Transcript Notes4 - Georgia Chiropractic Association

INSURANCE,
DOCUMENTATION
CASH PLANS,
&REVISITING ICD-10
OCTOBER 22, 2016
Patient Case Types
• Cash
• Group/Private Health Insurance
• HMO/PPO
• Automobile Accident Cases/Personal Injury
• Worker’s Compensation
• Medicare
Managed Healthcare
• HMO’s AND PPO’s
Primary purpose is the containment of health
care costs
HMO
• Health Maintenance Organization (HMO) is a type
of managed care organization (MCO) that provides a
form of health insurance coverage that is fulfilled
through hospitals, doctors, and other providers with
which the HMO has a contract. No out of network
benefits are available with a HMO policy
PPO
• A Preferred Provider Organization plan encourages
the insured to choose doctors, hospitals, and other
providers that participate in the plan. They do this
by increasing the portion of the bill they pay if the
insured stays in the network. If the insured chooses
to go out of network, they’ll have to pay a higher
out of pocket cost of the provider’s bill. Both in and
out of network benefits are offered for a particular
service.
Understanding Benefits and
Collecting Correct Amounts
• Deductibles
• Initial out of pocket expense payable by the patient
• Family deductible/Individual deductible
• Co-pays
• A specific dollar amount
• Co-insurance
• A specific percentage of services rendered or the contracted rate
• Co-pays and Co-insurance
• Sometimes it’s both and sometimes it’s a co-pay and a deductible
Co-insurance, Co-payments and Deductibles
• According to Medicare, routine waiver of deductibles, co-pay and co-insurance
is inappropriate because it results in false claims, violation of the anti-kickback
statute, and excessive utilization of the services and items that get paid.
• Insurance companies are communicating with patients and asking what they are
paying to their doctor’s office
Patient Education
• Educate your patients about Insurance Benefits
• Address medically necessary vs. wellness care
• May not be able to use all visits allowed by the
insurance policy
Completion of the
HCFA 1500
TOP HALF
For the most part is self explanatory
Check your spelling!
Mailing address
Insured’s ID number
Careful not to transpose numbers!
Insured’s policy group or FECA number
Insurance plan or program name
Accident related
BOTTOM HALF
• Needs to be a direct reflection of what is stated in your
patient files
• ICD-10 Codes
• What your patient is being treated for
• CPT Codes
• Type of treatment being rendered
Box 14
• Date of Current Illness, Injury, or Pregnancy (LMP)
• ID Qualifier Choices
• 431 Onset of Current Symptoms or Illness
• 484 Last Menstrual Period
• Medicare does not require an ID qualifier
Box 15 – Other Date
• ID Qualifiers
• 454 Initial Treatment - Cond | First consulted date
304 Latest Visit - Dates / Specialty / CMS tab | Last seen by
supv. physician
453 Acute Manifestation of Chronic Condition - Dates /
Specialty / CMS tab | complicated condition onset
439 Accident - Cond | Illness/injury occurred (*you do not have
to choose an accident type. See box 10) )
455 Last x-ray - Dates / Specialty / CMS tab | Last x-ray date
444 First Visit or Consultation - Cond | First consulted date
• Medicare says to leave this one blank
Box 17, Name of Referring Provider or Other Source
• Enter the name (First Name, Middle Initial, Last Name) followed by the
credentials of the professional who referred, ordered, or supervised the
service(s) on the claim
• Applicable qualifier to identify which provider is being reported
• DN Referring Provider
• DK Ordering Provider
• DQ Supervising Provider
Box 21 - Diagnostic Coding
• ICDA (International Classification of Diseases, Adapted) are
the codes used to report what condition the patient is being
treated.
• Document all diagnosis codes that pertain to the patient’s
condition.
ICD Linkage to CPT
• ICD codes form a crucial partnership with CPT procedural codes. The
ICD codes indicate the reason why the CPT procedure or service was
performed. ICD codes can also indicate what level CPT was performed
and why.
• Diagnosis to procedure edits are among the most common type of edits
applied to claims.
• The selection of the primary diagnosis for a patient encounter is usually
“the reason the physician saw the patient that day” and is not necessarily
the patient’s most serious condition
Basic Coding Principles
• It is important that you are coding based upon
what you have documented in your patient’s
records
• Code by subluxation first as mandated (ie.
Medicare)
• Symptoms and ill-defined conditions can be
used but only in the absence of a definitive
primary diagnosis
Basis Coding Principles cont…
• Injuries: When coding an injury, reference the condition, not just
the anatomical site.
• Choose specific diagnoses: Avoid codes for diagnoses that include
the words not otherwise specified or not elsewhere classified
(unless it is your only choice until more conclusive test results are
received)
• Select codes to their highest level of specificity
• Non-relevant conditions: Do not code conditions which are not
related to the current reason for the patient encounter
Coding Co-Morbidities
• Providers tend not to include Co-morbidities in the diagnoses.
However, if it can have a direct relation to the patient’s
progress and/or if it can “explain” the choice of care for the
patient, then it should be documented in the patient’s chart
and can be included as a diagnosis (depending on the carrier
policy).
• Ie. Obesity, Diabetes, and Hypertension are just a few
examples of co-morbidities/complicating factors that can
have an affect on treatment
Updating/Changing your DX
• New Conditions/New Injury
• Change in condition
• Improvement
• Exacerbation
It all goes back to documentation
This isn’t based on how many visits the patient has had or
the fact that it has been a couple of months since the last
time it was changed.
Don’t forget to change your illness date!
Box 22, Resubmission and/or Original Reference Number
• List the original reference number for resubmitted claims. Refer to the most
current instructions from the payer regarding the use of this field.
• When resubmitting a claim, enter the appropriate bill frequency code left
justified in the left-hand side of the field.
• 7 Replacement of prior claims
• 8 Void/Cancel of prior claim
Coding for
Treatment Rendered - Box 24
• CPT’s
• Current Procedural Terminology
• MODIFIERS
CPT’s
• CMT’s
• Chiropractic Manipulative Therapy
• Modalities
• Procedures
• E&M’s
• Evaluation & Management
CMT’s
98940 1-2 areas
98941 3-4 areas
98942 5 areas
98943 Extremities
The work value of CMT codes includes preservice,
intraservice, and post-service work, such as palpation
and routine range of motion testing. This is why E/M
codes and CMT codes get bundled together.
S Codes
• S8948
• Application of a modality (requiring constant provider
attendance) to one or more areas; low-level laser; each 15
minutes.
• S9090
• Decompression Therapy
• S8990
• Physical or manipulative therapy performed for maintenance
rather than restoration.
Modalities
• Any physical agent applied to produce therapeutic
changes to biologic tissues
• Two categories:
• Unattended/Passive Care
• Attended/Active Care
Georgia Rule 100-15-.01 does not allow a CA to place a patient
on therapy without the doctor being present/somewhere in
the building
Unattended/Passive
• 97010 thru 97028
• No time involved
• Supervised, constant attendance not needed. Does not
require direct one on one patient contact.
Attended/Active
• 97032 through 97039
• Time involved
-
Needs to be documented
-
Reduced time would constitute the use of modifier 52
• Can be reported in units
• Direct one on one contact by provider
Procedures
97110 through 97546
A manner of effecting change through the application of
clinical skills and/or services that attempt to improve
function.
-Time is involved (Modifier 52 if time is reduced)
-Must be documented
-Can be reported in units
-Direct one-on-one contact by provider
Procedures Defined
• 97110 Therapeutic Exercises, each 15 minutes, one or more areas
• Incorporates one parameter (strength, endurance, range of motion, flexibility) to one
or more areas of the body. Examples include, treadmill (endurance), isokinetic
exercise (range of motion), lumbar stabilization exercise (flexibility), and gymnastic
ball (stretching and strengthening).
• Documentation should include goals which focus on improvement of functional
deficiencies.
• Diagnoses: Loss or restriction of joint motion, strength, flexibility, functional
capacity, or mobility from a specific disease or injury
Procedures Defined
• 97150 Therapeutic Procedures, Group (2 or more individuals)
• If any therapeutic procedures are performed with two or more individuals, then only
97150 is reported. Do not code the specific type of therapy in addition to the group
therapy codes.
• Report 97150 for each member of the group
• Patients may or may not be doing the same activity
• Not a time based code! Reported per session, regardless of time involved
• If a patient performs group therapy, as well as individual, then both may be billed,
but the individual therapy must include modifier -59 (or one of the X modifiers)
Procedures Defined
• 97530 Therapeutic Activities (Dynamic Activities to Improve Functional
Performance)
• Include the use of multiple parameters, such as balance, strength, range of motion.
Examples include lifting stations, closed kinetic chain activity, hand assembly activity,
transfers (chair to bed, lying to sitting, etc) and throwing, catching, or swinging
• The service requires the skill of a provider or therapist who designs the activities to
address a specific functional need and who instructs the patient
• 97110 addresses a single parameter (ie. Loss of range of motion). 97530 differs in that it
addresses multiple parameters involved in the performance of an activity (ie. Patient is
unable to lift a box, it may involve strength, range of motion, as well as balance)
• Diagnoses: Loss of restriction of mobility, strength, balance, or coordination
Procedures Defined
• 97112 Neuromuscular Re-education, each 15 min, one or more areas
• Neuromuscular re-education of movement, balance, coordination, kinesthetic sense,
posture, and proprioception. Examples include proprioceptive neuromuscular
facilitation, feldenkreis, bobath, bap’s boards, and desensitization techniques
• Goals should include an increase in functional ability in self care, mobility, or patient
safety
• Diagnoses: Loss of deep tendon reflexes and vibration sense accompanied by
paresthesia, burning, or diffuse pain to the extremities. Nerve palsy, or injury that
leads to muscle weakness or flaccidity. Inability to sit or stand unassisted, loss of
gross and fine motor coordination, and hypo/hypertonicity.
Procedures Defined
• 97124 Massage, each 15 minutes, one or more areas
• Effleurage, petrissage, tapotement (stroking, compression, percussion)
• Use of a machine, such as a massage chair or mechanical device may not be
considered a cover service
• Some payers may not cover massage as an isolated treatment or when performed for
more than 30 minutes (2 units)
Procedures Defined
• 97140 Manual Therapy Techniques, each 15 min, one or more regions
• Manual therapy techniques consist of, but are not limited to; soft tissue mobilization,
joint mobilization and manipulation, manual lymphatic drainage, manual traction,
craniosacral therapy, myofascial release, and neural gliding techniques
• This code should not be used interchangeably with codes 98940 – 98942 for joint
manipulation
• Modifier required when billing the same visit as a 98940 - 98942
CPT’s Policy for Unlisted Codes
• Do not select a CPT code that merely approximates the
service provided. If no such procedure or service exists,
then report the service using the appropriate unlisted
procedure or service code
• In addition, don’t bill out under a specific CPT code just
because a particular vendor tells you (i.e., infrared for
low level laser)
E & M’s
• New Patient- 99201 through 99205
• Established Patient- 99211 through 99215
• The difference between a new patient and an established
patient is three years.
New Patient
• Must meet or exceed three out of three key components to
qualify for a particular level of service.
• History
• Examination
• Medical Decision Making
History
• 4 subcomponents:
•
•
•
•
Chief complaint (CC)
History of present illness (HPI)
Review of Systems (ROS)
Personal, Family and Social History (PFSH)
• Problem Focused (99201)
• Expanded Problem Focused (99202)
• Detailed (99203)
• Comprehensive (99204)
• Comprehensive (99205)
Examination
• Uses either the 1995 or 1997 Guidelines
• 1997 Guidelines are better suited for a specialist because they
outline more specific elements for particular body systems.
• Problem Focused (99201)
• Expanded Problem Focused (99202)
• Detailed (99203)
• Comprehensive (99204)
• Comprehensive (99205)
Medical Decision Making
• Essentially recognizes the clinical expertise required to appropriately manage patient
care. That management of a case is assessed by answering the following questions:
How many problems does the patient have (DX)? How much information needs to be
reviewed to properly understand the case? How risky is the patient’s problem? (Risk
of significant complications, morbidity and/or mortality)
• Straight Forward (99201)
• Straight Forward (99202)
• Low Complexity (99203)
• Moderate Complexity (99204)
• High Complexity (99205)
Established Patient
• Must meet or exceed two of the three key components to qualify
for a particular level of service.
• History
• Examination
• Medical Decision Making
History
• Minimal (99211)
• Problem Focused (99212)
• Expanded Problem Focused (99213)
• Detailed (99214)
• Comprehensive (99215)
Examination
• Minimal (99211)
• Problem Focused (99212)
• Expanded Problem Focused (99213)
• Detailed (99214)
• Comprehensive (99215)
Medical Decision Making
• Minimal (99211)
• Straight Forward (99212)
• Low Complexity (99213)
• Moderate Complexity (99214)
• High Complexity (99215)
E & M’s and Time
• If counseling and coordinating care dominates greater than
50 percent of the encounter, time may be a controlling factor
to determine the level of service billed. Time must be
documented. The progress note should show how much
time was spent for the visit and how much time was spent
counseling/coordinating care.
E & M Face to Face
Time Guidelines
• 99201
10 min
• 99211
5 min
• 99202
20 min
• 99212
10 min
• 99203
30 min
• 99213
15 min
• 99204
45 min
• 99214
25 min
• 99205
60 min
• 99215
40 min
Modifiers
-21 Prolonged E&M Time must be documented
-25 Significant Separate Identifiable E&M service
-52 Reduced Service (Time based codes)
-59 Distinct Procedural Service
DX to support
Must be documented
-76 Repeat Procedure by same physician
-51 Multiple Procedures/Extraspinal with CMT
-59 Modifier
The -59 modifier is used to indicate that a procedure is distinct and
separate from another procedure
Medicare has introduced a modifier subset to be used when the -59
modifier would otherwise be used
At this time, this subset is not to be used when billing other third
party payers
This change took place January 5, 2015
Check your Local Coverage Determination
The New Codes Are:
XE – separate encounter, a service that is distinct because it occurred
during a separate encounter
XS – separate structure, a service that is distinct because it was performed
on a separate organ/structure
XP – separate practitioner, a service that is distinct because it was
performed by a different practitioner
XU – unusual non-overlapping service, the use of a service that is distinct
because it does not overlap usual components of the main service
Medicare Modifiers
AT – indicates active/corrective treatment to treat an acute or chronic
subluxation
GY – Items or service statutorily excluded or does not meet the definition of
any Medicare benefit
GZ - Item or service expected to be denied and no ABN has been signed
GA - Item or service expected to be denied and an ABN has been signed
GX – Voluntary ABN was signed with regards to non-covered services
Will be reported along with a GY modifier
Documentation
Requirements
Documentation Criteria
The medical record should be complete and
legible. Every page in the record should contain
the patient’s name or ID number
The documentation of each patient encounter
should include the date, reason for encounter,
appropriate history and physical exam, x-ray
data if appropriate, assessment, plan of care, and
legible identity of the care-giver (doctor)
Past and present diagnoses should be accessible
to the treating physician
Reason for and results of x-rays, testing, etc
Documentation Criteria Continued
Relevant health and risk factors should be identified
(Medication, allergies, or adverse reactions)
The patient’s progress, including response to
treatment, change in treatment, change in dx, and
patient noncompliance should be documented
Written plan of care should include the treatment
plan, referrals and consultations, patient/family
education, and specific instructions for follow up
Documentation Criteria Continued
• The CPT/ICDA codes reported on the health
insurance claim form or billing statements should
reflect the documentation in the medical record for
each date of service
SOAP Notes
SOAP format is nationally recognized and commonly accepted
method of recording patient visits
S Subjective, Patient’s Complaints
O Objective, Visible or observable findings
A Assessment, Integration of subjective and objective
treatment plans
P Plan, Treatment plan for that particular patient
If your notes are dictated and transcribed, the printed document
must be dated and the name of the dictating doctor must be
noted. Additionally, the doctor needs to initial each note (date).
CASH PLANS
Compliant Cash Plans & Financial Arrangements
• All patients should be aware of your normal fees
• Do not provide discounts without advising
patients of the normal fees
• Prevents confusion when a cash patient returns as
an insurance patient
Cash Patient
• Time of Service Fee or Administrative Fee
• OIG allows up to 15%
• Pre-pay Plans
• Can violate your in-network agreement
• ChiroHealth USA
• Hardship
Financial Policies
• Gets patients to understand your office insurance
billing and collections procedures
• Patients should understand that collecting money
from insurance companies is not that easy
• It helps to educate the patient about acute care vs
chronic care vs maintenance/wellness care
Financial Policies continued
• Gets patients to understand that they are
responsible for a portion of the bill
• Enhances CA communication with patients
• Prevents patient-doctor upsets
• Give a signed copy to the patient
Revisiting ICD-10
THE HONEYMOON IS OVER!
ICD-10 at a glance
More codes
Longer codes –up to 7 alpha/numeric
Injury codes are grouped by anatomical site (rather than the category of injury).
More divisions (21 chapters).
Higher specificity; distinguishes between: Right and left
Initial encounter, subsequent encounter, sequela
↑coding specificity for statistical analysis & research.
ICD-10 Layout and definitions
Includes and Excludes
-Includes: gives definitions and examples
ICD-10 Layout and Definitions
-Excludes 1: “not coded here” (when two conditions
cannot occur together).
ICD-10 Layout and Definitions
-Excludes 2: condition not included here
(need additional code if documentations supports it).
-Code also: two codes may be required to fully
describe a condition.
Non-essential “modifiers”
[ ] Brackets enclose alternative wording or explanatory phrases.
( ) extra words present/absent that do not affect the code
number.
Non-essential “modifiers”
• AND : Either “and” or “or”
Example: A18.0 Tuberculosis of bones and joints.
• With: “associated with” or “due to”
ICD-10 Layout and Definitions
X = place holder
When the 7th character is needed, but there is no 6th character,
an X is used as a placeholder.
M48.8X1 Other specified spondylopathies, occipito-atlanto-axial region
Signs and Symptoms (Chapter 18)
Codes that describe signs and symptoms are
acceptable for reporting IF a definitive diagnosis has
not been established (confirmed).
• Only use signs and symptoms if no
definitive Diagnosis is established
Signs and Symptoms (S & S)
Don’t use S & S if:
they are routinely associated with a disease.
Do use S&S if:
not routinely with a disease process.
Example: Person comes in with Brachial Neuritis. To include a
diagnosis of shoulder pain would be redundant.
Uncertain Diagnosis
Code to the highest degree of certainty for that encounter/visit.
Do NOT use a diagnosis without certainty/documentation.
Do not code:
“probable”
“suspected”
“questionable”
“rule out”
“working diagnosis”
Acute and Chronic
If both are present:
Acute conditions get listed before chronic
Code all documented conditions that coexist
1) Code all documented conditions that require or affect patient
care treatment or management.
2) Do not code conditions that were previously treated and no
longer exist.
3) History codes (categories Z80-Z87) may be used if it impacts
current care or influences treatment.
Examples:
Z89.61 Acquired absence of leg above knee
Z82.62 Family history of osteoporosis
Z82.69 Family history of other diseases of the
musculoskeletal system and connective tissue
M codes (Chapter 13)
• “M” prefix –diseases of
musculoskeletal or connective.
• Diseases related to:
• Bone
• Joint
• Muscle
Proper Code Selection
• Find the GEM
• Read your exclusions
• Code specific to documentation
• The more specific – the more you increase the
necessity for service
Laterality
• Some ICD-10-CM codes indicate laterality, specifying whether the
condition occurs on the left, right or is bilateral. If no bilateral code is
provided and the condition is bilateral, assign separate characters (2
separate diagnosis) for both the left and right side.
• … 0 unspecified
• … 1 right
• … 2 left
• If the side is not identified in the medical record, assign the code for the
unspecified side.
Example: 724.4 Cervical Radiculitis
• Find the GEM
• Read your exclusions
• Code specific to documentation
• Note that for this one, it is specific to a level
and not a side
Documentation must support
• USE the most specific code that is SUPPORTED
by your documentation.
• More changes to the diagnosis
• LEGALLY responsible for EVERYTHING on the
bill-on paper or electronically.
Injury “S” Codes (Chapter 19)
Strains and Sprains
• S00-S09 Injuries to the head
• S10-S19 Injuries to the neck
• S20-S29 Injuries to the thorax
• S30-S39 Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals
• S40-S49 Injuries to the shoulder and upper arm
• S50-S59 Injuries to the elbow and forearm
• S60-S69 Injuries to the wrist, hand and fingers
• S70-S79 Injuries to the hip and thigh
• S80-S89 Injuries to the knee and lower leg
• S90-S99 Injuries to the ankle and foot
• For most of these blocks, the third character is the one that designates the type of injury. The "3" is for
sprains, while the "6" or "9" is for strains
Strains and Sprains
• It will help to remember the following information
when searching for Strains vs. Sprains:
• A strain is an injury found under
muscle/tendon/fascia
• A sprain is an injury found under
dislocation/ligament/joint
ICD 10 for Lumbar Strain
• Search for strain of the lumbar spine. Remember a STRAIN is a muscle, fascia and tendon
• S- Injury, poisoning and certain other consequences of external causes
• S3- Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals
• S39- Other and unspecified injuries of the abdomen, lower back, pelvis and external
genitals
• S39.0- Injury of muscle, fascia and tendon of the abdomen, lower back and pelvis
• S39.01- Strain of muscle, fascia and tendon of the abdomen, lower back and pelvis
• S39.012_ Strain of muscle, fascia and tendon of lower back
• S39.012A Strain of muscle, fascia and tendon of lower back, initial encounter
ICD 10 for Cervical Sprain
• Take a look at a sprain of the neck. It should be clearly documented as a sprain of the
ligaments of the cervical spine in order to assign the correct code. Remember a SPRAIN is
found under dislocation/ligament/joint
• S- Injury, poisoning and certain other consequences of external causes
• S1- Injuries to the neck
• S13- Dislocation and sprain of joints and ligaments at neck level
• S13.4- Sprain of ligaments of cervical spine
• S13.4xxA Sprain of ligaments of cervical spine, initial encounter
• This code does not have a fifth or sixth character, so we are instructed to drop in a couple
of "x" placeholders. Also, do not confuse the “A” -Initial Encounter for the Initial Visit. The
initial encounter should be used during the entire time the patient is receiving active
treatment for the condition.
7th Character – A, D, S
• Medicare States:
•A
• Active Care
•D
• Subsequent – Routine Care
•S
• Sequela – Late Effect
• This is not a universal rule yet! You may find other payers who will want to see “A” used for the
first visit and “D” used for subsequent (not routine) – it’s always best to ask the payer!
7th character - A, D, S
• While the patient may be seen by a new or different provider
over the course of treatment for an injury, assignment of the
7th character is based on whether the patient is undergoing
active treatment and not whether the provider is seeing the
patient for the first time.
HCFA Notes for ICD 10
• Decimal Point should not be showing up in your diagnosis
on your claim
• Punctuation should never show up on a claim form
• Your DX box should show a {0} indicating you are reporting
with ICD 10
Additional Notes…
• If you find that your ICD 10 claims are being rejected
check the following
• Did you use a valid ICD 10 code?
• Did you add characters that should not have been
added?
• Did you use a non specific code?
• If all looks good on your end, call the Payer
• They may have changed their policies and what
may have once been considered a covered code,
may no longer be so
Questions?