Transcript Coding and Billing for Internists` Services

Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
 AMA maintains CPT book of codes that describe physician services
 CMS supplements the CPT book as needed
 RBRVS, managed by CMS, determines payment for each physician
service
 Each service has a relative value for each of three main components—
work, practice expense, and professional liability insurance, with each
being adjusted to reflect geographic input price differences
 Medicare multiplies total, adjusted relative value for each service by a
dollar multiplier, or conversion factor
 Medicaid, other government, and private payers generally use RBRVS as
basis for payments
Medicare Payment Uncertainty

Medicare annual payment updates lag behind medical
inflation

Flawed sustainable growth rate formula regularly calls for
unsustainable cuts in Medicare physician payments
 Congress typically acts to replace an impending cut with
a freeze or small increase around time it is to take effect

Congress almost certainly will act to avoid large cut but is
avoiding a complete long-term fix because it’s costly

ACP participating in this messy process to represent the
interest of its members
Focus on What You Control

General coding and billing guidance
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Do what is medically necessary
Document what you did according to guidelines
Use up-to-date CPT and diagnosis codes
Investigate payment denials
Conduct periodic self audits
Engage in continual coding and billing education
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Understanding coding and billing rules is vital to health of
practice
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Coding and Billing Challenges and Opportunities
Challenge:
“Welcome to Medicare” Exam Benefit
 Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
 Can bill medically necessary E/M on same date as appropriate—use
modifier -25
 ACP has contended pay too low; CMS increased pay for service for 2010 to
$154, up from $92
 CMS working to establish details of an annual wellness visit/preventive
care plan benefit for 2011 as required by March 2010 federal health reform
law
Challenge:
Billing for Consultations
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Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the
requesting physician

Consulting physician can initiate treatment, e.g., diagnostic or
therapeutic tests or procedures, during consultation visit
 On-going care furnished by the consultant after initially
providing opinion or advice is billed using office, subsequent
hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change
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CMS no longer recognizes CPT consult codes for
Medicare payment purposes beginning in 2010
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CMS rationale for change:
• Agency long-expressed concern that physicians did not bill
consults correctly
• Reviews determined that Medicare overpaid as many consults
billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to
office, hospital, NF visits
Dramatic Medicare Consult Policy Change
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Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
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Change was unexpected and has far-reaching implications
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ACP position on Medicare consult payment policy is at
http://www.acponline.org/running_practice/practice_ma
nagement/payment_coding/medicare/changes2010/feesc
hedule.htm#advocacy
Documentation Implications of Consult Change
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Documentation rules for “replacement” codes apply based
on code used, thus:
• No requirement that the requesting and consulting physician
document request in medical record
• Consultant not required to send a written report with opinion /advice
back to requesting physician
• No need for auditors to distinguish a request for a consult from a
referral that constitutes a transfer of care
 Admitting physician bills initial hospital care code with a
“AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
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To redistribute the money that Medicare paid for the
no-longer-recognized CPT consult codes:
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Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services
increased about 1%
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In general, payments for consult services will be
lower as a result of use of CMS-required
replacement codes
Payment Implications of Consult Change
Consult
Code
99241
2009
Payment
$48.69
Replacement
2010
Code
Payment
99201
$38.96
99242
$90.90
99202
$67.45
99423
$124.80
99203
$97.75
99244
$184.32
99204
$151.49
99245
$226.52
99205
$190.45
Payment Implications of Consult Change
Consult Code
2009
Payment
Replacement 2010 Payment
Code
99251
$48.69
99252
$75.75
99253
$114.70
99221
$94.14
99254
$165.56
99222
$127.33
99255
$201.99
99223
$186.84
Payment Implications of Consult Change
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No clear guidance on how to bill low-level hospital
consults as no initial hospital code match for 99251-99252
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Consults furnished to established outpatients, 99211-99215,
experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing
established patient office visit
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Physicians who do a significant number of consults will
see overall revenue decline; those who do few see revenue
rise
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Confusion when a secondary payer is involved
Payment Implications of Consult Change
 Can bill prolonged service code in addition to an office or
hospital visit code (as appropriate and if documented)
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Consult can be billed as critical care service if it meets the
CPT definition of critical care
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Coordination of care could suffer if consultants feel less
compelled to send a written report to requesting physician
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Most private payers initially decided to continue to pay the
CPT consult codes but more are adopting the Medicare
policy
Tips for Billing Private Payers Consults
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Consultants can receive higher payments from private payers still
recognizing CPT consult codes
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Consult can be furnished by a physician in the same group as the
requesting physician—consultant is expected to practice a different
specialty but exceptions are made for same-specialty expertise
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The service resulting from a surgeon’s request to clear a patient as
being fit for surgery can be billed as a consultation for major
procedures
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Check if private payer follows the old Medicare rule that allows
billing a consult for patient-initiated second opinions before major
surgery or test
Challenge:
Medicare Teaching Physician Regulations
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Medicare pays teaching/attending physician for services
furnished involving a resident when:
• Services performed by teaching physician—duplicates resident
service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care
Exemption
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For first two scenarios, teaching physician must
personally see the patient, perform the critical/key
portion of the service, and participate in the management
Teaching Physician Regulations
 Teaching physician must tether/link note to resident’s note
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Billing is based on the combination of the teaching
physician’s and resident’s documentation
 Examples of acceptable documentation:
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I saw and evaluated the patient. Discussed /w resident and agree
w/resident’s findings and plan as documented in the resident’s note.
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See resident’s note for details. I saw and evaluated the pt and agree with the
resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion,
and participated in management
Teaching Physician Regulations
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Examples of unacceptable documentation:
• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
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Other documentation tips:
• There is no royal “we”; use “I” to demonstrate involvement
• Can use template/macro, such as through EHR, but must
sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed
(Resident’s Name) notes. I agree with the history,
physician exam and medical decision making with
the following additions/exceptions/observations :
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Attending’s Signature
Date
Teaching Physician Primary Care Exception
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Teaching physicians can be paid for certain services
furnished solely by a resident when they are provided in
outpatient facilities for which resident time is counted
toward the direct GME payment to the facility
 Teaching physician can only be paid for resident low-level
outpatient E/M visit services, 99201-99203 and 99211-99213
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Resident must have completed at least six months of
training program
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Teaching physician cannot supervise more than four
residents and must be immediately available to assist
Challenge:
Billing for “Incident-to” Services
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Medicare allows physicians to bill for outpatient services
performed by personnel that are “incidental” but integral and
be paid as if the physician performed the service
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Incident to rules enable physician to bill 99211 when service
furnished by office staff
• This minimal service can be performed by any clinical staff member,
e.g., medical assistant, RN, PA
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More complicated incident-to rules pertain to billing of 9921299215
• Service must be performed by CMS designated clinical staff PA, NP,
CNS
Billing for “Incident-to” Services
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Conditions must be met to bill for higher-level PA, NP, CNS
services
• Physician must perform the initial visit and establish the care plan for
patient/condition
• Physician must provide direct supervision, defined as in the office
suite but not necessarily in the same exam room, and be immediately
available to assist
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Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to
rules
• The practitioner furnishing the service must be listed on the
claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge:
Billing Anticoagulation Management Services
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Medicare payment policy makes it challenging to be
adequately paid for managing patients receiving longterm, outpatient anticoagulant drug, i.e., warfarin therapy
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ACP helped establish new CPT codes in 2007 to provide a
more rationale way for physicians to bill and be paid for
anticoagulation management services
• A code to report an initial 90-day period that involves at least 8
INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at
least 3 INRs, CPT 99364
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Codes encompass physician review and interpretation of
each INR, patient instructions, dosage adjustments, and
ordering additional tests
Billing Anticoagulation Management Services
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CMS refuses to pay for these new CPT codes, which would
generally increase amount Medicare pays physician
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The agency retained its policy that the practice can bill a
99211 when office personnel has a face-to-face encounter
with the patient, higher level when physician has direct
contact
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ACP is concerned that some Medicare contractors may
prohibit billing 99211 unless there is a change in drug
regimen, treatment plan
• This compounds the problem by making an inadequate billing
policy more restrictive
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Check with private insurers to see if they pay for CPT 99363
and 99364
Opportunity:
E/M Counseling Exception
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Have option to select an E/M level of service based on time
when counseling and/or coordination of care accounts for
more than 50% of physician face-to-face time with patient
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Compare total physician time for encounter to CPT “typical
time”
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Not subject to 1995 or 1997 E/M documentation guidelines
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List counseling time as fraction of total, e.g. “ccc 15/25” in
addition to describing pertinent issues discussed
Documentation should note amount of time counseling and
what was discussed (must be medically necessary)
Opportunity:
Home Health Care Plan Certification/Re-certification
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Bill HCPC G0180 for certification of the initial home health care
plan
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Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan
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Use if patient has received home health services within past 60 days
Medicare pays $44
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Document thought-process in agreeing with plan and/or in
changing to better meet patient’s needs
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Keep copy of approved care plan in record or be able to access it if
needed
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CMS goal is incentive to physician to carefully review home health
agency care plans to ensure appropriate utilization
Opportunity:
Smoking Cessation Counseling
 Medicare covers for:
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Patients with disease caused or exacerbated by tobacco use; or
Patients taking medications complicated by tobacco use
 Covers 2 attempts to quit per year
 Each attempt can involve up to 4 counseling sessions
 Bill CPT 99406 for 3-10 minutes of counseling
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Pays $13
 Bill CPT 99407 for >10 minutes of counseling
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Pays $25
 Append modifier -25 to office visit (or other service) done on same date
Opportunity:
Screening Pelvic/Breast Exam
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G0101 - cervical or vaginal cancer screening; pelvic and
clinical breast examination
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Medicare covers annually for women at high risk or of
childbearing age with abnormal Pap in last three years, and
every two years for all other female beneficiaries
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Pays $35
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Can bill in addition to other same-visit/date services:
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Obtaining a smear for screening Pap test Q0091—pays $40
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Acute/chronic “medically necessary” service, e.g., 99213
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Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity:
Use CPT Modifiers as Appropriate
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Modifier -25 – significant, separately identifiable E/M service
furnished by the same physician on the same date as procedure
or other service
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Can be used to bill an E/M service on the same date as a minor
procedure, e.g., joint injection
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Can be used to bill an E/M service on the same date as a
number of Medicare-covered preventive services, e.g.,
Medicare-covered screening pelvic/breast exam, HCPCS G0101
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Can be used to bill an E/M service on the same date as another
E/M service in limited circumstances, e.g., critical care service
in addition to initial hospital if patient crashes
Opportunity:
When a Patient is “New” Again
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You can bill a “new patient” service when neither you or
a physician of the same specialty in your group practice
have furnished a face-to-face professional service within
the past three years
• Patient you provided a flex sig two years ago, not a new patient
• Patient for whom you read an x-ray two years ago (without seeing
the patient) is a new patient
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Pay attention when providing office visits, new patient
visits receive higher payment
• 99204 – pays $151
• 99214 – pays $98
Opportunity:
Non-covered Medicare Services That
Can Be Billed to Patients
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Telephone services
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99441 - 5-10 min. medical discussion
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99442 – 11-20 min. medical discussion
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99443 – 21 -30 min. medical discussion
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Must be initiated by established patient call to physician
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Cannot be billed if face-to-face service results within 24 hours or if related to
face-to-face service provided within past 7 days
E-service
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99444 – on-line service to established patient
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Physician’s personal, timely response to patient inquiry that involves
permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed
to Patients
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E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
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Preventive Medicine Services, e.g. 99397 – periodic
comprehensive preventive medicine evaluation, established
patient, 65 years and older
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Medicare considers above services to be “non covered,” meaning
that physician can bill patient his/her usual charge
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Not necessary to have patient sign an ABN form but good idea to
discuss situation with patients in advance of billing them
Opportunity:
Medicare Bonus Payment – PQRI
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Medicare pay-for-reporting program, the Physician
Quality Reporting Initiative (PQRI)
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Report on how care furnished compares to evidence-based
clinical guidelines for a variety of medical conditions, e.g.
diabetes, heart disease
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Earn a 2% bonus for 2010 for reporting on how care
provided aligns with quality measures, selecting from a
variety of reporting methods
 ACP resources available at
http://www.acponline.org/running_practice/practice_m
anagement/payment_coding/pqri.htm
Opportunity:
Medicare Bonus Payment – E-Rx
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Earn a 2% bonus for 2010 for reporting e-prescribing events
using a qualified e-prescribing system
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List code G8553 on claim form to indicate an e-prescribing
event associated with eligible encounters, primarily office
visits
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Receive bonus if correctly report code a minimum of 25 times
in 2010
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Other reporting options, e.g., through an EHR, are available
ACP resources available at
http://www.acponline.org/running_practice/technology/ep
rescribing/medicare_program.htm
ACP Contacts for Questions/Comments

Regulatory and Insurer Affairs Department
•
Brett Baker - [email protected]
•
Debra Lansey - [email protected]
• Tenita Richards - [email protected]

Center for Practice Improvement and Innovation
• Margo Williams - [email protected]