coding and billing for internists services challenges and opportunities june 2010
TRANSCRIPT
Coding and Billing for Internists’ Services
Challenges and Opportunities
June 2010
Foundation on which Billing and Coding is Based
AMA maintains CPT book of codes that describe physician services
CMS supplements the CPT book as needed
RBRVS, managed by CMS, determines payment for each physician service
Each service has a relative value for each of three main components—work, practice expense, and professional liability insurance, with each being adjusted to reflect geographic input price differences
Medicare multiplies total, adjusted relative value for each service by a dollar multiplier, or conversion factor
Medicaid, other government, and private payers generally use RBRVS as basis for payments
Medicare Payment Uncertainty
Medicare annual payment updates lag behind medical inflation
Flawed sustainable growth rate formula regularly calls for unsustainable cuts in Medicare physician payments
Congress typically acts to replace an impending cut with a freeze or small increase around time it is to take effect
Congress almost certainly will act to avoid large cut but is avoiding a complete long-term fix because it’s costly
ACP participating in this messy process to represent the interest of its members
Focus on What You Control General coding and billing guidance
• Do what is medically necessary
• Document what you did according to guidelines
• Use up-to-date CPT and diagnosis codes
• Investigate payment denials
• Conduct periodic self audits
• Engage in continual coding and billing education
Understanding coding and billing rules is vital to health of practice
Coding and Billing Challenges and Opportunities
Challenge: “Welcome to Medicare” Exam Benefit
Changes in 2009 resulting from 2008 law implementation:
• Patients now eligible 12 months after enrollment, instead of 6 months
• No longer required to perform EKG, but must advise/refer as needed
• Now required to conduct BMI and discuss advance directive
• Use new HCPCS G0402, instead of old G0344
Can bill medically necessary E/M on same date as appropriate—use modifier -25
ACP has contended pay too low; CMS increased pay for service for 2010 to $154, up from $92
CMS working to establish details of an annual wellness visit/preventive care plan benefit for 2011 as required by March 2010 federal health reform law
Challenge: Billing for Consultations
Requirements for a billing a CPT consultation service code:
• Furnished at the request of another physician seeking opinion or advice
• Must make a treatment option(s) decision/recommendation
• Must provide opinion or advice in a written report back to the requesting physician
Consulting physician can initiate treatment, e.g., diagnostic or therapeutic tests or procedures, during consultation visit
On-going care furnished by the consultant after initially providing opinion or advice is billed using office, subsequent hospital, nursing facility visit codes
Dramatic Medicare Consult Policy Change CMS no longer recognizes CPT consult
codes for Medicare payment purposes beginning in 2010
CMS rationale for change:
• Agency long-expressed concern that physicians did not bill consults correctly
• Reviews determined that Medicare overpaid as many consults billed were not supported by documentation
• Agency believes consult service work is “clinically similar” to office, hospital, NF visits
Dramatic Medicare Consult Policy Change
Consults to be billed using CPT codes for:
• Office visits, 99201-99215
• Initial hospital care (admit). 99221-99223
• Initial NF care, 99304-99306
Change was unexpected and has far-reaching implications
ACP position on Medicare consult payment policy is at http://www.acponline.org/running_practice/practice_management/payment_coding/medicare/changes2010/feeschedule.htm#advocacy
Documentation Implications of Consult Change Documentation rules for “replacement” codes
apply based on code used, thus:
• No requirement that the requesting and consulting physician document request in medical record
• Consultant not required to send a written report with opinion /advice back to requesting physician
• No need for auditors to distinguish a request for a consult from a referral that constitutes a transfer of care
Admitting physician bills initial hospital care code with a “AI” modifier to distinguish service from consultant(s)
Payment Implications of Consult Change
To redistribute the money that Medicare paid for the no-longer-recognized CPT consult codes:
• Payment for each office visit increased about 3%
• Payment for initial hospital and initial NF care services increased about 1%
In general, payments for consult services will be lower as a result of use of CMS-required replacement codes
Payment Implications of Consult Change
Consult Code
2009 Payment
Replacement Code
2010 Payment
99241 $48.69 99201 $38.96
99242 $90.90 99202 $67.45
99423 $124.80 99203 $97.75
99244 $184.32 99204 $151.49
99245 $226.52 99205 $190.45
Payment Implications of Consult Change
Consult Code
2009 Payment
Replacement Code
2010 Payment
99251 $48.69
99252 $75.75
99253 $114.70 99221 $94.14
99254 $165.56 99222 $127.33
99255 $201.99 99223 $186.84
Payment Implications of Consult Change No clear guidance on how to bill low-level
hospital consults as no initial hospital code match for 99251-99252
Consults furnished to established outpatients, 99211-99215, experience biggest payment hit
• Consult for pre-op clearance on known beneficiary dictates billing established patient office visit
Physicians who do a significant number of consults will see overall revenue decline; those who do few see revenue rise
Confusion when a secondary payer is involved
Payment Implications of Consult Change Can bill prolonged service code in addition
to an office or hospital visit code (as appropriate and if documented)
Consult can be billed as critical care service if it meets the CPT definition of critical care
Coordination of care could suffer if consultants feel less compelled to send a written report to requesting physician
Most private payers initially decided to continue to pay the CPT consult codes but more are adopting the Medicare policy
Tips for Billing Private Payers Consults
Consultants can receive higher payments from private payers still recognizing CPT consult codes
Consult can be furnished by a physician in the same group as the requesting physician—consultant is expected to practice a different specialty but exceptions are made for same-specialty expertise
The service resulting from a surgeon’s request to clear a patient as being fit for surgery can be billed as a consultation for major procedures
Check if private payer follows the old Medicare rule that allows billing a consult for patient-initiated second opinions before major surgery or test
Challenge:Medicare Teaching Physician
Regulations Medicare pays teaching/attending
physician for services furnished involving a resident when:
• Services performed by teaching physician—duplicates resident service
• Services performed by teaching physician jointly with resident
• Services performed solely by resident under Primary Care Exemption
For first two scenarios, teaching physician must personally see the patient, perform the critical/key portion of the service, and participate in the management
Teaching Physician Regulations
Teaching physician must tether/link note to resident’s note
Billing is based on the combination of the teaching physician’s and resident’s documentation
Examples of acceptable documentation:• I saw and evaluated the patient. Discussed /w resident
and agree w/resident’s findings and plan as documented in the resident’s note.
• See resident’s note for details. I saw and evaluated the pt and agree with the resident’s findings and plan as written.
Examples demonstrate saw patient, performed key portion, and participated in management
Teaching Physician Regulations
Examples of unacceptable documentation:• “Agree with the above.”
• “Rounded, reviewed, agree.”
• “Discussed with resident. Agree.”
• Signature alone
Other documentation tips:• There is no royal “we”; use “I” to demonstrate
involvement
• Can use template/macro, such as through EHR, but must sufficiently modify to reflect specific encounter/scenario
Suggested Teaching Physician Documentation
I saw and evaluated the patient and reviewed (Resident’s Name) notes. I agree with the history, physician exam and medical decision making with the following additions/exceptions/observations : ____________________________________________________________________________________________________________________________________________________________________________________
Attending’s SignatureDate
Teaching Physician Primary Care Exception
Teaching physicians can be paid for certain services furnished solely by a resident when they are provided in outpatient facilities for which resident time is counted toward the direct GME payment to the facility
Teaching physician can only be paid for resident low-level outpatient E/M visit services, 99201-99203 and 99211-99213
Resident must have completed at least six months of training program
Teaching physician cannot supervise more than four residents and must be immediately available to assist
Challenge: Billing for “Incident-to” Services
Medicare allows physicians to bill for outpatient services performed by personnel that are “incidental” but integral and be paid as if the physician performed the service
Incident to rules enable physician to bill 99211 when service furnished by office staff
• This minimal service can be performed by any clinical staff member, e.g., medical assistant, RN, PA
More complicated incident-to rules pertain to billing of 99212-99215
• Service must be performed by CMS designated clinical staff PA, NP, CNS
Billing for “Incident-to” Services Conditions must be met to bill for higher-level PA,
NP, CNS services• Physician must perform the initial visit and
establish the care plan for patient/condition
• Physician must provide direct supervision, defined as in the office suite but not necessarily in the same exam room, and be immediately available to assist
Medicare pays 100% of its normal physician fee schedule amount
PA, NP, CNS can provide services that fail to meet the incident-to rules
• The practitioner furnishing the service must be listed on the claim/bill
• Medicare pays the practice 85% of its normal fee schedule amount
Challenge: Billing Anticoagulation Management Services
Medicare payment policy makes it challenging to be adequately paid for managing patients receiving long-term, outpatient anticoagulant drug, i.e., warfarin therapy
ACP helped establish new CPT codes in 2007 to provide a more rationale way for physicians to bill and be paid for anticoagulation management services • A code to report an initial 90-day period that
involves at least 8 INRs, CPT 99363
• A code to report each subsequent 90-day period that involves at least 3 INRs, CPT 99364
Codes encompass physician review and interpretation of each INR, patient instructions, dosage adjustments, and ordering additional tests
Billing Anticoagulation Management Services CMS refuses to pay for these new CPT codes,
which would generally increase amount Medicare pays physician
The agency retained its policy that the practice can bill a 99211 when office personnel has a face-to-face encounter with the patient, higher level when physician has direct contact
ACP is concerned that some Medicare contractors may prohibit billing 99211 unless there is a change in drug regimen, treatment plan• This compounds the problem by making an
inadequate billing policy more restrictive
Check with private insurers to see if they pay for CPT 99363 and 99364
Opportunity: E/M Counseling Exception
Have option to select an E/M level of service based on time when counseling and/or coordination of care accounts for more than 50% of physician face-to-face time with patient
Compare total physician time for encounter to CPT “typical time”
Not subject to 1995 or 1997 E/M documentation guidelines
Documentation should note amount of time counseling and what was discussed (must be medically necessary)
List counseling time as fraction of total, e.g. “ccc 15/25” in addition to describing pertinent issues discussed
Opportunity: Home Health Care Plan Certification/Re-
certification Bill HCPC G0180 for certification of the initial
home health care plan • Medicare pays $58
Bill HCPCS G0179 for re-certification of care plan • Use if patient has received home health services within
past 60 days
• Medicare pays $44
Document thought-process in agreeing with plan and/or in changing to better meet patient’s needs
Keep copy of approved care plan in record or be able to access it if needed
CMS goal is incentive to physician to carefully review home health agency care plans to ensure appropriate utilization
Opportunity: Smoking Cessation Counseling
Medicare covers for:
• Patients with disease caused or exacerbated by tobacco use; or
• Patients taking medications complicated by tobacco use
Covers 2 attempts to quit per year
Each attempt can involve up to 4 counseling sessions
Bill CPT 99406 for 3-10 minutes of counseling
• Pays $13
Bill CPT 99407 for >10 minutes of counseling
• Pays $25
Append modifier -25 to office visit (or other service) done on same date
Opportunity: Screening Pelvic/Breast Exam
G0101 - cervical or vaginal cancer screening; pelvic and clinical breast examination
Medicare covers annually for women at high risk or of childbearing age with abnormal Pap in last three years, and every two years for all other female beneficiaries
Pays $35
Can bill in addition to other same-visit/date services: • Obtaining a smear for screening Pap test Q0091—pays
$40
• Acute/chronic “medically necessary” service, e.g., 99213
• Medicare non covered comprehensive preventive billed to patient, e.g., 99397
Opportunity: Use CPT Modifiers as Appropriate
Modifier -25 – significant, separately identifiable E/M service furnished by the same physician on the same date as procedure or other service
Can be used to bill an E/M service on the same date as a minor procedure, e.g., joint injection
Can be used to bill an E/M service on the same date as a number of Medicare-covered preventive services, e.g., Medicare-covered screening pelvic/breast exam, HCPCS G0101
Can be used to bill an E/M service on the same date as another E/M service in limited circumstances, e.g., critical care service in addition to initial hospital if patient crashes
Opportunity:When a Patient is “New” Again
You can bill a “new patient” service when neither you or a physician of the same specialty in your group practice have furnished a face-to-face professional service within the past three years• Patient you provided a flex sig two years ago, not
a new patient
• Patient for whom you read an x-ray two years ago (without seeing the patient) is a new patient
Pay attention when providing office visits, new patient visits receive higher payment • 99204 – pays $151
• 99214 – pays $98
Opportunity: Non-covered Medicare Services That
Can Be Billed to Patients Telephone services
• 99441 - 5-10 min. medical discussion
• 99442 – 11-20 min. medical discussion
• 99443 – 21 -30 min. medical discussion
• Must be initiated by established patient call to physician
• Cannot be billed if face-to-face service results within 24 hours or if related to face-to-face service provided within past 7 days
E-service
• 99444 – on-line service to established patient
• Physician’s personal, timely response to patient inquiry that involves permanent storage of documentation pertaining to exchange
Non-covered Medicare Services that Can be Billed to Patients
E-service (cont.)
• Can only be reported once during same episode of care over 7 days
• Not related to face-to-face E/M service within past 7 days
Preventive Medicine Services, e.g. 99397 – periodic comprehensive preventive medicine evaluation, established patient, 65 years and older
Medicare considers above services to be “non covered,” meaning that physician can bill patient his/her usual charge
Not necessary to have patient sign an ABN form but good idea to discuss situation with patients in advance of billing them
Opportunity:Medicare Bonus Payment – PQRI
Medicare pay-for-reporting program, the Physician Quality Reporting Initiative (PQRI)
Report on how care furnished compares to evidence-based clinical guidelines for a variety of medical conditions, e.g. diabetes, heart disease
Earn a 2% bonus for 2010 for reporting on how care provided aligns with quality measures, selecting from a variety of reporting methods
ACP resources available at http://www.acponline.org/running_practice/practice_management/payment_coding/pqri.htm
Opportunity:Medicare Bonus Payment – E-Rx
Earn a 2% bonus for 2010 for reporting e-prescribing events using a qualified e-prescribing system
List code G8553 on claim form to indicate an e-prescribing event associated with eligible encounters, primarily office visits
Receive bonus if correctly report code a minimum of 25 times in 2010
Other reporting options, e.g., through an EHR, are available
ACP resources available at http://www.acponline.org/running_practice/technology/eprescribing/medicare_program.htm
ACP Contacts for Questions/Comments Regulatory and Insurer Affairs
Department
• Brett Baker - [email protected]
• Debra Lansey - [email protected]
• Tenita Richards - [email protected]
Center for Practice Improvement and Innovation
• Margo Williams - [email protected]