UT 42nd Review Course

1. 1 UT 42nd Review Course Compliance Documentation and Billing Education Session Steve Schrock, MD Residency Program Director Mabel Restuccio, CPC, CHC

2. 2 Learning Objectives General Compliance Information Midlevel Providers Selecting E/M Levels Consultations Q&A

3. 3 Medical Record Use Facilitates Continuity of Care Risk Management/Legal Purposes Billing & Reimbursement

4. 4 Changes You Need to Know About!

5. 5 MAC - Medicare Administrative Contractors Consolidation of administration of Hospital (Part A) and Professional (Part B) claims. Riverbend and Cigna have been replaced by a MAC! Cahaba GBA, located in Birmingham, is the MAC for TN.

6. 6 RAC- Recovery Audit Contractorsaka - Bounty Hunters Connolly Consulting awarded RAC contract for TN. RACs receive a % of identified incorrect payments (9-12%) RACs can request 45-50 records every 45 days from physician practices. RACs can extrapolate!

7. 7 Documentation? “I thought I was supposed to practice medicine!”

8. 8 Documentation Issues CMS requires documentation to be completed in a timely manner – that is as quickly as possible following the service (24-48 hours). Patient name and date of service must be on every page of the record (front and back).

9. 9 Documentation Issues CMS prohibits cloned notes as they are not patient-specific. Accuracy requires review and edit of electronic template-produced notes to reflect services provided at a particular encounter. You cannot reuse or copy someone else’s note and sign your name.

10. 10 Signature Requirements All documentation submitted to CMS must include an electronic or written signature that is legible. Credentials must be included. Orders for diagnostic and therapeutic testing (excluding laboratory services) also require the signature of the ordering provider.

11. Ordering Tests and Ancillary Services CMS required that all diagnostic tests and ancillary services have a written order that includes the reason for the test or service. The reason can be a sign/symptom or a confirmed diagnosis. It is inappropriate to use “rule out” or “screening” on requisitions when ordering diagnostic tests without providing signs/symptoms. This includes services performed in the office setting such as ekg or xrays and the administration of vaccines or other drugs.

12. 12 Nurse Practitioners & Physician Assistants CMS and State Requirements

13. 13 Protocols Required Jointly developed and approved by NP/PA and supervising M.D. Evidence-based guidelines for medical management of clinical conditions Must include all procedures Include Drug Formulary Reviewed and updated annually Must be dated and signed Site specific/population specific

14. 14 Review of NP/PA Documentation CMS and State Licensing Boards require the supervising MD to review and sign 20% of NP/PA notes. Choose a day of the week Choose a type of patient

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16. 16 Key Elements of E/M Coding  History Exam Decision Making

17. 17 Chief Complaint Concise statement that describes why the patient is seeking treatment. The words “follow-up” are insufficient without listing the specific condition followed. Each item listed in the chief complaint should be addressed in the note.

18. 18 History of Present Illness (HPI) Chronological description of the development of the patient’s present illness from the first sign or symptom or changes from the previous visit to the present. - location - quality - severity - duration - timing - context - modifying factors - associated signs/symptoms

19. History of Present Illness (HPI) Must be documented by the billing provider – not ancillary staff or students. When using an electronic template, recommend using free text for HPI in order to individualize note.

20. 20 Review of Systems (ROS) Inventory of body systems obtained through a series of questions seeking to identify signs/symptoms the patient is experiencing. Patient can complete form but provider must review and describe positives and pertinent negatives and indicate his/her personal review and confirmation of information.

21. 21 Review Of Systems (ROS)

22. 22 Past, Family and Social History (PFSH) Necessary to document for new patients and consultations! CMS will not accept the words “non-contributory” as a PFSH. A ROS and/or PFSH obtained during an earlier visit does not have to be re-recorded. Document review of the previous history with the patient and note whether or not there are changes (describe changes).

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24. Selecting Type of Examination

25. 25 Organ Systems Constitutional Eyes ENMT Cardiovascular Respiratory GI GU Musculoskeletal Skin Hem/Lymph/Immuno Psychiatric Exam – 1995 Guidelines Body Areas Head including face Neck Chest including Breast/axilla Abdomen Genitalia, groin, buttocks Back incl. Spine Each Extremity

26. 26 Level of Decision Making Number of diagnosis or management options Amount and complexity of data Overall level of risk

32. Determining E/M Code Level New Patient/Consultation - 3 of 3 key elements required Established Patient - 2 of 3 key elements required All services that are provided and billed must be medically necessary. The volume of documentation does not determine the level of service.

33. New Patient Definition “One who has not received any professional services from the provider or another provider of the same specialty who belongs to the same group practice, within the past three years.”

34. For a new patient with first example, best we could do is 99202 With improved note, still 99202 because of exam items…..given the fact that we could have had a detailed history, exam items should have been expanded to at least 12 – which would have gotten us a 99203. We cannot get a hospital admit with this note because criteria is not met. We could bill a 99231 which would be a level 1 hospital visit. With the improved note, we could have billed a 99232 – level 2 visit. We could not go to level 99233 because we did not have enough exam items. For a new patient with first example, best we could do is 99202 With improved note, still 99202 because of exam items…..given the fact that we could have had a detailed history, exam items should have been expanded to at least 12 – which would have gotten us a 99203. We cannot get a hospital admit with this note because criteria is not met. We could bill a 99231 which would be a level 1 hospital visit. With the improved note, we could have billed a 99232 – level 2 visit. We could not go to level 99233 because we did not have enough exam items.

36. 36 Time Based Codes If more than 50% of the visit was counseling or coordination of care, document the total time and counseling time with details.

37. Modifier 25 is used to indicate that on a day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E & M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. In order for modifier 25 to be used, the evaluation and management service must be above and beyond preoperative and postoperative care of the procedure. In our example, we have a patient who is seen in the office for evaluation of his COPD, coronary artery disease and diabetes. He is also complaining of swelling in his knee which developed after he fell while getting out of his car. The physician performs an expanded, problem-focused history and examination of his chronic illnesses along with his knee and performs a joint aspiration of the knee. Since there is a separately identifiable E & M service for the chronic illnesses, the office visit is coded with modifier –25 appended to show other services were rendered unrelated to the joint aspiration. Modifier 25 is used to indicate that on a day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E & M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. In order for modifier 25 to be used, the evaluation and management service must be above and beyond preoperative and postoperative care of the procedure. In our example, we have a patient who is seen in the office for evaluation of his COPD, coronary artery disease and diabetes. He is also complaining of swelling in his knee which developed after he fell while getting out of his car. The physician performs an expanded, problem-focused history and examination of his chronic illnesses along with his knee and performs a joint aspiration of the knee. Since there is a separately identifiable E & M service for the chronic illnesses, the office visit is coded with modifier –25 appended to show other services were rendered unrelated to the joint aspiration.

38. 38 Consultation Requirements Medicare is no longer accepting consultation codes. In the office setting, a new or established patient code should be reported. Most private payers are still accepting consultation codes.

39. 39 Consultation Requirements A consultation and a referral for treatment are not synonymous terms. The following language does not represent a consultation: “refer for treatment” “refer for evaluation” “refer for surgery” Consultations may be requested from another MD in the same group practice when the consulting MD has expertise in a specific medical area beyond the requesting professional’s knowledge. Hospital consultations for Medicare are reported with initial inpatient codes (99221-99223).

40. 40 Summary Good documentation facilitates quality care and maximizes payment for services provided. If it’s not documented it did not happen! And, if it is documented it did happen!

41. 41 QUESTIONS?