complex To The Simple. T. Brian Callister, M.D., F.H.M. National Medical Director, LifeCare Hospitals President-Elect, Nevada State Medical Association Nevada State Chair, AMA-OMSS Chairman, ALTHA Clinical Committee

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Moving targets coding advice to take you from the complex to the simple
Moving Targets:Coding Advice To Take You From The Complex To The Simple

T. Brian Callister, M.D., F.H.M.

National Medical Director, LifeCare Hospitals

President-Elect, Nevada State Medical Association

Nevada State Chair, AMA-OMSS

Chairman, ALTHA Clinical Committee

Associate Professor, University of Nevada


Objectives
Objectives:

At the end of the lecture, the attendee will be able to:

Understand how the recent coding changes effect your practice

Describe how to appropriately code for consultative services

List the documentation requirements for billing from the simple to the highly complex

Identify techniques for appropriately maximizing reimbursement

Summarize the changes necessary to convert specialty codes to new patient or follow up codes for inpatient, outpatient, nursing home, and observation levels of service


WAIVER:

  • This presentation is informational only and may not be used in differences of opinion or disputes with CMS, insurance carriers, or any other party. No implied or expressed warranty regarding this content is made, and you are urged to consult the constantly changing regulations, laws, and policies regarding coding on a regular basis.


Coding “101”

If You Get It, They Will Change It

  • ICD-9 and ICD-10

  • E/M and CPT

  • Maximizing Reimbursement

  • CMS – Fraud and Abuse


Coding “101”

If You Get It, They Will Change It

  • Evaluation and Management Defined

  • Current Procedural Terminology

  • Medicare Physician Fee Schedule

  • Recovery Audits


The Nature of E/M Services:

The ICD-9 and CPT Relationship

  • ICD-9 codes explain WHY the service was performed

  • CPT codes explain WHAT service was performed

  • Diagnosis codes must support the CPT code(s) assigned


The Nature of E/M Services:

Medical Necessity

  • Patient’s presenting problem or reason for the visit

  • Level of service IS medically reasonable AND necessary

  • Demonstrated IN the documentation – not by the amount of documentation

  • Must be supported by ICD-9 diagnosis


The Nature of E/M Services:

Evaluation and Management Defined

  • “Face to Face” Services

  • “Visit” – Examination, Evaluation, and Delivery of Care

  • Interaction and Independent Judgment

  • Documentation


The Nature of E/M Services:

Evaluation and Management Components

  • History*

  • Examination*

  • Medical Decision Making*

  • Counseling

  • Coordination of Care

  • Nature of Presenting Problem

  • Time

  • * Key Component


The Nature of E/M Services:

Evaluation and Management Components

  • Concurrent Care

    • Similar services, same day

  • Unit/Floor Time

    • Observation, inpatient, nursing home

    • Includes chart, exam, writing notes, discussion with family and/or other professionals


Medical Decision Making:

CMS and CPT Descriptions

  • Elements

    • Number of diagnoses & management options

    • Amount of data reviewed and orders

    • Level of risk of complications/morbidity/mortality

  • Levels

    • Straightforward

    • Low

    • Moderate

    • High

  • To qualify for a given type of decision-making, two of the three elements must be met or exceeded




Consultations

  • CMS “inactivated” consultation codes

  • Office Consultations: 99241-99245

  • Inpatient Consultations: 99251-99255

  • Exception: “telehealth” initial – G0425-7


Outpatient Consultations

  • New patient – not seen within 3 years

  • - use codes 99201-99205

  • Established patient – 99212 - 99215

  • No modifier required

  • Exceptions

  • Extended time -99358-99359

  • - no longer “add on”

  • - can be used independently

  • - may be used before or after

  • - MUST document




Inpatient Consultations

  • Use admit codes 99221-99223

  • NO modifier unless admitting

  • Modifier “AI” for admitter

  • Same process for nursing home consults

  • Follow up codes are the same 99231-99233

  • Critical Care codes often legitimate 99291-99292

  • Use extended time when appropriate!!!

  • 99356-99357


Inpatient Consultations

  • Requesting and consulting physicians must document request for consult – put it in the orders too!

  • Consulting physician must document opinion and/or advice

  • Concurrent care denials: Issue with more than one physician in the same specialty seeing patient with the same diagnosis

  • Document THE problems for which YOU are seeing the patient!


Inpatient Consultations

  • Time documentation is mandatory – TOTAL TIME

  • Especially important in documenting PROLONGED service

  • 99356-99357 inpatient prolonged service codes

    • Greatly increase reimbursement

    • Legitimate use is often under utilized!

    • Revenue can increase 35% or more

    • Use with 99232 and 99233 when appropriate

    • Do NOT use with 99231



Crosswalk to time some comparisons
Crosswalk to Time:Some Comparisons

  • 99255 was 110 minutes…..99223+99356 is 70 + 30 minutes

  • 99254 was 80 minutes…….99222+99356 is 50 + 30 minutes

  • 99253 was 55 minutes…99221 OR 99233 are 30 and 35 minutes

  • 99252 was 40 minutes……99232 is 25 minutes

  • 99251 was 20 minutes…....99231 is 15 minutes


Nursing Home Visits

  • 99304-99310, 99315-99316, 99318

  • No longer “face to face” time only

  • Now definition of time is “at the bedside AND on the patient’s facility floor or unit”


Telehealth Consultations

  • By law, CMS had to retain these codes

  • Initial inpatient telehealth consultation codes

    • G0425 initial inpatient 30 minutes

    • G0426 initial inpatient 50 minutes

    • G0427 initial inpatient 70 minutes

  • Crosswalks to initial hospital codes 99221-99223

  • Prolonged service codes NOT applicable


Preventative Health

  • G0402 – new to Medicare

  • Approximately equivalent to 99204

  • First 12 months of Medicare enrollment

    • Includes body mass index

    • Includes end of life planning with consent

    • Removed EKG as mandatory service


Preventive services
Preventive Services

99397 – GY PREVENTATIVE EXAM – 65 AND > YEARS

99396 - GY PREVENTATIVE EXAM - 40 – 64 YEARS

G0101 – GA PELVIC AND BREAST EXAM

Q0091 – GA OBTAIN PAP SMEAR

99406 TOBACCO COUNSELING, 3-10 MINUTES

99407 TOBACCO COUNSELING > 10 MINUTES


Examples of other preventive services
Examples of OtherPreventive Services

  • Initial Preventive Physical Exam

    • EKG

  • Pelvic examination

  • Pap - obtain

  • Occult Blood

  • Flu vaccine

  • Pneumonia vaccine

  • Hepatitis vaccine

  • Colonoscopy patient at high risk

  • Colonoscopy screening exam

  • Prostate exam

  • DM self-management

  • Bone Mass Measurement (DEXA)

  • Mammogram

  • Smoking Cessation 3-10 minutes

  • Smoking Cessation > 10 minutes

  • Cardiovascular screening

  • Diabetes screening


Home health

G0179 - Home Health Recertification - $50

G0180 - Home Health Certification - $65

G0181 – Home Health Agency – >30 Min -$110

G0182 – Hospice Care – >30 Minutes - $116

Home Health


Power mobility device

G0372 – Physician service required to establish and document the need for a power mobility device - $18

There must be an in-person physician-patient encounter.

The physician must perform a medical examination for the specific purpose of assessing the beneficiary’s mobility limitation and needs. The results of this exam must be recorded in the patient’s medical record.

The prescription must only be written after the in-person visit has occurred and the medical evaluation is completed. This prescription has seven required elements.

The prescription and medical records documenting the in-person visit and examination report must be sent to the equipment supplier within 45 days of the completion of the examination.

Power Mobility Device


Commercial payers
Commercial Payers document the need for a power mobility device - $18

  • Commercial primary and secondary – continue to bill consultation codes

  • Commercial primary and Medicare secondary

    • Bill consultation codes

    • Intercept and change secondary claim

    • Follow Medicare Rules

  • Medicare primary and Commercial secondary

    • Bill outpatient visit or inpatient visit codes OR

    • Intercept and change secondary claim


Healthcare Reform document the need for a power mobility device - $18

  • Outcomes and Criteria Development

  • Accountable Care Organizations (ACO)

  • “Bundling”

  • Budget “Neutral”


Moving Forward… document the need for a power mobility device - $18

  • ICD-10 and a whole new level of complexity

  • The “Provider” and “Doctor Nurse”

  • Hospitalists and the separation of primary care

  • Employed physicians, group practice, and the solo practitioner


Summary
Summary document the need for a power mobility device - $18

Coding rules will continue to change rapidly

You have a right to legitimately maximize your reimbursement just as your patient has a right to expect high quality medical care

With an aging population straining our ability to provide high quality care, it is more important than ever that we also learn to provide efficient care that is fairly compensated


CPT® Professional Edition, American Medical Association document the need for a power mobility device - $18

2010-2011 Coding Resources and References

ICD-9/HCPCS codebooks

As hundreds of coding changes occur every year in E/M and ICD codes, please keep informed on an ongoing basis!

For more information, visit:

https://www.cms.gov/nationalcorrectcodinited/

MGMA

CMS

National Correct Coding Initiative

Federal/State/OIG Regulations

ACP

6/9/2014


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