Transcript Coding Documentation and Reimbursement

AAPC Chapter Meeting
Presented by: Deb Kuehn, CPC, CRS
April 16, 2009
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Outpatient Facility Fee Schedule--Created a
new outpatient facility fee schedule based on
120% Medicare. Fee update 99201-99215 Feb 07
Cap on Chiropractor and physical therapy24/claim.
Pharmaceutical Fee Schedule--100% of MediCal.
Physicians Services Fee Schedule Cut--5%
reduction but not below the Medicare fee schedule
rate.
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California law requires the provider to treat
the patient at no cost to the patient
CA fees are set forth in the Official Medical
Fee Schedule (OMFS)
OMFS dictates how much a provider can be
paid for a particular service.
Most OMFS fees are set at Relative Value Unit
(RVU) times the conversion factor.
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Current CA OMFS conversion factors are:
 Evaluation and management - $12.50
 CPT Procedures and Medicine - $12.50
 Surgical Procedures - $153.00
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Example:
 99204 – New patient Evaluation and Management Visit
is 12.9 RVU x $12.50 = $161.25
 26600 – Closed treatment of metacarpal fracture,
single, without manipulation is 1.1 RVU x $153.00 =
$161.30
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Most OMFS services use the codes and
descriptors of the 1997 edition of (CPT)
nomenclature for reporting medical services
and procedures.
The physical medicine subsection of the OMFS
is based on the 1994 CPT. (Neither the 1994 or
1997 CPT are currently supported by the AMA.)
The use of outdated codes makes it difficult for
providers and payers to understand and use
the current OMFS.
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CA OMFS requires all services provided to be
medically necessary
Medical necessity is defined as a service:
◦ Provided as remedial treatment for an on-the-job
illness or injury, and
◦ Appropriate to the patient’s diagnosis and clinical
conditions in relation to any industrial injury; and
◦ Performed in an appropriate setting; and
◦ Consistent with published medical literature and
practice Ground Rules generally accepted by the
practitioner’s peer group.
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The “primary treating physician” is the
physician who is primarily responsible for
managing the care of an employee.
The provider must have examined the
employee at least once for the purpose of
rendering or prescribing treatment.
The provider has monitored the effect of the
treatment thereafter.
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OMFS uses CPT Evaluation and Management Codes
Supply bundling rules same as current CPT coding
with some exceptions
OMFS will reimburse separately for:
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Casting and strapping materials
Taping supplies for sprains
Iontophoresis electrodes
Reusable patient electrodes
DME Items
Application of a cold pack as a modality is not
separately reimbursable but a dispensed cold pack
is. ($9.22)
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OMFS reimburses DME items on the DMEPOS
fee schedule up to 120% of fee schedule
DMEPOS fee schedule items are billed with
the applicable HCPCS codes
Invoice is not required for DMEPOS paid items
DME items include:
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Crutches
Canes
Splints
Braces
Moist Heat Packs
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DME items or supplies not on the DMEPOS fee
schedule are paid By Report (BR)
Use CPT code 99070 for these items
DME items can be billed at acquisition cost
(including tax and freight) plus 50% not to
exceed a maximum amount of $25.00
Non DME items can be billed at acquisition cost
plus 20% up to a maximum amount of $15.00
The carrier has the right to request a purchase
invoice on non-DMEPOS paid supplies.
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Immunizations for codes 90725-90749 and
90710-90711 are reimbursable at the cost of
the vaccine plus $15.00 for administration.
All other vaccine codes cannot be reimbursed
for an administration fee in addition to the
vaccine.
Oral Medications are reimbursed based on
the Medi-Cal website fee by NDC number.
This information is supplied on 4/9/2009 for a date of service of
3/1/2009 .
Price date Number
Unit
Label name
Product
(start)
of units
price
NAPROXEN
9/1/2004
30 1.1533
34.599
SODIUM 550
MG TAB
Total of ingredients:
$34.60
Plus the Medi-Cal dispensing fee of $7.25
$7.25
Equals subtotal:
$41.85
Which is higher than the usual and customary price of:
$22.00
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Pharmacy drugs not paid under Medi-Cal system
are paid using CPT code 99070 at the lesser of:
◦ Providers usual charge or
◦ The fee established by the formulas for brand name
and generic pharmaceuticals
This applies to all pharmaceuticals dispensed by a
provider regardless of site of service.
All prescription medications allow for the $7.25
dispense fee per prescription.
Over the counter medications are not eligible for a
dispense fee even though they may be prescribed
by the provider.
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For Brand Name pharmaceuticals the formula
is the average wholesale price (AWP) times
1.10 plus a $4.00 dispensing fee.
For generic pharmaceuticals the formula is
the average wholesale price (AWP) times 1.40
plus a $7.50 dispensing fee.
When a generic costs more than a brand
name the price will be the brand name
equivalent calculated under the above
formula.
CA Worker’s Compensation requires that the
National Drug Code (NDC) number be on the CMS
claim form for a drug to be paid
DWC requires providers to be current with NDC
numbers and fees within 90 days of updates to the
Medi-Cal fee schedule
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Surgical Procedures are paid by the unit value in
OMFS times the conversion factor
Certain procedures are designated as By Reports
(BR) with no unit values
Unlisted or BR services are paid based on the time
and effort required for the procedure.
Documentation submitted should include:
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Report of the procedure/service performed
Complexity of symptoms and final diagnosis
Pertinent physical findings
Diagnostic and therapeutic procedures
Concurrent problems and follow up care
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OMFS still has the starred * procedure
designation
Starred procedures at the time of an initial
visit if the procedure is the primary service
reported with CPT code 99025
Starred procedures have no global days.
Under OMFS simple and small intermediate
laceration repairs have no global days.
◦ CPT 12002 a 3cm laceration of the scalp has no
global days
◦ All follow up care is coded and billed separately.
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MPN is created by the carrier as a base of providers
by specialty
Many carriers have specific guidelines for providers
they enroll
Providers must meet requirements for:
◦ Proven documentation compliance
◦ Geographic availability
◦ Report writing compliance
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Employer/Insurer Control
Treatment must meet medical guidelines
Employee’s first visit is to employer’s choice.
Employee may change physicians within the MPN.
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Some treatment reports required under OMFS
are not separately reimbursable. They
include:
◦ Doctor’s First Reports of Occupational Illness or
Injury (DFR)
◦ Initial treatment report and plan
◦ Treating Physician’s Report of Disability Status
(DWC Form RU-90)
◦ Report by Secondary Provider to the PTP
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Submit within 5 working days following the initial
examination
Submit this report using Form DLSR 5021
Emergency and urgent care physicians are also
required to submit a Form DSLR 5021 following the
initial visit
Each new primary treating physician is required to
submit a Form DLSR 5021
following initial examination of the employee
Reimbursable Reports include:
Primary Treating Physician’s
Progress Reports (PR2)
Final Treating Physician’s Reports
of Disability Status (DWC RU-90)
Primary Treating Physician’s Final
Discharge report
Primary Treating Physician’s
Permanent and Stationary Report
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The primary treating physician is responsible for
submitting reports to the claims administrator as
required by the California Code of Regulations,
Title 8, §9785.
Sending only one copy of the required report to the
claims administrator satisfies the reporting
requirement.
Reports may be transmitted to the claims
administrator by mail or FAX or by any other means
satisfactory to the claims administrator, including
electronic transmission.
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If a narrative report is used, it must:
◦ be entitled “Primary Treating Physician’s Progress
Report” in boldfaced type;
◦ indicate clearly the reason the report is being
submitted;
◦ contain the same information using the same
subject headings in the same order as Form PR-2;
◦ And as in Form PR-2, contain the following
declaration: “I declare under penalty of perjury that
this report is true and correct to the best of my
knowledge that I have not violated Labor Code
§139.3”
Submit report within 20 days when any one or more of
the following occurs:
 The employee’s condition undergoes a previously
unexpected significant change;
 There is any significant change in the treatment plan
reported, including but not limited to:
an extension of duration or frequency of treatment
new need for hospitalization or surgery
new need for referral to or consultation by another physician
change in methods of treatment or in required physical
medicine services, or
• need for rental or purchase of durable medical equipment or
orthotic devices;
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◦ The employee’s condition permits return to modified
or regular work;
◦ The employee’s condition requires him or her to leave
work, or requires changes in work restrictions or
modifications;
◦ The employee is released from care;
◦ The primary treating physician concludes that the
employee’s permanent disability precludes, or is likely
to preclude the employee from engaging in the
employee’s usual occupation or the occupation in
which the employee was engaged at the time of the
injury;
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Submit report within forty-five days
from the last report if no event
described above has occurred.
If examination has occurred,
submit the report within 20 days of
the examination.
Submit this report using Form PR-2
or in the form of a narrative report.
Reimbursement for the PR2 report
is $11.69
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Submit report when the employee’s condition
is determined to be permanent and stationary
(P & S)
Submit report within 20 days from the date of
examination
Report must include:
◦ any findings concerning the existence and extent of
permanent impairment limitations, and
◦ any need for continuing and/or future medical care
resulting form the injury.
◦ Submit the report using Form PR-4
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Billing for a P & S report is performed with:
◦ Appropriate E/M level for the evaluation
◦ CPT code 99080 for the report pages up to a
maximum of 6
◦ CPT code 99354-99358 for prolonged services.
◦ CPT code 99358 can be used for billing review of
extensive medical records from other sources.
◦ 99358 is billable in 15 minute increments. ($36.34
per 15 minutes)
◦ Requires provider to document what was reviewed
and how the information was used in the treatment
plan.
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A claims administrator may request additional
information necessary to administer the claim
Submit response to this request by using
Form PR-2, or in a narrative report letter
format.
A letter format response must also include
the same declaration under penalty of perjury
as found in Form PR-2
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OMFS follows E/M Guidelines for Consultation
report criteria
Confirmatory Consultation Codes are still
applicable CPT 99271-99275
Consultation codes may not be billed when
care has been transferred by the PTP to
another physician
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Modifier 18 – Used to identify a form which is
not legally mandated or contains additional
information requested by a claims
administrator.
Modifier 19 – Reports a return E/M visit on
same date of service.
Modifier 30 – Consultation service during
Med-Legal evaluation
86 – Used to indicate prior authorization
received for services which exceed OMFS
ground rules
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Modifier 88 – Used to identify claims for a
marriage, family and child counselor or
licensed clinical social worker.
Modifier 93 – Interpreter required at time of
examination
◦ OMFS pays 10% premium above E/M fee schedule
fee for use of interpreter
◦ Documentation must indicate first and last name of
interpreter
◦ No requirement for who the interpreter can be.
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Physical and Occupational Therapy is capped
under OMFS at 24 visits
Regardless of provider type visits can only
total 24
PT evaluations are still 1997 codes with 5
levels for new and 4 for re-evaluation.
CPT codes 98770-98778
PT services billable only once every 30 days
without prior auth.
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No more than 4 physical medicine
procedures/modalities reimbursed in one visit.
Multiple physical medicine and acupuncture
services are reimbursed as follows:
◦ Major (highest valued allowable procedure or
modality); 100% of listed max allowable fee
◦ Second (second highest value allowable procedure or
modality) 75% of listed maximum allowable fee
◦ Third (third highest valued allowable procedure or
modality): 50% of listed maximum allowable fee
◦ Fourth (fourth highest valued allowable procedure or
modality): 25% of listed maximum allowable fee
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Physical Medicine codes include routine
follow up assessment for evaluation and
management purposes.
When separate E/M service is provided on
same day 2.4 units of value are deducted
from the treatment codes ($14.76)
CPT codes 97700-97752 cannot be billed
with an E/M code
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OMFS allows a premium fee for after hours
and holiday unscheduled visits.
After Hours is defined as any unscheduled
visit between 6:00 PM and 7:00 AM Monday –
Friday
This designation in OMFS is regardless of the
normal operating hours of the clinic.
CPT code 99050 ($22.20) is billed in addition
to the E/M service
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Services provided on Sundays and Holidays are
billed with CPT code 99054 ($25.12)
This service is billed in addition to the
Evaluation and Management service.
CPT Code 99058 ($28.63) is used to report
office services provided on an emergency
basis.
This code can be used when a medical
emergency presents during clinic hours and the
provider interrupts care of another patient to
treat the emergency.
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Contact Information
◦ [email protected]
◦ 661-678-2438