Coding and Compliance

1. New and Reappointments Program for Anesthesia Faculty School of Medicine Compliance Office 843-8638 Coding and Compliance

2. Course Objectives • Why coding and compliance is important to you and your practice • Documenting anesthesiology services • Teaching physician (TP) rules. In order to bill Medicare and Medicaid for services when working with residents and fellows, teaching anesthesiologists must abide by pertinent federal and state laws and regulations

3. Why coding and complianceis important to you and your practice

4. Reimbursement • Doing only what is medically necessary • Documenting what you do • Billing what you document Providing good care while billing accurately and confidently requires: Understanding and applying coding and compliance conventions can improve the level of reimbursement for UNC P&A practices as well as the quality of the medical record documentation.

5. Why Compliance • Residents are paid through the hospital by Part A Medicare. Medicare pays a portion of the residents’ salaries based on the proportionate share of Medicare at the teaching hospital. • Teaching physicians are paid by Part B Medicare on a fee-for-service basis. • The government, through Medicare, will pay for both resident and TP services if both participate. If the TP does not participate in a given patient service, the TP cannot bill.

6. Why Compliance • Medicare and Medicaid require teaching physician presence for key parts of anesthesia services and personal documentation of that presence in order to bill for the service • Medicare requires similar personal presence and documentation for billing of evaluation and management services (consultations) and other procedures • Medicaid consultations and other evaluation and management (E&M) services require that the TP be "immediately available" to the resident and use "direct supervision" for procedures. The teaching physician must co-sign the resident note and assume responsibility for the patient’s care.

7. Documenting Anesthesiology Services This short course will focus on the services below which account for over half of the dollar volume of all anesthesia billings • General anesthesia services • Consultations • Daily inpatient follow-up • Regional Anesthesia Procedure Note • Subsequent Daily Management of Catheters

8. General Anesthesia Services

9. General Anesthesia-medical direction Medicare and Medicaid physician requirements for coverage of medical direction of nurse anesthetists • Perform a pre-anesthetic examination and evaluation • Prescribe the anesthesia plan • Participate personally in the most demanding procedures in the plan including induction and emergence • Ensure that the anesthetist performs the anesthesia plan • Monitor the course of the administration at intervals • Remain in the operating suite for the entirety and available to return if needed • Provide indicated post-anesthesia care

10. Medical direction - documentation Medicare and Medicaid require the billing physician to document the following: • Performance of pre-anesthesia exam and evaluation • Provision of indicated post-anesthesia care • Presence during some portion of the anesthesia monitoring • Presence during the most demanding procedures including induction and emergence

11. Medicare/Medicaid require a concurrency modifier -AA    -   Physician personally performed. -QY    -   Medical direction of one CRNA by an anesthesiologist. -QK   -    Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. -AD    -   Medically supervised by a physician for more than four concurrent procedures. -QX    -   CRNA with medical direction by a physician. -QZ    -   CRNA without medical direction by a physician. -QS    -   Monitored anesthesiology care services (can be billed by a CRNA or a physician).

12. Medical direction or supervision • Medical direction of one CRNA • payment at 50% of each provider’s allowable • Medical direction of two, three or four concurrent procedures Physician services are not payable by Medicare or Medicaid if the billing physician: • leaves the immediate area of the operating suite for more than a short duration • devotes extensive time to an emergency case or • is otherwise not available to respond to the immediate needs of the patient • Supervision of more than four concurrent procedures • Anesthesiologists are reimbursed at a lower rate • CRNA will get paid at the above rate

13. Teaching physicians and residents Medicare and Medicaid payment may be made for attending physician services when a resident is involved in the patients care if the teaching physician: • personally examines the patient • is present at induction and emergence • performs other activities that distinguish an attending physician relationship The teaching physician must personally document h/her involvement in the record.

14. How anesthesia services are paid • Basic value + • Time units + • Physical status modifier + • Any qualifying circumstances + • Any additional modifiers for unusual procedures or services

15. How anesthesia services are paid • A basic value is listed for anesthetic management of most surgical procedures • Base unit includes • pre and post anesthesia care • administration of fluids and/or blood products incident to anesthesia care • interpretation of non-invasive monitoring • Base unit does not include • placement of arterial, central venous and pulmonary artery catheters • use of transesophageal echocardiography (TEE)

16. How anesthesia services are paid • Time units • Begins when the anesthesiologist begins to prepare the patient • Ends when the patient may be safely placed in post-anesthesia supervision • Generally reported in units of 15 minutes, Medicare requires actual minutes

17. How anesthesia services are paid • Physical status modifiers All anesthesia services are reported using one of the following modifiers Unit values P1- A normal healthy patient P2 - A patient with mild systemic disease P3 - A patient with severe systemic disease P4- A patient with severe systemic disease that is a constant threat to life P5 - A moribund patient who is not expected to survive without the operation P6 - A declared brain-dead patient whose organs are being removed for donor purposes • 0 • 0 • 1 • 2 • 3 • 0

18. How anesthesia services are paid • Qualifying circumstances Bill as many as apply for extraordinary conditions, unusual risk factors or notable conditions in addition to the procedure code Unit values +99100 - Anesthesia for patient of extreme age, under one year and over 70 +99116 - Anesthesia complicated by utilization of total body hypothermia +99135 - Anesthesia complicated by utilization of controlled hypotension +99140 - Anesthesia complicated by emergency conditions (specify) • 1 • 5 • 5 • 2 • 1 • 5 • 5 • 2 (an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part.)

19. How anesthesia services are paid • Additional modifiers for unusual procedures or services 22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedures, it may be identified by adding modifier “22” to the usual procedure code. Documentation is required to be sent with claim. 23 Unusual Anesthesia: Occasionally a procedure which usually requires either no anesthesia or local anesthesia, because of unusual circumstances, must be done under general anesthesia. 25 Significant, separately identifiable evaluation and management service performed by the same physician on the same day as a procedure. Added to the E&M service for both to be paid.

20. The Anesthesia Record The following two slides are instructions on completing the front and back side of the Anesthesia Record which is also used to extract billing information. It is the bread and butter of the practice, so it is important to know how to properly complete it and direct others to complete it to assure appropriate reimbursement.

21. Patient name and MR# • Anesthesiology attending name • Resident/CRNA name • Date of service • OR room or location • Anesthesia start time • OR arrival time • OR leave time • Anesthesia stop time (signed over to PACU) • Agent and/or drugs given incl amount and prox time) • BP and heart rate monitoring • Reading for ECG, temp, pulse, O2 • Antibiotic, dose 1 Patient name and medical record number 13 Write in any anesthesia-specific diagnoses (for MAC, PA catheters, CVPs and A-lines) here. 3 2 10 4 6 5 7 8 For Medicare, teaching physician attestation of presence must be completed 9 11 Document any procedures (PA Catheter, epidural, TEE, A-line, CVP) with a procedure note on the front of the record. Include medical necessity. 12 Record beginning and ending time for CPB If placing an epidural or a catheter (brachial, sciatic, femoral nerve) or performing a nerve block, the note must state that it is for post-op pain (may abbreviate “POP”)

22. CPT code from ASA Relative Value Guide 2. Procedures (check box) • 3. When a procedure is performed by a different provider than will sign the bottom of the form, fill out “Placed” and “Managed” fields signed with complete name of resident or CRNA • 4. Intubation type and post-conceptual age sections for ABA reporting The back side of the Anesthesia Record blue striped copy - for reimbursement 1. 5. Check mark for each section: a. type anesthesia, b. ABA category surgery, c. location, surgery service 6. Fill in surgical procedure, surgeon, resident/CRNA and attending signature 4. 2. 3. 3. 5b. 5a. 5c. 6a. 6b. 6c. 6d.

23. Teaching physician documentation • Print and sign name on the original (orange striped) Anesthesia Record form near the top right hand side after: “Anesthesia attending __________” • Write a statement attesting to presence (if applicable) during induction, line placement, emergence and availability throughout and sign • Services are not billed to Medicare or Medicaid until the teaching physician personally provides a statement of involvement

24. Consultations and daily inpatient care Evaluation and Management (E&M) Services

25. Evaluation and Management Categories Inpatient E&M categories for anesthesiologists: • Inpatient consultations (5 levels) 99251- 99255 • Subsequent hospital care (3 levels) 99231-99233 There are dozens of different Evaluation and Management (E&M) categories; only those shown below are addressed in this course:

26. Consultations • A consultation is an E&M service provided by a physician whose opinion and advice is requested by another physician or appropriate source involved in that patient’s care • Consultations should be viewed as a three-part cycle (1) a request is made (2) an evaluation is undertaken and (3) an opinion is rendered and sent to the requesting physician. • The consultant may initiate diagnostic and/or therapeutic services at the same visit.

27. E&M Components • History • Physical examination • Medical decision making E&M services have three basic components identified below.

28. E&M Components (continued) • History • Physical examination • Medical decision making Consultations (inpatient and outpatient) must include all three of the components shown below. Subsequent hospital care must include any two of the three:

29. E&M Levels - Subcomponents In and out-patient consults all have 5 levels of service; subsequent hospital care has 3 levels. The level is determined by evaluating the three basic components of E&M services with attention to the subcomponents, shown on the next three slides.

30. E&M Levels – History Subcomponents History • History of present illness • Review of systems • Past family and social history The three basic components of E&M services: history, physical examination and medical decision making have the subcomponents shown below and on the next two slides.

31. E&M Levels – Physical Examination Subcomponent the 1995 Medicare guidelines or the 1997 Medicare guidelines Physical examination - based on the examination of organ systems/body areas as defined by: • The treating physician determines which of the above to use

32. E&M Levels – Medical Decision Making Subcomponent • Number of diagnostic or management options • Amount and complexity of data reviewed • Overall risk of the treatment plan or patient’s condition Medical decision making takes into account any two of the following three subcomponents

33. E&M Levels, Other billing information • Though not required, there is a detailed E&M coding course at www.med.unc.edu/compliance/education-resources-1 • The laminated, lab coat pocket-sized physician’s coding cards are valuable guides to correct coding and documentation. • Additional training on anesthesiology billing from Per-Se Technologies is available on the Department’s network. It can be found on anesdata/shared/compliance and documentation training/physician anesthesia coding inservice

34. Consultations • The attending physician must personally perform or observe the key portions of the history, physical exam and medical decision making and write a personal note so indicating in the record for Medicare patients. • Inpatient anesthesia service consults should be documented on the WebCIS “create note” template for Inpatient Consultation Notes. When entered by a resident they are forwarded to the attending anesthesiologist’s activity list for the appropriate personal attestation and signature.

35. Pain site • Requested by • Patient location • Indication • Time interval for block placement and date • Resident/CRNA/Attending signature and provider number • Only if block is for post-op pain, mark procedure and Dx on back of form 1. 2a. 2b. 3. 4. 5. 7a. 7b. 6a. 6a. 6b.

36. Complete “Subsequent Daily Management of Catheter” form each day the patient is seen for an epidural placed solely for post-op pain • Write the reason you are seeing the patient in the diagnosis blank • For Medicare to be billed, the attending must be present for the key portions of the service and document h/her involvement in the note. A preprinted statement does not suffice. I was present for the evaluation and agree with the assessment. Attending signature/date required “Post-op pain” is not sufficient

37. Where To Get Help • www.med.unc.edu/compliance/ • School of Medicine Compliance Office 843-8638 • Heather Scott, CPC, Compliance Officer • Keishonna Carter, CPC, Compliance Review Analyst • Nirmal Gulati, CPC, ComplianceAuditor • Lateefah Ruff, Office Assistant • Confidential Help Line for compliance concerns 800-362-2921