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Woodland Hills AAPC Medicare Seminar. Presented by Kathy A. Montoya Senior Provider Relations Representative Palmetto GBA.

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Woodland hills aapc medicare seminar

Woodland Hills AAPCMedicare Seminar

Presented by

Kathy A. Montoya

Senior Provider Relations Representative

Palmetto GBA


The information provided in this presentation was current as of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.


Objectives
Objectives of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • To enhance the knowledge base of Medicare coverage and billing guidelines

  • To decrease the National Paid Claims Error Rate

  • To protect the Medicare Trust Fund

  • To ensure the delivery of quality care to our Medicare beneficiaries


Agenda
Agenda of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Updates/Reminders

    • JE bid

    • Fee Schedule changes

    • Therapy Services

    • Ordering/Referring


Agenda1
Agenda of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Documentation

    • Principles of documentation

    • Common Errors

    • Amendments


A b mac jurisdiction e

A/B MAC Jurisdiction E of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

May 2013


Jurisdiction e awarded
Jurisdiction E Awarded of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Announced September 20, 2012

  • Noridian Administrative Services (NAS)


Jurisdiction e
Jurisdiction E of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Noridian launched JE website April 16, 2013

    • https://www.noridianmedicare.com/je/

    • Outlines implementation timeline

    • Presents calendar of transition events

    • States physical presence in California


Https www noridianmedicare com je
https://www.noridianmedicare.com/je/ of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.


Implementation dates
Implementation Dates of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Noridian will be the MAC for Jurisdiction E:

    • Part A – August 26, 2013

    • Part B –September 16, 2013


Communication resources
Communication Resources of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Website/Listserv: www.noridianmedicare.com/JE

  • Contact provider organizations/associations

  • Meet and Greet meetings with providers

  • Mailings to providers

  • Web based provider workshops/ACTs


Listserv 2
Listserv of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.2

  • For providers not registered with J1 prior to March 1, 2013

    • Go to: https://www.noridianmedicare.com and select “E-mail Newsletter Sign Up” at the bottom of the left hand navigation menu.

    • Instructions listed in Listserv article on JE website


Key website items
Key Website Items of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Contact Information

    • phone numbers and mailing addresses

    • implementation questions

  • Current news and relevant changes

  • IVR

  • Schedule of Events


Key website items1
Key Website Items of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Cutover dates

  • Payment cycles

  • FAQs

  • EDI - focus on vendors and direct submitters

  • Provider Portal


Contact information
Contact Information of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Single Toll-free number after JE Implementation

    • Provider Contact Center (PCC)

    • Electronic Data Interchange Support Services (EDISS)

    • Telephone Reopenings

    • Provider Enrollment

    • User Security


Contact information1
Contact Information of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Questions regarding implementation

    • Email to [email protected] or

    • Call Implementation Hotline at 1-800-361-8289

      • Hot Line available 8:00 am to 5:00 pm (PT), Monday-Friday


Welcome
Welcome of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Noridian is proud to be your Medicare Administrative Contractor (MAC) for Jurisdiction E (JE) – formerly Jurisdiction 1. They look forward to working with you in the near future to serve your Medicare needs.


New costs

New Costs of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.


2013 part b deductible and coinsurance rates
2013 Part B Deductible and Coinsurance Rates of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

Deductible-$147.00

Coinsurance

20% of eligible charges


2013 part a deductible and co pays
2013 Part A Deductible of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.and Co-Pays

  • $1,184 deductible

    • 1st 60 days of hospitalization

  • $296 co-pay

    • Days 61-90

  • $592 co-pay

    • Days 91 – 150 Lifetime Reserve

  • $148 co-pay

    • SNF days 21 - 100


2013 part b premiums
2013 Part B Premiums of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.


2013 part a premium
2013 Part A Premium of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Fewer than 30 quarters

    • $441.00 per month

  • 30 to 39 Quarters

    • $243.00 per month


Updates

Updates of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.


Payment reduction april 1 2013
Payment Reduction of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.April 1, 2013

  • The Budget Control Act of 2011

    • Requires Federal spending reductions, sequestration

  • The American Taxpayer Relief Act of 2012 postponed sequestration for two months

    • President Obama issued a sequestration order on March 1, 2013


Payment reduction april 1 20131
Payment Reduction of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.April 1, 2013

  • Medicare FFS claims

    • Part B - dates-of-service ≥ April 1, 2013

    • Part A - dates-of-discharge ≥ April 1, 2013

    • Two percent reduction

  • CR7825


Transitional care management services tmc
Transitional Care of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.Management Services (TMC)

  • New codes 99495 and 99496

    • Established patient

    • Moderate to high complexity medical decision making


Transitional care management services tmc1
Transitional Care of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.Management Services (TMC)

  • Transition period from an inpatient setting (IP, LTC, SNF, rehab) to the patient’s community setting

  • TMC begins on date of discharge + 29 days

  • One face-to-face visit combined with non FTF services provided by physician or clinical staff


Transitional care management services tmc2
Transitional Care of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.Management Services (TMC)

  • Medical decision making/date of the first face-to-face visit are used to select the code

    • 99495 TMC service

      • Communication with patient/caregiver within 2 business days

      • Moderate complexity

      • Face to face within 14 calendar days of discharge


Transitional care management services tmc3
Transitional Care of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.Management Services (TMC)

  • 99496 TMC service

    • Communication with patient/caregiver within 2 business days

    • High complexity

    • Face to face with 7 calendar days of discharge


Transitional care management service tmc
Transitional Care of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.Management Service (TMC)

  • Date of Service = 30th day

  • Place of Service = POS for face to face visit

  • What if patient dies during the 30 day period

    • Bill E/M code only


Psychiatry
Psychiatry of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Initial Psychiatric Evaluation

    • 90801 and 90802 were deleted

    • Distinction made between service by MD and one by non physician


Psychiatry new codes
Psychiatry – New Codes of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • 90782 = Initial evaluation with physician services

  • 90791 = Initial evaluation done by a non physician

  • 90785 = New add on code for interactive complexity


Multiple procedure payment reduction mpprs
Multiple Procedure Payment Reduction (MPPRs) of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • CR7848

  • Effective January 1, 2013

  • Reduction to Technical Component (TC)

    • Diagnostic Cardiovascular

    • Ophthalmology procedures


Multiple procedure payment reduction
Multiple Procedure Payment Reduction of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Multiple services to same patient, same date

  • Affected codes

    • http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1149OTN.pdf

  • Remittance Advice

    • Adjustment Reason Code 59


Multiple procedure payment reduction1
Multiple Procedure Payment Reduction of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Cardiovascular Services

  • Same physician, or multiple physicians in same group

    • Full TC payment with highest value

    • Subsequent TC paid at 75%


Multiple procedure payment reduction2
Multiple Procedure Payment Reduction of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Ophthalmology services

  • Same physician, or multiple physicians in same group

    • Full TC payment with highest value

    • Subsequent TC paid at 80%


Mpprs cardiovascular payment reduction example
MPPRs Cardiovascular Payment Reduction Example of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.


Mpprs ophthalmology payment reduction example
MPPRs Ophthalmology Payment Reduction Example of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.


Cr7260
CR7260 of May 1, 2013. Any changes or new information super ceding the information in this presentation will be provided in articles and publications dated after May1, 2013 posted at www.palmettogba.com/J1B.

  • Health Insurance Claim Number (HICN) and Name Mismatch

  • Effective October 1, 2012

  • Claims will reject MA 130 and MA61

  • Take information exactly as shown on Medicare card


MEDICARE HEALTH INSURANCE

SOCIAL SECURITY ACT

NAME OF BENEFICIARY

JOHN D. DOE

MEDICARE CLAIM NUMBER SEX

123-45-6789A MALE

IS ENTITLED TO EFFECTIVE DATE

HOSPITAL INSURANCE (PART A) 1/1/98

MEDICAL INSURANCE (PART B)

John D. Doe

SIGN

HERE


Therapy services

Therapy Services INSURANCE


Multiple procedure payment reduction mppr for selected therapy services
Multiple Procedure Payment Reduction INSURANCE(MPPR) for Selected Therapy Services

  • CR 8206

  • Effective April 1, 2013

  • MPPR increased to 50% from 20% for all settings

    • Applies to the practice expense

    • Applies to HCPCS codes on the “always therapy” list


2013 financial limitation for outpatient therapy services
2013 Financial Limitation for Outpatient Therapy Services INSURANCE

  • Effective January 1, 2013

  • 2013 Therapy Cap amounts:

    • $1,900 for OT

    • $1,900 combined PT and SLP


2013 financial limitation for outpatient therapy services1
2013 Financial Limitation for Outpatient Therapy Services INSURANCE

  • Section 603 of American Taxpayer Relief Act of 2012

  • Outpatient Therapy claims cap

    • Extended through DOS December 31, 2013

    • $3,700 for PT and SLP

    • $3,700 for OT

  • Manual Review of claims > $3,700


Changes for therapy services in 2013
Changes for Therapy Services in 2013 INSURANCE

  • Reporting requirements

    • Use Functional status codes

    • Use Functional Limitation modifiers

    • Every 10 treatments or 30 calendar days, whichever is earlier


Functional reporting g codes
Functional Reporting INSURANCEG-Codes


Functional reporting g codes1
Functional Reporting INSURANCEG-Codes


Functional status codes
Functional Status Codes INSURANCE

  • Three codes

    • Current status

    • Goal status

    • Discharge status



Functional reporting
Functional Reporting INSURANCE

  • Use of G codes and modifiers is required

    • At the onset of therapy episode of care

    • At least once every 10 treatment days


Functional reporting1
Functional Reporting INSURANCE

  • Same date of service that an evaluation/re-evaluation procedure

  • At the time of discharge from therapy episode of care

  • On the same date of service the reporting of a functional limitation is ended


Claim reporting
Claim Reporting INSURANCE

  • Onset of therapy and each reporting period

    • Report two G codes with modifiers

      • Current status, goal status

  • Discharge

    • Report two G codes with modifiers

      • Current status, discharge status


Manual medical review
Manual Medical Review INSURANCE

  • CMS Update March 21, 2013

  • Recovery Auditors (RA) to conduct MMR at $3,700 thresholds (PT and SLP, OT)

    • Prepayment Review Demo – California

    • Pos-tpayment Review – Nevada, Hawaii


Manual medical review1
Manual Medical Review INSURANCE

Reference

http://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medical-review/therapycap.html


Manual medical review2
Manual Medical Review INSURANCE

  • Prepayment Review

    • California

      • Palmetto GBA to send a Additional Documentation Request (ADR) to provider

        • Request documentation be sent to the RA

      • The Recovery Auditor will conduct prepayment review

        • Within 10 business days of receiving documentation

        • Will notify Palmetto of payment decision


Manual medical review3
Manual Medical Review INSURANCE

  • Postpayment Review

    • Hawaii and Nevada

      • Palmetto GBA to send a Additional Documentation Request to the provider

        • Request documents be sent to the RA

      • The Recovery Audition will conduct a post payment review

        • Will notify Palmetto GBA of the payment decision


Ordered and referred services

Ordered and Referred Services INSURANCE

Reminders and Updates


Phase 1 ordering referring rejects
Phase 1 INSURANCEOrdering/Referring Rejects

  • Affordable Care Act §6405

    • Required Ordering/Referring providers to be enrolled in Medicare

    • Name and NPI needed on claim

  • Phase 1

    • Began October 5, 2009

    • Incorrect, Missing information – rejected claim

    • Informational messaging on Remittance Advices


New edit phase 2
New Edit INSURANCEPhase 2

  • Planned Effective/Implementation May 1, 2013 - Delayed

  • Claims will be denied when Ordering/Referring provider needed

    • Provider not enrolled in Medicare

    • No NPI on claim

    • Wrong specialty for service/supply

  • Denied as Non-covered


  • Denial reason codes
    Denial Reason Codes INSURANCE

    • N264 = Missing/incomplete/invalid ordering provider name

    • N265 = Missing/incomplete/invalid ordering provider primary identifier


    New edit resources
    New Edit INSURANCEResources

    • SE1305

    • CRs 6421, 6417, 6696, 6856

    • Ensure your in PECOS

      • Look up your NPI

      • http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html


    Order or referral must include
    Order or Referral INSURANCEMust Include

    • Specific services requested

      • CPT/HCPCS code

      • Indicate preventive or diagnostic

      • Use appropriate gender specific codes if applicable


    Order or referral must include1
    Order or Referral INSURANCEMust Include

    • Applicable ICD-9-CM code

      • Screening versus diagnostic codes

      • Sign or symptoms

      • Patient diagnosis

      • Use appropriate gender specific codes if applicable


    Order or referral must include2
    Order or Referral INSURANCEMust Include

    • Ordering/Referring Provider’s Name and NPI number

    • Ordering/Referring Provider’s signature if necessary

    • Plan of Care if applicable


    Reporting ordering referring information
    Reporting Ordering/ INSURANCEReferring Information

    • Don’t use nicknames

    • Don’t enter credentials (Dr.)

    • First name first, Second name second

      • John Smith

    • Use individual not group information


    Resources
    Resources INSURANCE

    • Fact Sheet

      • http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html

    • NPI registry

      • https://www.nppes.cms.hhs.gov/NPPES/Welcome.do


    Resources1
    Resources INSURANCE

    • Enrollment

      • http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html


    Documentation important for billing important for audits

    Documentation INSURANCEImportant for BillingImportant for Audits


    Basic coverage rule
    Basic Coverage Rule INSURANCE

    • Social Security Act in Section 1862 (A) 1

      • No payment for expenses not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member


    855 i section 15 bullet 4
    855 I, Section 15, Bullet 4 INSURANCE

    • Abide by Medicare laws, regulations and program instructions

      • Provider must know

    • Claim payment based upon

      • Claim

      • Underlying transaction

      • Supplier’s compliance with conditions of participation


    Medicare audits
    Medicare Audits INSURANCE

    • They happen

    • Be prepared

      • Create thorough documentation

      • Read request carefully

      • Use Medicare Self Help tools

      • Learn from mistakes


    Medicare audits1
    Medicare Audits INSURANCE

    • Medical Review of Palmetto GBA

    • Comprehensive Error Rate Testing (CERT) program

    • Recovery Audit Contractors (RACs)

    • Zone Program Integrity Contractors (ZPICs)


    Audits
    Audits INSURANCE

    • Pre-payment or post payment

    • Documentation

      • Follow industry, specialty, CMS and Palmetto GBA guidelines


    Additional documentation request adr
    Additional Documentation INSURANCERequest (ADR)

    • Outlines requested information

    • Indicates date of service(s)

    • Outlines timeline for return of documents

    • Provides return address


    Use medicare self help tools and articles
    Use Medicare Self Help INSURANCETools And Articles

    • www.PalmettoGBA.com/J1B

      • CERT section

      • Articles section

      • ADR Checklists


    Learn from mistakes
    Learn From Mistakes INSURANCE

    • Review results

      • Medical review audits

      • CERT and RAC audits

      • Office of Inspector General (OIG)


    Code of federal regulations 42 cfr 424 5 a 6
    Code of Federal Regulations INSURANCE42 CFR 424.5 (a) (6)

    • Sufficient information. The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.


    Medical record documentation
    Medical Record INSURANCEDocumentation

    • Thorough proper documentation

      • Verifies service/level provided

      • Key to audit success

      • Ensures payment for services rendered

      • Protects patients and provider


    Documentation should paint a picture
    Documentation Should INSURANCEPaint a Picture

    CHOOSE A NORMAN ROCKWELL OR ANDREW WYETH PAINTING

    NOT A JACKSON POLLOCK OR VASILY KANDINSKY PICTURE


    Medical record documentation1
    Medical Record INSURANCEDocumentation

    • Evaluate, plan and monitor

    • Communication, coordination and continuity

    • Claims payment and review

    • Utilization and quality evaluations

    • Research and education


    Principles of documentation
    Principles of Documentation INSURANCE

    • Complete and legible

      • Transcribe if necessary

    • Reason for encounter

    • Relevant history

    • Physical examination


    Principles of documentation1
    Principles of Documentation INSURANCE

    • Diagnostic test

      • Rationale for ordering

      • Results

    • Assessment, clinical impression or diagnosis

    • Plan for care

    • Date and legible signature


    Principles of documentation2
    Principles of Documentation INSURANCE

    • Past and present diagnoses

    • Identify health risk factors

    • Patient's progress

    • Response to and changes in treatment

    • Revision of diagnosis

    • Support CPT and ICD-9-CM code selection


    General documentation tips
    General Documentation Tips INSURANCE

    • Patient name on each page and date of service

    • Templates/forms OK, but must be individualized

    • Computerized notes OK, but must be individualized


    General documentation tips1
    General Documentation Tips INSURANCE

    • Document time when coding is based on time (face to face)

    • Must be legible, when in doubt transcribe

    • Each entry must be signed (first, middle, last) with credentials

      • Signature log O.K. to use

      • Electronic signature O.K. to use


    Illegibility
    Illegibility INSURANCE

    • Read by others for treatment/care

    • Proof of services rendered

    • Illegibility leads to denials

    • ‘If it isn’t documented it didn’t happed’

    • Auditors cannot use inference in evaluation of records


    Missing provider signatures
    Missing Provider Signatures INSURANCE

    • Acceptable signature required

      • Each entry

      • First, middle and last name

      • Include credentials

      • Date

    • Use signature log or attestation statement

    • (CR) 6698

      • www.cms.gov/transmittals/downloads/R327PI.pdf


    Insufficient documentation
    Insufficient Documentation INSURANCE

    • Documentation should answer

      • What was wrong?

      • How was it manifested?

      • What did it look like?

      • What was the procedure to fix it?

      • What was the plan of care


    Insufficient documentation1
    Insufficient Documentation INSURANCE

    • Paint picture of need for service

    • Vague statements not detailed enough

      • ‘Status quo’, ‘no change’ or ‘patient stable’

      • Give details


    Insufficient documentation2
    Insufficient Documentation INSURANCE

    • Medical documentation submitted does not include pertinent patient facts (e.g., patient’s overall condition, diagnosis, extent of services performed)

  • Use narrative with chart templates

  • Document need for a complete or comprehensive services


  • Incorrect date of service
    Incorrect Date Of Service INSURANCE

    • Incorrect date of service received

    • Read ADR letter carefully

    • Check before responding

    • Send multiple dates if asked


    Missing patient name
    Missing Patient Name INSURANCE

    • Missing patient name on documentation

    • Check copies before mailing

      • Both sides

      • Beware of photocopies


    New patient versus established patient denials
    New Patient Versus INSURANCEEstablished Patient Denials

    • ‘New patient’

      • Not seen within the previous three years

      • From physician or physician group practice (same physician specialty)

      • Hospital services count


    Combined billing
    Combined Billing INSURANCE

    • Physicians in same group, different specialties

      • Bill and paid regardless of group


    Combined billing1
    Combined Billing INSURANCE

    • Physician in same group, same specialties

      • Bill and paid as single physician

      • Only one E/M per day

      • Unless unrelated problems

      • Select E/M level to incorporate all


    Documenting services
    Documenting Services INSURANCE

    • Comments Field – NTE 02

      • Provide explanation of multiple physician treatment

      • Identify subspecialty if applicable

    • Send documentation when requested or for appeals

      • Show need for1+ visits per day

      • Identify subspecialty if applicable


    E m guidelines
    E & M Guidelines INSURANCE

    • “1995 Documentation Guidelines for Evaluation and Management Services”

    • “1997 Documentation Guidelines for Evaluation and Management Services.”

    • Use either set

    • Use only one per E & M service


    E m guideline resources
    E & M Guideline Resources INSURANCE

    • IOM 100-04, Chapter 12, §30.6

      • http://www.cms.gov/manuals/downloads/clm104C12.pdf

    • CMS “Evaluation and Management Services Guide”

      • http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp


    Http www cms gov mlnproducts downloads eval mgmt serv guide pdf
    http://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    E m services
    E & M Serviceshttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

    • Grouped by categories and subcategories

      • Setting

      • Type of service

      • 3 to 5 levels of service


    Components of e m services
    Components of E/M Serviceshttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

    Chief complaint

    History

    Exam

    Decision making


    Components of e m services1
    Components of E/M Serviceshttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

    Counseling

    Coordination of care

    Nature of presenting problem

    Time


    Evaluation and management scoresheet tool

    Evaluation and Management Scoresheet Toolhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    Basic patient information
    Basic Patient Informationhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    History components
    History Componentshttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    Review of systems
    Review of Systemshttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    Physical examination
    Physical Examinationhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    Medical decision making
    Medical Decision Makinghttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    Amount and complexity of data reviewed
    Amount and Complexity of Data Reviewedhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    Assessment of risk
    Assessment of Riskhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    Counseling and or coordination of care
    Counseling and/orhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfCoordination of Care


    Selection of code
    Selection of Codehttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

    Select ‘Update”

    for CPT code

    selection

    Select ‘Print’

    to print a copy

    of scoresheet


    Common e m documentation coding errors

    Common E/M Documentation/Coding Errorshttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    Common e m documentation errors
    Common E/Mhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfDocumentation Errors

    • Missing documentation

      • Beneficiary’s name

      • Date of Service

      • Rendering physician’s/NPP’s signature

      • Supporting documentation (referred to ROS, PFSH, or orders)

    • Minimum documentation requirements not met (down coded)


    Common e m documentation errors1
    Common E/Mhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfDocumentation Errors

    • Medical necessity/reasonableness was not established

    • Illegible documentation

    • Billed in error (per physician/NPP)

    • Cloned records


    Common e m documentation errors2
    Common E/Mhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfDocumentation Errors

    • The chief complaint/reason for visit was not clearly documented

    • Billed higher level services

    • Extensive PFSH was documented for lower-level services


    Common e m documentation errors3
    Common E/Mhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfDocumentation Errors

    • Complete PFSH was missing

      • New patient or initial services

  • Expansive ROS was documented for lower-level services

  • Missing ROS for the system(s) related to the presenting problem or system(s) related to the presenting problem were “negative”


  • Common e m documentation errors4
    Common E/Mhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfDocumentation Errors

    • Documented diagnoses under ROS

    • Extensive examination was documented for lower level services

    • Unable to determine if diagnosis/problem is stable or worsening


    Common e m documentation errors5
    Common E/Mhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfDocumentation Errors

    • The assessment contained a list of diagnoses/problems that were not addressed during the encounter

    • Documented “labs reviewed” without further information

    • Unable to determine if the physician/NPP independently reviewed image, tracing, or specimen


    Common e m documentation errors6
    Common E/Mhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfDocumentation Errors

    • Didn’t summarize old records/history from others

    • Ancillary staff/scribe documentation requirements were not met

    • Counseling/coordination of care missing time/documentation

    • Incident to requirements were not met


    Medical record amendments

    Medical Record Amendmentshttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf


    Medical record amendments1
    Medical Recordhttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfAmendments

    • General Medicare requirements

      • After medical records are sign & dated

        • Additional information can be added in form of an appropriate Amendment or addendums

        • On rare occasions & not used as common practice


    Accepted as an appropriate addendum to medical records
    Accepted as an Appropriate Addendum to Medical Records http://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

    • Must be added timely within a few days/one week

    • Must contain individualized, patient-specific clinical information for each date of service amended.

      • Blanket statements, declarations or attestations not accepted


    Accepted as an appropriate addendum to medical records1
    Accepted as an Appropriate Addendum to Medical Recordshttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

    • Should be chronological in records

    • Must be legible, signed and dated

    • Should address additional, clinically relevant information

      • Not added to meet regulatory requirements

      • Not added to support downcoded claim


    Making corrections to the medical record
    Making Correctionshttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfto the Medical Record

    • Follow legal requirements

      • Never write over, erase, or obliterate an entry

      • Draw a single line through incorrect information

        • Write correction near deletion

        • All information should still be legible

        • Should be signed and dated


    Making corrections to the medical record1
    Making Correctionshttp://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdfto the Medical Record

    • A correction can also be made by submitting the original record and adding the correction(s) as an addendum, preferably typed

      • A full explanation of why the record was in error

      • Practitioner should sign and date the correction


    Questions

    Questions?http://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

    Please fill out Evaluations


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