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Top Ten Coding Errors for Pediatric Gastroenterologists

Top Ten Coding Errors for Pediatric Gastroenterologists. Kathleen A Mueller, RN, CPC, CCS-P, CMSCS ASKMUELLER Consulting, LLC Lenzburg, Il 62255. #10 Lack of Use of Modifier 63. Modifier 63 to be used on all infants less than 4 kg.

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Top Ten Coding Errors for Pediatric Gastroenterologists

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  1. Top Ten Coding Errors for Pediatric Gastroenterologists Kathleen A Mueller, RN, CPC, CCS-P, CMSCS ASKMUELLER Consulting, LLC Lenzburg, Il 62255

  2. #10 Lack of Use of Modifier 63 • Modifier 63 to be used on all infants less than 4 kg. • Appropriate for procedures only. Not for use on diagnostic studies or visits • Adds 25% increased reimbursement for most commercial payors

  3. #9 When There Is No CPT Code • Procedure does not quite fit definition of existing CPT code • Use modifier 22 or 52, or • Use an unlisted procedure code • Claim must be accompanied by procedure report and a detailed description of what was done beyond the existing definitions, including time, and crosswalk your proposed compensation to other codes

  4. #8 Place of Service Errors • Billing place of service inpatient when should have been observation and vice-versa • This is a submission error. Billers should be checking for the visit history in the hospital prior to submitting all charges.

  5. #7 Diagnosis Code Inaccuracies C.E.R.T. (Certified Error Rate Testing) indicates that diagnosis codes submitted on the claim must match what is documented in the medical record or this is considered an error in billing. Train all providers to be specific with diagnosis codes. Includes all types of visits specifically inpatient visits. When the patient’s symptoms/conditions change, so should the diagnosis codes to reflect the change in billing.

  6. #7 Diagnosis Code Inaccuracies • Update all charge tickets for proper diagnosis codes. Educate providers on specificity and use of signs and symptoms • Medical necessity and payment is based on complexity of decision making • Now is the time to prepare all providers for ICD-10-CM which requires greater specificity in the assignment of diagnosis codes

  7. #6 Medical Necessity The level of service billed is not supported by the documentation in the medical record. This is determined by: History Examination Decision Making or Time if more than 50% of the visit is dedicated to counseling and coordination of care

  8. #6 Medical Necessity • It is essential to train all providers on the evaluation and management billing and coding • http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf • Do self audits within the practice or hire a consultant(s) to perform audits and educate all providers. • Utilize benchmarking by comparing national data to practice data

  9. # 6 Medical Necessity • Use appropriate diagnosis codes to support the level of service billed. Moderate complexity decision making should be reflected by the diagnosis codes utilized.

  10. #5 Lack of Time documentation Common Scenario Patient and family comes in for test results. Visit should be totally based on time spent in counseling and coordination of care. However, note looks like this: Extensive time spent with patient and family discussing…………………………. This will only support 99212 since there is no history or exam to back up anything.

  11. #5 Lack of Time documentation Instead, the note should look like this: The entire 45 minute visit was spent with Tyler and his mother going over test results. All questions were answered and we will proceed with………. 99215 would be the proper code based on time.

  12. #5 Lack of Time documentation How much time has been spent reviewing records before or after the visit? Was this in the medical record? If so, can bill: 99358 Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); first hour (List separately in addition to code(s) for other physician service(s) and/or inpatient or outpatient Evaluation and Management service)

  13. #5 Lack of Time documentation 99359 Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); each additional 30 minutes (List separately in addition to code for prolonged physician service)

  14. #4 E/M Service and Procedures on Same Day The E/M visit isbillable only if decision to perform procedure occurs during visit and documentation is above and beyond the need for the procedure. E/M service not billable prior to ascheduled open-access procedure. 25 modifier required on E/M service prior to minor procedure of 0-10 day global period 57 modifier required on E/M service prior to major procedure of 90 day global period

  15. #4 E/M Service and Procedures on Same Day • Check the Federal Register when new Medicare fee schedule is released. Will be released November 25, 2009. This contains the global period assigned to each procedure code. Update your billing software accordingly. • Just because the patient is new to the provider doesn’t mean that a visit can be billed.

  16. #3 Surgical Modifiers for Physician Billing: 51 versus 59 51 Do not use unless instructed by payer. Has no effect on reimbursement. Not required by Medicare since 12-1-2002. Still required by some Medicaid carriers. 59 Used for procedures that are bundled into other procedure under the Correct Coding Initiative (CCI) edits.

  17. Surgical Modifiers for Physician Billing: 58 versus 78 versus 79 • 58 Staged or Related procedure • Restarts global period • Not used to report complications • Visits not billable prior to procedure Example: Redo suction biopsy • 78 Return to OR • Complication of original procedure • Does not restart global period • Payable at intraoperative percentage only

  18. Surgical Modifiers for Physician Billing: 58 versus 78 versus 79 • 79 Unrelated procedure • Visit payable before procedure with 24 modifier • Restarts global period Example: Colonoscopy or EGD within global of suction biopsy.

  19. #2 Shared Services Common Scenario Practice hires an NP or PA (NPP) Consultations and New Patient visits are scheduled with the physician NPP sees patient and documents History, Examination, and Treatment Plan Physician sees patient briefly and/or discusses patient with NPP Physician adds to documentation and/or co-signs note Service is billed under physician’s provider number

  20. “Incident to” Included in the original CMS regulations Modified over time Applies to services provided by one person and billed under another

  21. “Incident to” “To qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.”

  22. Shared Service Consultations in any location and New Patient Visits in the office can not be billed “incident to” even if physician sees patient after the NPP. Service must be billed under NPP’s provider number A “Shared Service” is permitted for hospital visits other than Consultations.

  23. Office/Clinic Setting “When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient.” If “incident to” requirements are not met for the shared/split E/M service, the service must be billed under the NPP’s NPI.

  24. Hospital Inpatient/Outpatient/Emergency Department Setting When a hospital inpatient / outpatientor emergency department E/M is shared between a physician and an NPP from the same group practice And the physician provides any face-to-face portion of the E/M encounter with the patient The service may be billed under either the physician's or the NPP's provider number

  25. Hospital Inpatient/Outpatient/Emergency Department Setting However: If there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by reviewing the patient’s medical record) then the service may only be billed under the NPP's provider number.

  26. Split/Shared E/M Service CMS Manual System Department of Health & Human Services (DHHS) Pub. 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS) Transmittal 178 Date: MAY 14, 2004 www.cms.hhs.gov/transmittals/downloads/R178CP.pdf

  27. #1 Consultations vs. New Patient Visits New Patient (99201-99205) A patient that is self referred Or referred for a procedure to evaluate a problem And has not received any face-to-face service by anyone in the practice of the same specialty for any reason for at least three years

  28. Consultations (99241-99255) Requires a documented request from another physician/NPP Request is for an evaluation and opinion regarding a problem Requires a separate letter back to requesting physician/NPP summarizing findings and recommendations

  29. Consultations - Continued Request should come in writing but must be documented in consultant’s chart Copy of chart notes does not meet requirement for separate letter Can initiate treatment or order diagnostic tests and still bill initial encounter as a Consultation If initial intent of referring physician is to transfer care or for a procedure, service is a New Patient/Established Patient Visit.

  30. When Not to bill a Consultation • When you have been asked to do a procedure (insert PEG, change PEG, manage patient condition, do endoscopic procedure since this is a transfer of care) • When you are admitting the patient since this is a transfer of care • When you don’t see a request from another provider seeking your opinion of a problem • When the patient/guardian is seeking a second opinion • When you are asked to see the patient again during the same hospitalization even if for a different problem

  31. Consultation Update • Effective 1-1-2010, consultations will no longer be paid by Medicare. Claims will be denied. • Updates in the Medicare websites will be done in the next few weeks. • Commercials and Medicaid have yet to make any statements. • New patient visits, initial hospital care, initial SNF visit and established patient visits to be billed in place of consultations

  32. RAC (Recovery Audit Contractors)TOP 10 #10.Debridement Coding #9. Duplicate Billing-Filing claims more than once for the same service #8. Stark Violations-Physicians referring patient to services in which they have a financial interest or in which a family member has a financial interest

  33. RAC (Recovery Audit Contractors)TOP 10 #7. Pharmaceutical Coding in Physician Offices- Incorrect use of codes or units in billing of injections #6. Social Work Services in Facilities- Some clinical social worker services provided to inpatients in hospitals or skilled nursing facilities cannot be billed under part B

  34. RAC (Recovery Audit Contractors)TOP 10 #5. Psychiatric Services- Over utilization of psychiatric services provided in outpatient setting. #4. Medical Necessity- Documentation not supporting the level of service provided in the outpatient setting #3. E/M Billed During Global Periods #2. Place of Service Errors

  35. RAC (Recovery Audit Contractors)TOP 10 #1. Incident-to Errors- Physician assistants and nurse practitioners performing services for a physician but not following billing-specific guidelines related to the physician’s relationship to the patient and the physician’s presence in the office

  36. Contact Information Kathleen Mueller, RN, CPC, CCS-P, CMSCS, PCS ASKMUELLER CONSULTING, LLC askmueller@aol.com

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