Transcript Basic Billing and Coding

Basic Billing and Coding
Susan Moore
Faculty
Indiana
University
Adapted from
The Coker Group
Alpharetta, GA
A Nurse Practitioner Faces Risks at
Each Patient Encounter
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Clinical Risk
 Treatment plan errors
 Patient outcomes
 Perceived bad treatment by patient
Compliance Risk
 False claims
 HIPAA compliance issues
Financial Risk
 Authorizations and certifications
 Private payer regulations
 Patient/payer mix
 Can’t pay, won’t pay, late payments
OIG Reports that for First Half
of 2007
Collected $2.9 billion in investigations
Excluded 1,278 providers
Prosecuted 209 criminal actions
Won 123 civil actions
OIG Semi-annual report www.oig.hhs.gov/publications/docs/semiannual/2007
Resources
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CPT – Identifies the services which
are provided during an encounter
(Annual)
ICD-9 – Identifies why a service
was provided during an encounter
(Medical Necessity) (Semi-annual)
Regulations
All health care professional
regulation is:
 Performed at the state level
 Enacted by state legislature
 Administered by state regulatory
agency
 U.S. Congress is not involved in
health care profession regulation
Regulation
States will specify:
 Education requirements
 Certification/Licensure
 DEA registration
 Prescribing restrictions
 Physician/NP supervisory ratio
 Scope of practice
Medicare Guidelines
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NPs who treat Medicare patients
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Must have National Provider Identifier
(NPI)
Can choose to bill “incident to” or
under own number
When billing under MD PIN = 100%
When billing under own PIN= 85%
When NP Bills Under Physician PIN
(“Incident To”)
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Use carrier guidelines for “incident to”
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Office/clinic when physician on site
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New patient – see MD for care plan establishment
Follow up – see NP for “incident to”
New problem – see MD or bill under NP number
Within ‘shouting’ distance
Physician on site does not have to be who initiated
care plan but does have to be part of the practice
May be independent contractor
May be W-2 leased employee
Practice must cover expense of NP salary
“Incident To” Is Never Appropriate In A
Hospital Setting
BUT
“Shared” visits are!
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Both MD & NP see patient face to face
Both document their findings on the
chart
Combine documentation & bill under MD
PIN
Consults can NOT be shared anywhere
Shared Services
Apply “shared visit” rule (patient seen
by several providers) to services
provided in the place-of-service:
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21
22
23
24
(hospital inpatient)
(hospital outpatient)
(emergency room)
(ambulatory surgical center)
Third Party Payers Guidelines For
Payments Differ Among Carriers
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Do they recognize NPs
Amount of supervision of NP
Who can render that supervision
Where the service needs to be rendered
The scope of services the NP is permitted
to render
They can be different from state
regulations
Generally differ among carriers
Coding Overview
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CPT Codes (with modifiers)
99254 - Inpatient Consult
What you did
ICD9 Codes (to 4th or 5th digit)
786.50 - Chest Pain
Why you did it
Coding = using numbers to tell a story
Coding causing no payment
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Wrong code used
Incorrect use of CPT code
Inappropriate unbundling of CPT
Required modifier omitted
Diagnosis does not support service
2 providers bill for same service
Insufficient documentation
Who is Responsible for Coding?
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Appointment schedulers
Receptionist/patient intake specialist
Clinical staff/ancillary staff
Nurse practitioners/physician assistants
Physicians
Billers/coders
Managers/administrators
CPT – Coding and sites
The CPT code assigned
 Depends on nature of presenting problem
 Work physician performed (History, Exam,
Medical Decision-making)
 Documentation in chart
Physician/NP/PA services provided in
 Office
 Inpatient
 Nursing home
 Outpatient
 Home
Undercoding
E/M codes can impact revenues by this
under coding
 For example,
 Average reimbursement 99212 =
 Average reimbursement 99213 =
 Average reimbursement 99214 =
example of
$36.20
$50.32
$78.91
Coding 1000 visits a year as 99212 when
supported 99213 = $ 14,120
Lost revenue
% of Times Used
Provider Utilization Comparison
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Practice
National
99211 99212 99213 99214 99215
Level of Service
http://www.cms.hhs.gov/statistics/feeforservice/default.asp
Implications
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If your practice is much different
than the national practice norms for
your specialty then your practice is
a red flag.
Therefore, know the national
averages for what is happening with
your type of practice
Evaluation & Management of Coding
Charting tells the reviewer
History
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CC, HPI, ROS, Family, Social
Exam
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System(s) & Detail
Decision Making
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Complexity & Risk
E&M Charting –
How Staff Can Help but NP is KEY
History
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HPI – must be recorded by provider
CC,ROS, F&SH – Can be recorded by staff and/or
patient with new patient form and reviewed by
provider
Exam
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Staff can perform & record three of seven vital signs
Decision Making
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Documentation of lab, x-ray, etc.
Medication list update
Problem list update
Coding
Level of History
+
Level of Examination
+
Complexity of Medical Decision
Making =
Correct Code !
Nature of presenting problem
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How long does it take you to discern
how involved a visit is going to be?
How often do you review the past
medical, family, and social history?
When do you do a complete 8 organ
system examination?
How much time do you spend with
each patient?
CPT Clinical Examples
in the CPT Book
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The clinical examples, when used
with E/M descriptors, provide a
comprehensive and powerful tool
for reporting services provided to
patients
Submitted by specialty associations
to the AMA for the CPT book
Must be used with documentation
guidelines
Clinical Examples - 99212
10 year old female, established patient,
who has been swimming in a lake, now
with 1 day history of L ear pain with
purulent drainage
 Established patient follow up of clearing
patch of localized contact dermatitis
 65 year old, established patient, with
eruptions on both arms from poison oak
exposure
Straight forward, brief, focused
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Clinical Examples - 99213
60 year old, established patient,
with chronic essential hypertension
on multiple drug regimen, for blood
pressure check
 62 year old female, established
patient, for follow-up for stable
cirrhosis of the liver
Expanded, low complexity, 2 to 4
systems evaluated
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Clinical Examples - 99214
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32 year old female, established patient, with new
onset right lower quadrant pain
68 year old established patient, for routine review
and follow up of non-insulin dependent diabetes,
obesity, hypertension and congestive heart
failure. Complains of vision difficulties and admits
dietary noncompliance. Patient is counseled
concerning diet and current medications adjusted.
77 year old male, established patient, with
hypertension, presenting with 3 month history of
episodic substernal chest pain on exertion
Clinical Examples - 99215
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Evaluation of recent syncopal attacks in a
70 year old woman, established patient
30 year old male, established patient with
3 month history of fatigue, weight loss,
intermittent fever, and presenting with
diffuse adenopathy and splenomegaly.
70 year old female, established patient,
with diabetes mellitus and hypertension,
presenting with a two-month history of
increasing confusion, agitation and short
term memory loss
Important is the medical necessity
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“Medical necessity of a service is the overarching
criterion for payment in addition to the individual
requirements of a CPT code. It would not be
medically necessary or appropriate to bill a higher
level of evaluation and management service when
a lower level of service is warranted.
The volume of documentation should not be
the primary influence upon which a specific
level of service is billed. Documentation
should support the level of service reported
Try Your Knowledge
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33 year old female, established patient,
follow up for recently started treatment
for hemorrhoid complaints, resolving
50 year old, established patient with
diabetes, diet controlled. Now complains
of frequency of urination and weight loss,
blood sugar 320 and negative ketones on
dipstick
65 year old, established patient, with
stable diabetes and stable coronary artery
disease, for monitoring
Decision Making from Coker Group
2007
Medical Decision Making (2 of 3): Documented DM _________
Decision Making
# diagnosis/mgmt options
Amt of data to be reviewed
Risk (refer to table of risk)
SF
Minimal
(1)
Minimal
/None
(1)
Minimal
(1)
Dx and Management Options:
Problem
Number X
Categories
Self-limited, minor
Est.problem;
stable, improved
Est. problem;
worsening
New prob; no
add’l workup
New prob.; add’l
workup planned
Low
Limited
(2)
Limited
(2)
M
Multiple
(3)
Multiple
(3)
Low
(2)
Moderate
High (4)
(3)
Amt and/or Complexity of Data:
Points =
(Max = 2)
Score
1
1
2
(Max = 1)
High
Extensive
(4+)
Extensive
(4+)
Points
1
1
1
1
2
1
3
2
________
4
Total =
Counseling and Coordination of Care:
Diagnosis(es):
Yes
No
Type of Data
Review and/or order of clinical lab tests
Review and/or order tests in 7xxxx of CPT
Review and/or order of tests in 9xxxx of CPT
Discuss test results with performing MD
Independent review of image, tracing or
specimen
Decision to obtain old records and/or obtain
Hx from others
Review and summarize old records, and/or
obtain Hx
Total
Times Documented Yes
N0
Risk Table
History from Coker Group, 2007
Examination summary from Coker
Group, 2007
New or Established Patient
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“New Patient” is a patient who has not
received any professional services from
the physician within the previous 3 years.
Physicians in Group Practice
 In same specialty – bill and be paid as
though they were a single physician
 In different specialties – bill and be paid
without regard to membership in the
same group
Consultations
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Performed at the Request of a physician
or other appropriate source (must be
documented)*
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Report of findings provided to requesting
physician
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Recommendations for treatment are
made
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*guidelines further clarified in CMS Transmittal 788, January 2006
Documenting Counseling Visits
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Total face-to-face time
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choose level of service by total face time
Show counseling took > 50% of time
List medically appropriate topic(s)
“I spent 35 minutes total time with this
patient, over half involved in discussing
importance of compliance with diet
instructions.”
Medically Appropriate Counseling
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Diagnostic results
Prognosis
Risk & benefits of management option
Instructions for mgmt &/or follow-up
Importance of compliance
Risk factor reduction
Patient & family education
New ICD-9 Codes
October 1, 2007
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144 revised or new codes
Published May 3, 2007 Federal
Register
No grace period!
Failure to use may result in rejected
claims after October 1, 2007
Have You Seen Services Denied
Because:
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“The information in your case does not
support the need for this treatment”
“Medicare does not pay for this service for
this illness or condition”
“Medicare does not pay for this many
services in this time period”
“Services for same illness by more than
one doctor are denied”
Then you have been denied payment
because of lack of medical necessity.
Diagnosis Coding Must…
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Support and be “mapped” to the
service rendered
Be carried to the 4th or 5th digit if
applicable
Be reported to the highest degree of
specificity
For Medicare payment, must be
supported by Local Medical Review
Policy
CMS Guidelines and Medical Necessity
“The rationale for ordering diagnostic and
other ancillary services should be easily
inferred if not documented.”
“The CPT and ICD-9-CM codes reported on
the health insurance claim form or billing
statement should be reflected by the
documentation in the medical
record.”
Most Over-Reported ICD-9-CM
Diagnoses
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285.9 Anemia, unspecified
401.9 Unspecified hypertension
429.2 Arteriosclerotic cardiovascular
disease
786.50 Chest pain
724.9 Unspecified disorder of the back
784.0 Headache
786.05 Shortness of breath
789.00 Abdominal pain
Example:
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Patient comes into office
complaining of a burning pain in his
stomach. He describes as
moderately severe and improves
when he takes antacid. Nurse
Practitioner suspects an ulcer and
refers the patient to a
gastroenterologist for endoscopy.
Today’s diagnosis is:
Code to highest degree of specificity
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Abdominal pain
 789.00 unspecified site
 789.01 RUQ
 789.02 LUQ
 789.03 RLQ
 789.04 LLQ
 789.05 periumbilic
 789.06 epigastric
 789.07 generalized
 789.09 other unspecified
Concurrent Care
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May be denied “services not
separately payable”
Documentation must reflect that
each provider managed separate
problem
For example:
484.3 pneumonia
033.3 pertussis
Compliance Issues with Diagnosis
Coding
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Coding a “rule out” or “suspected” condition
as a confirmed diagnosis
Using a slightly higher level of diagnostic
code in order to support the care given
Coding diagnoses that are no longer
applicable
Not supplying diagnosis or reason for
service when ordering ancillary tests
Not obtaining a signed waiver from
Medicare patient before rendering a service
that may not be covered for the diagnosis
given
Summary
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Follow “incident to” and “shared visit” guidelines
when billing for Nurse Practitioner services
Select the E/M code based on the level of service
performed and medical necessity
Document the work according to CMS
Documentation Guidelines
Use consultation and new patient codes
appropriately
Add modifiers to indicate something “out of the
ordinary” took place
Code only documented diagnoses