CODING FOR SUCCESS 2010: Basics of the Business Coding Conventions Consultations Signatures and Such Re-enrollment for R

1. CODING FOR SUCCESS 2010: Basics of the Business Coding Conventions Consultations Signatures and Such Re-enrollment for Referrals ACP Northern Chapter San Francisco November 21, 2010

2. We Will Discuss • Coding Challenges • Consultations for Specialists • E & M Situations • Modifiers for IM • Coding by Teaching Physicians • Current Medicare Problems • Signatures and Legibility • Enrollment / Revalidation • Documentation Dilemmas • Responding to Reviews • Respond to Record Requests • Appeal Process • Looking to the Future: • Primary Care and Other BonusesICD-10 is Coming • Other

3. President Johnson signing the Medicare Bill-1965

4. CONSULTATION CODES • Maintained in 2010 CPT for some non-Medicare insurance • ? effect private insurance & Medicaid • Distinguish consult from • Transfer of care • Co-management • Patient request 2nd opinion

5. CONSULTATION • As of 1/1/2010: Consultations no longer reimbursed by Medicare…here is how to code for services formerly called consult: • Use Initial E&M admission visits codes for initial inpatient hospital & SNF services • Can have as many initial inpatient services as needed if different specialty • Regular follow up codes for hosp / SNF-NF • Regular office initial & follow up codes • All E&M services follow E&M guidelines • Principal MD of record uses a modifier: AI

6. CONSULTATION • Financial Offset to Consultation Codes • Work value RVUs for new or established office visits increased by 6% • Work value RVUs for hospital and facility visits increased by 2% • Increased bundled global payments for 10 and 90 day surgical or interventional procedures to recognize increased office or hospital visit payments

7. EMERGENCY ROOM VISITS • ED Physician bills ED codes • Attending MD admits patient from ER, use hospital admit codes • Attending doc adds modifier AI • Docs called to see patient in ED bill regular ED codes • If seen by 2nd physician (or by a specialist) code office visit if not admitted—because patient is an outpatient

8. HOSPITAL OBSERVATION • Initial observation codes only for doctor who “admitted” to obs svs (modifier: AI) • Must have full timed and dated obs notes • One payment for all services that day • All others seeing patient bill office or other outpatient (initial or subsequent) • Only physician who “admitted” patient to hospital observation may bill initial obs care. • Observation after surgical procedure • Part of surgical global service in most cases • Exception if Modifiers 24, 25, 57 apply and all observation data applies • Decision for surgery—bill office/ other outpatient services if in ED or initial hosp if admitted

9. INITIAL HOSP ADMISSION SVCS • Initial hosp admission code if seen in ED then admitted---all services done same day one code • All docs use initial hosp admission codes but attending of record uses modifier AI • Physician performing level 5 visit in office several days prior to admission, unless complex admission needed & completely documented, bill full office visit then lowest level hosp visit

10. IF MEDICARE SECONDARY • Can bill Primary Insurance with Consultation Codes but if sending to Medicare • Use regular visit codes • Show amount of money paid from Primary Insurer • Can bill Primary Insurance with regular visit codes and bill Medicare with same codes

11. HIGHEST LEVEL E&M CODES • To bill highest level visit codes, services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet CPT’s definition of a comprehensive history). • Comp. exam may be a complete single system exam (e.g. cardiac, respiratory, psychiatric) or a complete multi-system exam BUT MUST BE COMPLETE

12. Note: Both CERT and RAC are now focusing on E & M services HIGHEST LEVEL E&M CODES • Comp. history must include a review of all the systems and a complete past (medical and surgical) family & social history obtained at that visit. • For established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family, and social history from the last encounter, but must review the entire history for it to be considered a comprehensive history.

13. HISTORY EXAM DECISION MAKING COUNSELING COORDINATION OF CARE NATURE OF PRESENTING PROB. TIME COMPONENTS OF (E&M) SERVICES: Back to Basics

14. History of Present Review of Past, Family, and/or Type of History Illness (HPI) Systems (ROS) Social History (PFSH) Brief N/A N/AProblemFocused BriefProblem N/A Exp. Problem Pertinent Focused Extended Extended Pertinent Detailed Extended Complete CompleteComprehen. To qualify for a given level of history all three levels must be met.

15. PROBLEMFOCUSED EXPANDED PROBLEM FOCUSED DETAILED COMPREHENSIVE Limited exam of affected body area /organ sys. Limited exam affected body area & symptomaticrelated body areas Extended exam of affected body area and any other symptomatic or related body area. General multi-system … ..Or complete single system and symptomatic or related body areas EXAM DOCUMENTATION

16. 1. MULTISYSTEM 2. CARDIOVASCULAR 3. E.N.T. 4. OPHTHALMOLOGY 5. G.U. (Female) 6. G.U. (Male) 7. HEME / LYMPHATIC 8. MUSCULOSKETAL 9. NEUROLOGICAL 10 PSYCHIATRIC 11 RESPIRATORY 12 SKIN Any internist can bill multisystem exams or specialty exams 12 TYPES OF EXAMS ANY PHYSICIAN CAN BILL A MULTI-SYSTEM EXAM ANY PHYSICIAN CAN BILL A SINGLE SYSTEM EXAM

17. BASICS OF DECISION MAKING • The number of possible diagnoses and/or management options considered • The amount and/or complexity of records, diagnostic tests, and information that must be obtained, reviewed, and analyzed • The risk of significant complications, morbidity / mortality, and comorbidities, associated with the patient's presenting problem, the diagnostic procedures, and/or the possible management options

18. DECISION MAKING CHART

19. OFFICE VISITS: NEW 99201 99202 99203 99204 99205 OFFICE VISITS: SUBUBSEQUENT 99211 99212 99213 99214 99215 HOSPITAL VISITS: INITIAL 99221 99222 99223 HOSPITAL VISITS: SUBSEQUENT 99231 to 99233 HOSPITAL DISCHARGE 99238 99230 BASIC VISITS

20. Critical care is the direct delivery by a physician(s) of medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition 99291 – 1ST 30-74 MIN. 99292 – ADD. 30 MIN The following services are included in critical care Interpretation of cardiac output measurements Chest x-rays Pulse oximetry Blood gases Information data stored in computers (eg, ECGs, blood pressures, hematologic data) Gastric intubation Temporary transcutaneous pacing Ventilator management Vascular access procedures CRITICAL CARE CODES

21. INITIAL CARE 99304 99305 99306 SUBSEQUENT CARE 99307 99308 99309 99310 --99315 NURSING FACILITY D/C 30 MIN --99316 NURSING FACILITY D/C >30 MIN --99318 OTHER (ANNUAL) N. F. ASSESS. NURSING HOME VISITS(Also Interm. & Long Term)

22. OTHER E&M MEDICAL VISITS • HOSPITAL EMERGENCY ROOM • HOSPITAL OBSERVATION • HOSPITAL DISCHARGE • HOME VISITS (NEW & ESTAB.) • DOMICILLARY-REST HOME- CUSTODIAL CARE (NEW & ESTAB.) • PROLONGED PHYSICIAN SVCS • CARE PLAN OVERSIGHT • ETC.

23. TEACHING PHYSICIAN REQUIREMENTS • INSTITUTIONS GET SOME ADDITIONAL PAYMENT FOR RESIDENTS AND FELLOWS • TEACHING PHYSICIANS MUST BE PRESENT FOR PRINCIPAL PORTION OF ALL PROCEDURES • TEACHING PHYSICIANS MUST EITHER BE PRESENT FOR OR PERSONALLY PERFORM & DOCUMENT SIGNIFICANT PORTIONS OF E&M VISITS IN ORDER TO BILL FOR THEM • SIGNATURES ALONE ON A CHART ARE NOT ENOUGH

24. FINAL THOUGHTS ON CODING: Be Appropriate • E&M code must be appropriate to service • Time can be used if longer visits needed • Indicate time on progress notes when time used • Face to face, Psych, therapy, ICU, etc. • Using modifiers improves reimbursement • Listed in Palmetto website (-25, -24, 22, 59, etc) • Learn the few that involve your practice • Don’t overcode, but don’t undercode either • You are entitled to be paid for your service • You are not entitled fo be paid for your ego • Learn the codes you actually use • Make sure your billers know what you did We have E&M scoring tools on our web site

25. www.PalmettoGBA.com/J1B

38. SIGNATURES • Handwritten signatures or initials • Must be legible in all notes and orders • Electronic signatures:  • Digitized- an electronic image of an individual’s handwritten signature reproduced in its identical form using a pen tablet • Electronic signatures usually contain date & timestamps and include printed statements, e.g., 'electronically signed by,' or 'verified/ reviewed by,' followed by physician’s name & preferably a professional designation.  Note: The responsibility and authorship related to the signature should be defined in the record • Digital signature - an electronic method of a written signature typically generated by encrypted software that allows for sole usage

39. Signature required on all orders, chart notes, labs, etc. SIGNATURES: WHAT WE ARE FINDING • Illegible, unrecognizable handwritten signatures or initials • Unsigned “typewritten” progress notes with a typed name only • Unverified or unauthorized electronic signatures • No indication of the rendering physician/practitioner • Sometimes, no name of doctor, patient or office

40. SIGNATURES • CMS Rules for signatures unchanged but had not been enforced earlier • Many times with teams of physicians, author of note is uncertain • Various review organizations now are looking for legible signatures • If no signature, claim rejected • If illegible signature, claim rejected

41. IF SIGNATURE IS AN ILLEGIBLE SCRAWL… • Have an official signature page with name and signature OR • Send an attestation statement certifying that physician saw patient and wrote note on that date

42. ORDERING-/-REFERRING RULES FOR MEDICARE • MD Clin. Nurse Specialist • DO Clin. Psychologist • Dental Surgery Nurse Midwife • Dental Medicine Clin. Social Worker • Podiartist Nurse Practitioner • Optometrist Chiropractor • Physician Assistant These providers can order / refer

43. ORDERING PHYSICIAN • Claims ordered / referred must have: • NPI of ordering provider • Number in PECOS system • Specialty as listed • Grace Period • Initial: 10/5/09 to 12/31/10 warning message on remittance • ACA Reform: 6/04/10 and after: claim rejected if referring individual not in PECOS or MAC list • CMS is not enforcing as yet---will enforce sometime before 1/1/11

44. OTHER ENROLLMENT • Revalidation of all physicians not already in PECOS (Provider Enrollment Chain Online System) • Revalidation of some labs & IDTFs • Need to update any changes within 30 days – in PECOS or paper change • Address, phone, suite • New members in group • Other changes • If no claims to Medicare in one year—physician is automatically disenrolled

45. SOME 2010 CHANGES • Cardiac Rehabilitation • Cardiac Rehab (93797 – 93798) • Intensive Cardiac Rehab (G0422 – G0423) • Pulmonary Rehabilitation • For moderate to severe COPD (G0424) • Kidney Disease Patient Education • Up to 6 sessions (G0420 – G0421) • For level 4 CKD (GFR 15-25 ml/min) • Increased Reimbursement-Primary Care • Increased this year • More increases with ACA

46. CHANGES IN MEDICARE REIMBURSEMENT • Increases in reimbursement for cognitive services • Decrease for imaging services • More emphasis on primary care • Decreases in surgical / procedural services • Sustainable Growth Rate still in limbo • Need Congressional change • Unlikely until after elections

47. FINANCIAL WINNERS AND LOSERS CHANGES FOR 2010

48. POTENTIALLY MISVALUED SERVICES • Site of service anomalies • Services with high volume growth • High intra-service work per unit time • New technologies – need pricing • Shifts from practice expense to work • Harvard valued codes (not studied) • Services often billed together • Multiple procedure payment reduction • Reduced tech component of CT-MR-PET • High cost supplies Potential changes in future

49. UP & COMING-ICD-10 • ICD-10 will start Oct 1, 2013 • In what ways is it different: • More granular—more coding specificity • 3 to 7 alpha and numeric digits • Thousands more codes than ICD-9 • Some codes expanded, bilateral, etc • More inclusions and exclusions • More post-op complications

50. UP & COMING-ICD-10 • Injuries list by anatomical area, not by type of injury; • Category restructuring and code reorganization will result in classification of certain diseases and disorders different from ICD-9-CM; • Certain diseases reclassified to different chapters or sections • New code definitions (e.g., definition of acute myocardial infarction is now 4 weeks rather than 8 weeks)