CODING FOR SUCCESS 2010: Documentation Responding to Requests for Review ACA and Internal Medicine Other Changes and Cha

1. CODING FOR SUCCESS 2010: Documentation Responding to Requests for Review ACA and Internal Medicine Other Changes and Challenges ACP Northern Chapter San Francisco November 21, 2010

2. We Will Discuss • Documentation • Why necessary • What we expect in charts • Responding to Reviews • Who can request records • Respond to Record Requests • National and Local Coverage Policies • Distinctions and Reconsiderations • Advance Beneficiary Notifications • Appeal process • Looking to the Future: • PQRI, Electronic Rx • Primary Care and Other BonusesAccountable Care Organizations • Other

3. DOCUMENTATION • DOCUMENTATION SHOULD PAINT A COMPLETE PICTURE OF: • HOW PATIENT IS DOING / WHAT IS NEW DURING HIGHER CODE VISIT • NEED FOR UNUSUAL / ATYPICAL DRUGS, LABS OR UNUSUAL DIAGNOSTIC TESTS - EXPLAIN • NEED FOR FREQUENT VISITS OR HIGHER E&M VISITS • ANY SPECIAL PROBLEMS WITH THAT INDIVIDUAL PATIENT– INCLUDING COMORBIDITIES • INCLUDE OBSERVATIONS AND SUPPORTIVE DATA AS NEEDED • DOCUMENTATION NEED NOT BE EXTENSIVE • BUT MUST BE LEGIBLE

4. DOCUMENTATION POINTS • Templates/forms OK, but must be individualized for each visit • Patient name, date, time, and ID of who documented chart • Computerized notes okay if individualized, but medical necessity still rules on review • Note time when service is time related-e.g. explain surgery • If poorly legible, send typed or printed copy with original

5. DOCUMENTATION POINTS • Contractors and CMS expects chart notes to be signed by individual providing service • Stamps not allowed, some electronic signatures are – best is written signature • Attach documentation to paper claims when documents needed • Attachments to electronic claims: fax separately but indicate fax is coming • Some additional info can be put in “information loop” of E claims best is written signature

6. DOCUMENTATION POINTS • Don’t use abbreviations known only to you or your specialty • For new EHR, we would not expect to see the same note---word for word---on each visit • If the service you are doing is atypical, or needs an unusual modifier, it needs explanation • Copying office / consultation notes to a hospital chart may explain need for a service

7. DOCUMENTATION POINTS • Many different people will review your documentation • Consultants and colleagues • Nurses and hospital personnel • Insurance & utilization folk • Potential peer review • Physicians who do not know you or your abbreviations • Potential liability attorneys • Learn to be brief but accurate

8. SOME FINAL THOUGHTS • A small number of docs are responsible for the majority of improper claims • Many billing mistakes are technical---hire trained coding / billing personnel • Understand what you do in terms of coding • Most true fraud done by non-physician entrepreneurs: be careful with whom you are associated

9. MORE FINAL THOUGHTS • Just because you think something is reasonable and necessary does not mean it is • Medicare cannot and will not tell you how to practice… but it does not have to pay for that practice • The red Porche convertible that is speeding on the freeway is more likely to be stopped than the black or gray Toyota---stay below the radar

10. RESPONDING TO MEDICAL REVIEW • WHO CAN ASK FOR RECORDS / DOWNCODE OR DENY PAYMENT • MEDICARE A/B ADMIN. CONTRACTORS (MACs) • MEDICAL INTEGRITY (FRAUD) CONTRACTOR • CERT CONTRACTOR • RAC CONTRACTOR • QIO • BUNDLING AND MEDICAL UNLIKELY EDITS • PRIVATE INSURANCE COMPANIES (FOR MEDICARE ADVANTAGE)

11. MAC CONTRACTORS REVIEW • Must be part of written & documented strategy submitted to CMS • Based on accumulated claim data • Statistically different from peers in other states, areas, jurisdictions • Progressive Corrective Action process • 20-40 CHARTS REQUESTED • % DENIAL CALCULATED • Based on published NCD, LCD or reviewed medical necessity • Review by clinicians • Several levels of appeals available • Contact at Palmetto always available

12. WHO GETS REVIEWED DATA OUTLIERS • UNUSUAL FREQUENCY • UNUSUAL LEVEL OR PLACE OF SERVICE • POOR DOCUMENTATION IN PROBE REVIEW • PATIENT COMPLAINTS • REPEAT FALLOUTS & WARNINGS • POSSIBILITY OF FRAUD

13. PREPARE FOR REVIEWS:DO 1.GET PERSONALLY INVOLVED 2. COPY ALL OFFICE, FACILITY OR OTHER RECORDS REQUESTED: --PROGRESS/THERAPY NOTES (CURRENT AND EARLIER IF HELPFUL TO EXPLAIN) --NURSING NOTES, CLINICAL OBSERVATIONS, AND ANY CONSULT NOTES IF HELPFUL --LAB & DIAGNOSTIC TESTS IF RELATED TO SERVICE --CHANGE IN DX, MEDS, OR IN THE CURRENT CONDITION 3. WHEN IN DOUBT SEND MORE RATHER THAN LESS TO SUPPORT MEDICAL NECESSITY OF SERVICE

14. PREPARE FOR REVIEWS:DO 4. CHECK FOR CORRECT DATES & NAMES---CORRECT PATIENT & DATES ---CORRECT PHYSICIAN 5. SUBMIT TIMELY AND TO CORRECT ADDRESS REQUESTED ON LETTER 6. KEEP RECORD OF INDIVIDUAL ASKING FOR YOUR RECORDS AND WHY THEY ARE ASKING 7. CHECK FOR LEGIBILITY – CAN RETYPE NOTES IF ALSO SEND ORIGINAL 8. CALL IF ANY QUESTIONS – THE LOCAL CONTRACTORS PROBABLY HAVE ANSWERS

15. PREPARE FOR REVIEW: DO NOT 1. HAND OFF TO OTHERS AND LEAVE 2. IGNORE REQUESTS FOR INFORMATION— REVIEWERS WILL NOT GO AWAY 3. CREATE NEW (& STILL WET) PROGRESS NOTES OR DOCUMENTATIONTHAT CLEARLY DID NOT EXIST BEFORE ---CAN SEND CORRECTIONS ---CLARIFICATIONS WITH ORIGINALS 4. DELAY BEYOND DATES STATED 5. CALL MEDICAL DIRECTOR AND SWEAR

16. PREPARE FOR REVIEW: DO NOT 6. DO NOT PANIC • YOU HAVE VARIOUS LEGAL AND APPEAL RIGHTS---TO BE DISCUSSED • MOST AUDITS EDUCATIONAL, NOT PUNITIVE, AND CAN BE RESOLVED

17. IF YOU HAVE PROBLEMS YOU CANNOT RESOLVE • CALL CONTACT PERSON AT PALMETTO & ASK FOR AN IN PERSON OR TELEPHONE MEETING • YOU SHOW YOU CARE ABOUT THE SITUATION • THE CONTACT ALONE MAY TEACH YOU HOW TO SOLVE THE PROBLEM • CALL CMA, LACMA OR YOUR SPECIALTY SOCIETY STAFF FOR HELP • MEDICARE CONTRACTORS CARE ABOUT GOOD RELATIONS WITH ORGANIZED ASSOCIATIONS • REMEMBER, CMA (OR COUNTY MED) STAFF CAN CALL US TO HELP EXPLAIN THE REGS AND SOLVE THE PROBLEMS – WE ARE HERE TO HELP

18. CERT AND MEDICAL INTEGRITY CONTRACTORS • CERT Contractors • Ask for only a single chart or case • Purpose to review the reviewers • If denied money must be returned • Appeals possible if you disagree • MIP Contractors • CalBisc (SafeGuard Systems) in Calif. • Potential fraud or abuse cases • Respond promptly, get all info, may be misunderstanding with patient

19. RAC-RECOVERY AUDIT CONTRACTOR • New Contractor HDI named & has started in California • Reviews old claims (up to 3 years from date of claims-start 10/01/07) • Reviews medical necessity • Reviews proper coding • Paid a percent of what it brings in • Look at medical necessity and incorrect coding for over and underpayment • Can appeal denials several levels: MAC-QIC-ALJ, etc.

20. RAC-RECOVERY AUDIT CONTRACTOR • HealthDataInsights, Inc (Las Vegas) • Part A: 866-590-5598 • Part B: 866-376-2319 • E-mail: racinfo@emailhdi.com • Must have medical director • Look at medical necessity and incorrect coding for over and underpayment • Must have educational outreach to physicians and other providers

21. Summary of Medical Record Limits (for FY 2009) • Inpatient Hospital, IRF, SNF, Hospice 10% of avg monthly Medicare claims (max of 200) per 45 days • Other Part A Billers(Outpatient Hospital, HH) 1% of avg monthly Medicare services (max of 200) per 45 days • Physicians Solo Practitioner:10 medical records per 45 days Partnership of 2-5individuals:20 medical records per 45 days Group of 6-15 individuals:30 medical records per 45 days Large Group (16+ individuals):50 medical records per 45 days • Other Part B Billers (DME, Lab) 1% of average monthly Medicare services per 45 days

26. OTHER REVIEWS OR POSSIBLE DENIALS • Medicare bundling edits: “Correct Coding Initiative” (CCI) • Some procedure codes part of other codes and not split apart • If bill separately you may be paid lesser code • Medicare unbelievable edit (MUE) • Occurs when frequency of services extremely unusual compared to norm • Usually coding error not medical necessity error • MUA: Medication unlikely audit • For medication dosage extremely high

27. DEALING WITH MISTAKES • Physicians & their offices do sometimes make mistakes • If challenged, check your coding and billing processes • Check your CPT, ICD-9, and with colleagues or with expert coders • Acknowledge mistakes; if you correct problems many reviews will stop there • Be decent with reviewers they are doing their jobs • Humbleness never hurt any review situation…

28. not again DEALING WITH MISTAKES • Make sure you coders and billing personnel understand what you actually did • If you have a special type of practice, be able to demonstrate & document it • Medicare cannot by law tell you how to practice but it can refuse to pay or demand money back • Know your rights and the appeals process • You have the right to get out of Medicare / Medicaid

29. NATIONAL AND LOCAL POLICIES: NCDs and LCDs • National Polices: from CMS • Describe what is covered, when, how • Can be reconsidered • No exceptions to national policies • Local Polices: from Palmetto GBA • Presented at CACs, can be reconsidered with open meetings • Give codes, frequencies, instructions • All Policies published and on web • Learn those that apply to your practice –they tell you how to code

30. www.cms.hhs.gov/bni HOW YOU COPE WITH MEDICAL POLICIES • Know what is covered and which diagnoses and CPT codes to use- they’re written in most LCDs • e.g., screening vs diagnostic • J HCPCS codes for drugs • Know the number tests, number specimens, frequencies or time frames that will be paid • Doctor should chart any unusual cases or exceptions if may need to appeal • If you believe Medicare will not pay: • Have patient sign an ABN (Advanced Beneficiary Notice) • ABN is downloadable from CMS

32. NEW ABN- MODIFIERS • Transfer financial liability to beneficiary • Use for potential denials of: • Medical Necessity, Non-coverage, Frequency Limits • All information fields must be completed prior to services rendered to patient • Modifiers • GA – Expect Medicare will deny an item or service as not reasonable and necessary and a signed ABN is on file – a required ABN issued and patient responsible • GX – Voluntary ABN issued for service statutorily excluded –Patient liabile – can use with “GY” auto denied • GY – Item/service is statutorily non-covered or is not a Medicare benefit – No ABN needed. Auto denied—a secondary insurance may cover • GZ – Expect Medicare will deny item or services as not reasonable and necessary and ABN has not been signed by beneficiary

33. USE OF NEW ABN • Copy to patient and put copy in patient file • Not for routine use in all cases • Repetitive Services • Single ABN for extended course of treatment • Patient sign and date every visit • Services not listed require separate ABN • Valid for one year • Beneficiary refuses to sign • Prepare as usual, document beneficiary refusal in chart & form • Both your signature and an office witness signature • Bill modifier GA and file as usual • Laboratory specimen • Forward ABN to lab if test in question • Let patient know

34. APPEALS PROCESS • Initial Determination from Palmetto GBA • Redetermination from Palmetto GBA • Qualified Independent Contractor (QIC) • Administrative Law Judge (ALJ) • Department Appeals Board (DAB) • Federal Court

35. APPEALS PROCESS • Instructions come with any denial • Time frames • Addresses • No penalty for appeals • Fresh person with each appeal • Often higher level review • Recommend appeals with CERT, RAC • Useful to discuss with med organizations and societies to see if other appeals win

36. CONTINUATION OF EXISTING PROGRAMS • PQRI: Continues to give 2% extra payment for reporting quality issues • Electronic Prescribing: Still gives 2% for appropriate electronic prescriptions • Welcome to Medicare initial evaluation and soon Annual Health Evaluation will start

37. ELIGIBLE PROFESSIONALS • MEDICARE PHYSICIANS: • MD, DO, DPM, Optometrists, Oral Surgeons, Dentists, Chiropractors • PRACTITIONERS: • PA. NP, Clinical Nurse Specialist, CRNA, Certified Nurse Midwife, Clinical Social Worker, Clinical Psychologist, Registered Dietician, Nutrition Professional • THERAPISTS: • PT, OT, SLP

38. 2010-2011 PHYSICIAN PQRI • The 2010 PQRI measures list and descriptions are available in "Downloads" section below. • Separate codes required for each measures along with the codes of the services being reported. • NPI must be used to identify the specific physician for any bonus payment • No specific enrollment needed • 119 measures available WWW.CMS.HHS.GOV/PQRI/

39. 2010-2011PROGRAM CONTINUES • Can enroll 12 months or just 6 months • Can report individual items or “measures groups” based on diseases • 8 options for reporting data and reporting periods • 12 months • 6 months • Claims based • Registry based • Check website for details • www.cms.hhs.gov/pqri

40. PQRI: Higher Incentives and Registry Options • 2010 Incentive Continues at 2% • Can Report Through Registries • 32 qualified registries selected • http://www.cms.hhs.gov/PQRI/ • Registries have been tested by CMS • Must use registered registry • Registry will charge for service but may make financial sense for you

41. www.cms.hhs.gov/pqri

42. ELECTRONIC PRESCRIBING FOR 2010 • 2% additional incentive for e-prescribing • Must use qualified e-Prescribing system • Communicate with patient pharmacy • Help MD identify appropriate drugs and give info on lower cost alternatives • Give info on formulary and tiered formulary meds • Generate alerts about adverse events---interactions, allergies, etc. • In future money subtracted if no e-RX done

43. REPORTING OF E-PRESCRIBING • Report for every patient visit (denominator) • Report on 50% eligible patients • Use with Office CPT codes • Must make up 10% of docs total Part B Medicare charges • Coding: • G8443: all Rx generated use E-Rx • G8445: no Rx generated or doc has no access to E-Rx system • G8446: some or all Rx generated were printed or phoned in, as required by state or patient request or pharmacy unable toaccept e-Rx

44. OFFICE CPT / HCPCS CODES FOR E-PRESCRIBING • 90801 – 90809 • 92002, 92004, 92212, 92014 • 96150—96152 • 99201—99205 • 99211—99215 • 99241—99245 • G0101, G0108, G0109

46. Please don’t let them change the rules before I finish these claims LOOKING AT THE FUTURE • “Mankind faces a crossroads. One path leads to despair and utter hopelessness, the other to total extinction.”—Woody Allen

47. President Obama Signing the Patient Protection and Affordable Care Act - March 23, 2010

48. LOOKING AT THE FUTURE • Medicare and the Accountable Care Act • Some increases in $ for HPSA areas and 10% for Primary Care Services (if 60% of care primary service) – Medical Home Demos • Some reductions for overpriced services, (higher cost imaging, multiple services same day, usually bundled services, etc.) • 2011 - Increased Preventive Services and Annual Comprehensive Health Assessment begin to take effect • Substantial money for Comparative Effectiveness Research, and for Electronic Health Records • Increased patients with insurance but ? Reimbursement / patient • 2014 expansion of Medicaid and higher Payments for 2 years • Reduction in Part D “doughnut hole” for eligible patients • Provisions to simplify and standardize private and public health insurance transactions – less paperwork • Most issues not fleshed out yet---Amendments can occur • SGR not addressed and is major unresolved issue THIS YEAR

49. Accountable Care Organizations—”ACO” • An “ACO” is an organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare patients in fee-for-service program who are assigned to it. • For ACO purposes, “assigned” means those beneficiaries for whom the professionals in the ACO provide the bulk of primary care services. Assignment will be invisible to the beneficiary, and will not affect their guaranteed benefits or choice of doctor. A beneficiary may continue to seek services from the physicians and other providers of their choice, whether or not the physician or provider is a part of an ACO.

50. Organizations Forming an ACO? • Physicians and other professionals in group practices • 2) Physicians and other professionals in networks of practices • 3) Partnerships or joint venture arrangements between hospitals & physicians / professionals • 4) Hospitals employing physicians & professionals • 5) Other forms that the Secretary of Health and Human Services may determine appropriate.