Medical Coding

E&M Coding

General

· Include all co-morbidity for EM coding

o If not listed as an impression, a reference should be made to the “significant medical history” and “need for pre-operative medical evaluation” in the discussion and planning for surgery.

· OIG Items of concern

§ Indications for MRI- Medicare spent over $7 Billion in 2005.

§ E&M codes during the global period- Use of the -24 modifier for evaluation of an unrelated issue during a post-operative period will be a red flag. Obviously documentation will be critical.

§ 99214 is under scrutiny by the OIG who said 99214 was billed incorrectly in 37% of cases

E&M Categories

· The AMA's CPT guidelines state that a patient is "new" if he hasn't received professional services from you or another physician in the same specialty and group within the last three years.

Outpatient

· 9920x: New Patient

· 9921x: Established Patient

· 9924x: Outpatient Consultations

§ If the patient is re-consulted, even for the same problem, it is a new consult. Patient can be new or established.

§ A patient seen in the ER is a consultation by the ER physician. (RVU= 5.25 for 99245)

§ Patients seen in the office referred by an ER physician may not be a consult - controversial

§ Consultations are a high audit risk because they pay ~30% more

§ Consult may be verbal but written is preferred

§ The consultation report needs to include a letter along with the encounter report. This letter should include a statement like “Thank you for asking me to see Ms Jones in consultation today.”

§ The CC should begin with a statement such as “Ms Jones is seen today in consultation requested by Dr. Smith for ____.

o This also applies to hospital/ER consultations except add “in the hospital” as well.

· 9928x: Emergency Room. Either ER or consulted physician. Lower RVU (non-facility differential) – consider consult code (9924x) instead

Inpatient

· 9922x: Initial Hospital Care (RVU= 4.96 for 99223)

o Use when admitting to hospital even from another hospital.

o Should dictate H&P on hospital system

o If admitting from ER use this code, if going to OR from the ER use the Outpatient Consult code with the -57 Modifier

· 9923x: Subsequent hospital care

· 9925x: Initial Inpatient Consultation

o Report to consulting MD is not required.

o Only able to consult once per admission.

o Must be written?

· 9929x: Critical care services. Time-based: 99291 = 30 to 74 min.; 99292 each additional 15-30min. Includes minor procedures (not ventriculostomies)

· 9923x: Discharge Services. 99238 (<30 min), 99239 (>30min)

· Observation Services

· 9935x: Prolonged services

Modifiers

· Justify coding, do increase or decrease RVU

· -24: unrelated problem in global

· -25: done day of procedure

· -32: mandated services (government, provider)

· -57: when in global, not H&P

· Historical Component

o For Comprehensive (level 4-5)

§ Chief complaint

§ HPI

· At least 4 elements are required

· Must be recorded by the MD or PA, not by the nurse

· Document if unobtainable – why, other sources used

§ PMH, FH and SH

· Need at least one element in each category

· Should be reviewed and noted at each visit

§ ROS

· At least 10 systems needed

· A statement that says “all other systems reviewed and non-contributory” will be acceptable if you sign the encounter sheet

· Examination Component

o May be general or specialty exams (i.e. cardiovascular, neurologic)

o For Comprehensive (level 4-5)

o It will be easier to set up exam under the 1995 guidelines

o Must include 8 organ systems (Bold are common areas already included)

§ Vitals: AT LEAST 3 of BP, HR, RR, Temp, weight, height – must be measured, not patient-reported

§ ENT

§ Eyes

§ CV

§ Resp

§ GI

§ Musculoskeletal

§ Skin

§ Neurological

§ Psychiatric

§ Hematological/Immunological

o Document the Cranial nerves individually

· Medical Decision Making

o Complexity of Data (Bold are valued higher)

§ Review labs

§ Review radiology report

§ Review old records

§ Discuss case with another MD

§ View films

§ 3 points by reviewing films and reports.

§ An additional point for review of old records.

§ For the highest complexity you need at least 4 points

o Diagnosis

§ Established problem (stable or improved)= 1

§ Established problem (worse) 2

§ New problem (no additional w/u) 3

§ New problem (w/u planned) 4

§ May have 2 problems if established and can multiply points

§ Need 4 points for highest level

o Level of Risk

o Moderate

§ RX given

§ Elective surgery without comorbidity

o High

§ Elective surgery with risk factors

§ Emergency surgery

§ IV medication

§ Decision for DNR

§ Drug therapy that requires monitoring

o Highest 2 of the 3 is used to determine the level which means that for the most part we should use level 4 for new patients

· Time-Based

o Applicable when counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter

o Document either total time and time spent in counseling or the the total time of the visit and that “counseling comprised more than 50% of the visit”.

o Counseling documentation must be detailed (patient’s questions, family questions, specifics about diagnosis, treatment options, risk reduction factors) to support medical necessity.

o It is estimated (Medicare Part B Newsletter excerpt) that 20% of patient encounters might be counseling encounters.

· Audit

o Recommend audits of five charts per period (quarter) and based on profile evaluation

Procedural Coding

CPT Codes

· CPT (Common Procedural Technology) designed in 1966. National coding standard under HIPPA (2000). Owned & licensed by the AMA

· CPT Revision Process:

o AMA CPT editorial members: 15-20 members. Review and define new codes. AMA appointed

o AMA CPT advisory panel: c. 100 members. Specialty society representatives.

Modifiers

· -22: Unusual Services. Used for prior surgery, XRT, infection, trauma, obesity. Must be reflected in op report. Should be >25% more work than typical. Usually requires manual review. Some procedures excluded. Delays reimbursement 2-3mos. Usually augments 20-25%.

· -50: Bilateral. Certain procedures only. 50% reduction in 2^nd side.

· -51: Multiple procedures. 50% reduction in 2^nd procedure.

CPT categories

· Category I: commonly accepted procedures. FDA approved. Supporting research (not industry sponsored)

· Category II (-V Codes): Tracking codes for performance measurement (PVRI)

· Category III (-T Codes): Temporary (experimental) codes being assessed for Cat I usage. Cat III generally needs pre-approval for payment

· All procedures listed must be discussed in the body of the OP note

· ICD-9 Code must match CPT code

· CCI edits: The Correct Coding Initiative (CCI) edits identify pairs of services that normally should not be billed by the same physician for the same patient on the same day and identify whether specific CPT and Healthcare Common Procedure Coding System modifiers may be used to override certain edits.

· Surgeons and their staffs should check CMS Web site at http://www.cms.gov/physicians/cciedits on a quarterly basis (January, April, July, and October) to download the most current version of the CCI edits.

Academic Coding

· Medicare will pay separately for an assistant at surgery when the assistant is a physician (other than a resident), NP, PA, or CNS. However, Medicare does not pay separately for an assistant at surgery when a resident is available.

· A teaching physician’s presence is necessary during the “critical portions” of the procedure and they must be immediately available during the entire procedure.

o Their presence is not required during opening/closing.

o When the teaching physician is involved in overlapping surgeries, he must be present for the critical or key portions of both surgeries. When he is not present during the non-critical portions of either surgery, he must arrange for another qualified surgeon to be immediately available to assist the resident in the other case, as needed.

o A resident does not qualify as another physician for this purpose.

o There is no specific definition of “immediately available”.

o The name of the second available surgeon should be indicated either in the operative dictation notes or the medical record.

· A physician’s time spent teaching is not counted toward critical care time. Only the time spent by the teaching physician alone with the patient, and the time spent by the teaching physician and resident together with the patient, is counted toward critical care time. For time-based codes with code descriptors of greater than 30 minutes (e.g., CPT 99239), the teaching physician must document the actual amount of time spent with the patient.

· A student’s services must be independently documented by the physician, i.e., the physician cannot simply refer to the student’s notes. Documentation of an E/M service by a student that may be referred to by a teaching physician is limited to documentation related to the review of systems and/or past family/social history.

General Recommendations

· Organize the payer profiles and benchmarks and review quarterly.

· Prepare template letters and documentation for the common denials to expedite the appeals process.

· Schedule (at least) monthly meetings with billing, coding, and clinical representatives to review denials and reimbursement issues.

· Run EM profiles (quarterly) to compare with national and regional averages. For any deviations, pull at least 5 charts for audit and make adjustments as needed.

· Send in bills according to the CPT guidelines regardless of the payers response. Appeal when needed and then adjust the AR to reflect an accurate balance.

· Look at the PVRP guidelines possible for increase of 1.5%

· Ask other payers if they are implementing plans (page 50)

Medicare Website

· www.cms.hhs.gov/physicians

· CMS has incorporated its national coverage determinations, the draft and final versions of Medicare Part B carriers’ local carrier determinations (formerly called local medical review policies), and national coverage analyses into the Internet-based CMS Medicare coverage database. A search of the database will allow you to determine whether CMS or Part B carriers are considering or have developed national or local payment decisions for procedures surgeons perform. www.cms.hhs.gov/coverage/default.asp

· CMS’ “Medlearn Matters...Information for Medicare Providers” translates regulatory language into an easily understood format. Each article provides guidance about the effective date of a policy change, which provider groups are affected by the policy, what providers need to do to comply with the policy, and a brief explanation of why the change will be implemented. www.cms.hhs.gov/medlearn/matters.

Documentation Guidelines

1995 Principles and Guidelines www.cms.hhs.gov/MLNProducts/Downloads/199 5dg.pdf/1995dg.pdf

1997 Principles and Guidelines

www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf.pdf

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Revised: 2/9/07