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Practice Management: “Show me the Money… !! Vikram Arora, MD, MPH Associate Director Heritage Valley Family Medicine Residency

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Page 1: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

Practice Management:

“ShowmetheMoney…!!

VikramArora,MD,MPHAssociateDirector

HeritageValleyFamilyMedicineResidency

Page 2: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

Agenda

•  ReviewTop5CommonTopicsonBoards– CodingandBilling– MedicarerulesandregulaGons– HIPAAetcetc.– MalpracGce– DischargingpaGentsfromyourpracGce

•  TopicReview…BoardQuesGons

Page 3: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

•  ABFM– FewquesGonsrelatedtoPracGceManagement– MostlyrelatedtoMedicareandMalpracGce

•  AOA– MorePracGceManagementquesGons– Varietyoftopics

WhydoIcare…

Page 4: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

WhydoIcare…

$158,000–averagemedicalschooldebt

Page 5: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

CodingandBilling

•  CommonProceduralTerminology(CPT)fromtheAMAoutlinescriteriaforeachcode

•  EachofficevisitwillhaveaCPTforEvaluaGonandManagement(E&M)services

•  LevelofinvolvementofapaGentencounter

– AndmayhaveaddiGonalprocedure(CPT)codesforproceduresperformedonthepaGent(modifiers)

Page 6: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

CodingandBilling•  Howyoucodedictateswhatyouwillgetpaid!•  OfficevisitshavefiveE&Mcodinglevels

Page 7: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

$30-40 $60-90 $100-130

WELLVISITSANNUAL$150-180

Page 8: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

CodingandBilling

•  AddiGonaly….isthepaGentanewpaGentorestablishedpaGent?(ad'saddiGonal$20-40)

–  NewpaGentifnotseenwithinthelast3yearsinyourpracGce

–  EvenifyouarethePCPontheirinsurance,theyarenewifnotseenwithinthelast3years

•  Modifiers–25,50etc.

Page 9: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

HospitalVisits

•  IniGalandsubsequentvisitsgofromalevel1whichisstraightforwardtoalevel3(high-complexity)

•  ConsultaGonsgetcodedfromalevel1to5

•  ObservaGon/discharges•  VisittopaymentGmeabout3months

Page 10: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

CodingandBilling

•  WhichofthefollowingfactorsallowsyoutocodeatahighercomplexityforavisitbasedoncounselingorcoordinaGngcare?

a)  Complexityofcareb)  PresenceofpsychiatriccondiGonsc)  Numberoftestsorderedd)  Numberofreferralsmadee)  Timespent

Page 11: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

CodingandBilling

•  AccordingtotheCurrentProceduralTerminology,anewpaGentisonethathasnotreceivedprofessionalservicesfromthephysicianwithinthelast:

a)  Oneyearb)  Twoyearsc)  Threeyearsd)  Fouryearse)  Fiveyears

Page 12: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicareRulesandRegulaGons

•  Createdin1965aspartofSocialSecurityAct•  BegancoveringpaGentsin1966•  Covers:– Allpersons65yearsofageandolder– Specialgroups:•  Longtermdisability•  ESRD

Page 13: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

– PartA:Hospitalcoverage•  PaidforbyFICA(taxdeducGon)

– PartB:OutpaGentcoverage•  premiumdeductedfromSScheck

– PartC:MedicareAdvantage– PrivateinsurersthatlocallyadministrateMedicare

– PartD:PrescripGondrugcoverage

MedicareRulesandRegulaGons

Page 14: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicareRulesandRegulaGons

•  Hospicecare:– Lifeexpectancyislessthan6months

•  SkilledNursingFacility(SNF)– Typicallyneedshospitalstay(3daysormore)– Coversupto100daysinSNF

•  Homehealth•  Needawheelchairorwalker,specialtransportaGon•  mayleavehomeformedicaltreatmentetc..

Page 15: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicareRulesandRegulaGons

•  Medicareexclusions:Х MostcarereceivedoutsidetheUnitedStates(withexcepGonsforemergenciesalongtheCanadianandMexicanborders)

Х  Custodialcare,includingmostlong-termnursinghomecare

Х  AnnualgynecologicexamsХ  RouGnedental,eyeorfootcareХ  Eyeglassesandhearingaids

Page 16: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicareRulesandRegulaGons

•  WhichofthefollowingcriteriamustbemetforapaGentcoveredbyMedicaretobeeligibleforhospice?

a)  PaGenthassignedaDoNotResuscitateorderb)  PaGentmustagreetoforgofuturehospitalizaGonsc)  PaGentmustfirstbetransferredoutofthenursinghomed)  PaGent’sprognosismustbesixmonthsorlesse)  PaGent’sreferralmustcomefromhisorherprimarycare

physician

Page 17: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicareRulesandRegulaGons

•  MedicareofferscoverageforwhichofthefollowingrouGneservices?

a)  Adultfostercareplacementb)  EmergencyroomvisitonvacaGoninFrancec)  Dentalcared)  Mammographye)  Hearingaids

Page 18: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicareRulesandRegulaGons•  PaGentonHospiceduetopancreaGccancerdevelopsacute

pneumoniawithrespiratoryfailureandrequesGngtohavefulltreatmentinhospital?

a)  RecommendaspaGentisonhospicehecannotreceivefulltreatment

b)  PrescribehimsomePOanGbioGcsc)  Admithimtothehospitalacutelytomanagehispneumoniad)  Heisprobablydeliriousandcannotmakeanydecisions

Page 19: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

No,it’snotafemalehippopotamus.Anyoneelseknow?

HIPAA

•  HealthInsurancePortabilityandAccountabilityAct(1996)

•  MainlyaffectsphysiciansthroughtheProtectedHealthInformaGon(PHI)area–  PHIisanyinformaGonaboutanpersonspast,present,orfuturemedicalhistory,ortreatmentspluscontainspaGentidenGfierssuchasname,address,phone#’s,etc.inanyformofstorageortransmission

Page 20: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

HIPAA

•  AlsoextendstohealthcareprovidersyettoseethepaGent

•  AllhealthcareprovidersandhealthcareinsGtuGons/agenciesmustcomplywithHIPAA

•  ViolaGonscanresultinfinesorsancGons

Page 21: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

HIPAA•  WhencanapaGent’sPHIbeshared:– Theysignaconsentforreleaseofspecificmedicalrecords -or-

– TheysignaNoGceofPrivacyPracGcesandarequestforPHIfallsintooneofthefollowing:•  Treatment-anotherphysicianinvolvedinthecareofthepaGent•  Payment-theinsurancecompany,billingoffice•  HealthOperaIons-Qualityofficer,audits

Page 22: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

EMTALA

•  EnactedIn1986,toensurepublicaccesstoemergencyservicesregardlessofabilitytopay

•  Medicare-parGcipaGnghospitalstoprovideamedicalscreeningexaminaGon(MSE)foranemergencymedicalcondiGon(EMC),includingacGvelabor,regardlessofanindividual'sabilitytopay

*EmergencyMedicalTreatmentandAc5veLaborAct

Page 23: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

StarkLaw

•  Enactedin1989

•  Itprohibitsphysicianreferralsofdesignatedhealthservices("DHS")ifthephysician(oranimmediatefamilymember)hasafinancialrelaGonshipwiththatenGty

•  AfinancialrelaGonshipincludesownership,investmentinterest,andcompensaGonarrangements

Page 24: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

RegulaGons•  WhatlegislaGoncoverstheprivacyofpersonalhealthinformaGon?a)  ClinicalLaboratoryImprovementsAct(CLIA)b)  EmergencyMedicalTreatmentandAcGveLaborAct

(EMTALA)c)  FamilyMedicalLeaveAct(FMLA)d)  HealthInsurancePortabilityandAccountabilityAct

(HIPAA)e)  StarkLaw

Page 25: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

RegulaGons•  WhichofthefollowingiscorrectregardingHIPAA(HealthInsurancePortabilityandAccountabilityAct)regulaGons?

a)  PrivatephysicianofficesareexemptfromtheseregulaGons

b)  PrivatephysicianofficesarecoveredbytheseregulaGonsonlyiftheyacceptMedicare

c)  HospitalvolunteersareexemptfromtheseregulaGonsd)  InadvertentbreachesofconfidenGalityarenotviolaGons

oftheseregulaGonse)  Allhealthcareprovidersandsitesarecoveredbythese

regulaGons

Page 26: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicalMalpracGce

Page 27: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicalMalpracGce

•  TypesofmalpracGceinsurance:

– Occurrence(25%)•  CoversallincidentsthatoccurduringtheeffecGvedatesofthepolicyregardlessofwhentheywerereported

–  Claims-made(75%)•  CoverscaseswheretheincidentoccurredandtheclaimwasmadeduringtheeffecGvedatesofthepolicy(employment)

Page 28: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon
Page 29: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicalMalpracGce

•  TypesofmalpracGceinsurance:– Tail•  CoversclaimsmadeforaperiodofGmeaKertheeffecGvedatesofthepolicy(claimsmadepolicy)

– Nose•  CoversclaimsmadeforaperiodofGmebeforetheeffecGvedatesofthepolicy(occurrencebasedpolicy)

Page 30: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon
Page 31: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicalMalpracGce

•  WaystoavoidaClaimagainstyouifareguiltyofcommipngamedicalerror:

– MakecontactwiththepaGent/family– BeempatheGctowardsthepaGent/family– Candidlyexplainwhatwentwrong– Donotblameanotherphysician– Explainhowyouwilltrytomakethingsright

Page 32: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicalMalpracGce

•  WhichtypeofmedicalmalpracGceinsuranceispurchasedattheGmeofreGrementfromamedicalpracGce?

a)  Claims-madepolicyb)  Claims-paidpolicyc)  Nosecoveraged)  Occurrencepolicye)  Tailcoverage

Page 33: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

MedicalMalpracGce•  Whichoneofthefollowingistrueregardingmedicalerrors?a)  MalpracGceliGgaGonismorecommonwhenphysicians

discloseerrorstopaGentsb)  Theuseoftheword“error”shouldbeavoidedwhen

disclosingmistakestopaGentsc)  PhysiciansinprivatepracGcearemorelikelytodisclose

errorstopaGentsthanthosephysiciansemployedbyaninsGtuGon

d)  PaGentsprefertoreceiveapologiesandexplanaGonswhenamedicalerrorhasbeenmade

e)  ItisethicallydefensibletoonlydiscloseanerrorifthepaGentisawarethereisaproblem

Page 34: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

DischargingPaGentsfromyourPracGce

•  IfyouhaveneverseenapaGent,youcannotbeforcedtoseethem(atleastnotyet)

– ManypracGcesare“full”andwillnottakenewpaGents–  PaGentswillhavetoselectanotherphysiciantoprovidemedicalservicesforthem

Page 35: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

DischargingPaGentsfromyourPracGce

ForestablishedpaGents,youcan“discharge”themfromyourpracGceaslongasyou:

1.  ProvidethemwithalererstaGng:–  EffecGvedateofthedischarge–  Reasonyouaredischargingthem•  Rudeorinappropriatebehavior•  Notfollowingmedicaladvice•  Failuretocometoscheduledappointments

2.  ProvidecareforanaddiGonal30days

Page 36: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

DischargingPaGentsfromyourPracGce

•  FailuretofollowthisprocesscanresultinachargeofAbandonment–  Canbeonthelosingendofalargeserlement

•  ItisnotAbandonmentif:–  Thephysician/paGentrelaGonshipismutuallyterminated–  Thephysician/paGentrelaGonshipisterminatedbythepaGent

Page 37: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

DischargingPaGentsfromyourPracGce

•  WhenphysiciansdecidedtodischargeapaGentfromtheirpracGcetheyarerequiredtoprovidethepaGentwithwhichofthefollowing?

a)  CopyofthepaGent’schartb)  Reasonforthedischargec)  Referraltoanewphysiciand)  ReviewofthepaGent’saccounte)  Emergencycareforthenext30days

Page 38: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

DischargingPaGentsfromyourPracGce

•  WhendischargingapaGentfromamedicalpracGce,thephysicianmustprovideemergencycareforaperiodofGmesoastoavoidachargeof:

a)  Abandonmentb)  DiscriminaGonc)  Fraudd)  Mandamuse)  Negligence

Page 39: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

Summary

•  ReviewedTop5CommonTopicsonBoards– CodingandBilling– MedicarerulesandregulaGons– HIPAA,EMTALA,Stark– MalpracGce– DischargingpaGentsfromyourpracGce

•  QuesGons?

Page 40: “Show me the Money…...Coding and Billing • Common Procedural Terminology (CPT) from the AMA outlines criteria for each code • Each office visit will have a CPT for Evaluaon

CodingandBillingPracGce

•  hrp://emuniversity.com/index.html


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