i have no disclosure to report...medicare as secondary payer. we will identify medicare payments...
TRANSCRIPT
I have no disclosure to report
Disclosure information No relevant relationships disclosed
Coding Conservatively – is it an issue?
Co-pays – are they collected
Verification of insurance benefits and deductibles
Fees that are not current – review
Diagnosis not appropriate to encounter
Not coding all services – hospital consults, subsequent care, procedures
Timeliness of submission
Tips for Improving Your Revenue
4
Revenue Management Scheduling of patients – charging for n/s?
Procedures, allergy testing, oral challenges, rapid desensitization
Staff overload – overtime?
Lack of research for best price – antigens, supplies
New procedures and equipment not recognized as payable by carriers
95012- Nitric oxide expired gas determination
Multiple hours for oral challenges???
5
Fee Schedules
Read your contracts thoroughly before signing
Know your reimbursement rates
Will the rates change related to ACA?
Ask if the carrier follows CMS guidelines
What about mid level providers????
What bundling program is used – are they available on the carrier website
Preventive a covered benefit?
6
Fee Schedules What is the “legal” payment time for your state
Does the carrier change your codes?
When should you contact your insurance commissioner or medical society?
What is proper for appealing claims?
7
Maximizing for a greater profit Review, posting & processing of EOB to patient account
–payment correct
Following guidelines published per carrier
Regular auditing & monitoring of all phases
Are all charges being collected
What is percentage of uncollected charges
Continual education and training of all staff
Results? Profitable practice
Patient satisfaction
Staff accountability, pride and support
Introduction Instructions for Use of the CPT Codebook
….When advanced practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same sub-specialties as the physician…………
…A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service but who does not individually report that professional service……
Introduction Request To Update the CPT Nomenclature
Application Submission Requirements
Introduction General Criteria for Category I Codes- new or revised
All device and drugs necessary for performance have received FDA clearance or approval when such is required for performance of the procedure or service
The procedure or service is performed by many physician or other qualified healthcare professionals
The procedure or service is performed with frequency consistent with the intended clinical use
The procedure or service is consistent with current medical practice
The clinical efficacy of the procedure or service is documented in literature that meets the requirements set forth in the CPT code change application
Introduction Category III Criteria The procedure or service is currently or recently performed in humans;
and One of the following additional criteria has been met The application is supported by at least one CPT or HCPAC advisor
representing practitioners who would use the procedure or service The actual or potential clinical efficacy of the specific procedure or
service is supported by peer reviewed literature whish is available in English
There is at least one Institutional Review Board-approved protocol of a study of the procedure or service being performed; a description of a current and ongoing United States trail outlining the efficacy of the procedure or service or other evidence of evolving clinical utilization
2014 Evaluation & Management Codes Interprofessional telephone/Internet Consultations
An assessment and management service which a patient’s treating physician or other qualified healthcare professional requests the opinion and /or treatment advice of a physician with specific specialty expertise to assist the treating physician in the dx and/or mgmt of the patient’s problem without the need for the patient’s face to face contact with the consultant
2014 E/M Codes – The timing may make face to face service with the
consultant not feasible.
Codes should not be reported if there is a transfer of care before the assessment
Are appropriate if the transfer happens after the initial interprofessional telephone/internet consultation
2014 E/M Codes – Patient may be a new or an established patient with a
new problem or an exacerbation of an existing problem
Requires no face to face encounter with the last 14 days or in the next 14 days (or next available appointment) these are codes are not reported.
Greater than 50% of the service time must be devoted to the medical consultative verbal/internet discussion
Interprofessional telephone/internet consultations
99446 – Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review
Interprofessional telephone/internet consultations
99447 11-20 minutes of medical consultative discussion and review
99448 21-30 minutes of medical consultative discussion and review
99449 31 minutes or more of medical consultative discussion and review
2014 CPT Changes 69210 – cerumen removal requiring instrumentation,
UNILATERAL
(For bilateral procedure, report 69210 with modifier 50)
RVU 2.92
Watch your payments for changes to RVU values since it is now a unilateral code
CMS is not recognizing the code currently as a bilateral code
2014 CPT Changes For cerumen removal that is not impacted or does not
require instrumentation, eg, by irrigation only, see E/M service codes which may include new or established patient office or other outpatient services
Medicare Publication December 10, 2013
CMs has published the RVU values for 2014
Medicare Administrative Contracts have fee schedules on their websites
Conversion factor for 2014 - $35.8228 until March 31, 2014
Extension of Medicare Physician Work Geographic Adjustment Floor - 1.0
Medicare The final rule also includes several provisions
regarding physician quality programs and the Physician Value-Based Payment Modifier. In 2016, the CMS will put the finishing touches on proposals to apply the modifier to groups of physicians with 10 or more eligible professionals, and to apply upward and downward payment adjustments based on performance to groups of physicians with 100 or more eligible professionals.
Medicare Only upward adjustments based on performance (not
downward adjustments) will be applied to groups of physicians with 10 to 99 eligible professionals.
Physician Quality Reporting System (PQRS) for 2014, including a new option for individual eligible professionals to report quality measures through qualified clinical data registries.
Medicare Physicians and other eligible professionals can report a
measure once to receive credit in all quality reporting programs in which that measure is used.
Data collected in 2012 for groups reporting certain PQRS measures under the Group Practice Reporting Option will be publicly reported on the CMS Physician Compare Web site in 2014.
CMS Changes for Meaningful Use Stage 2 would be extended through 2016; and
Stage 3 would begin in 2017 for health care providers who have completed at least two years in Stage 2 of the program.
According to a blog post by Robert Tagalicod -- director of CMS' Office of E-Health Standards and Services -- and acting National Coordinator for Health IT Jacob Reider, the revised timeline would offer a variety of benefits, such as:
Allowing for more analysis of stakeholder feedback on Stage 2 progress and outcomes;
The availability of more data on Stage 2 adoption and measure calculations;
CMS Changes for Meaningful Use Allowing for more consideration of possible Stage 3
requirements; Providing additional time for preparation for Stage 3
requirements; and Giving vendors adequate time to develop and distribute
certified EHR technology ahead of Stage 3 and to incorporate usability and customization lessons.
In the fall of 2014, CMS is expected to release a notice of proposed rulemaking for Stage 3 and ONC will release the corresponding NPRM for the 2017 Edition of ONC Standards and Certification Criteria, according to the blog post.
The NPRMs will offer additional details on the new proposed timeline.
The final rule on Stage 3 of the meaningful use program is expected to be released in the first half of 2015.
OIG – Cloned EHR Records CMS said it will develop guidelines to ensure that
copy-and-paste "is used appropriately." It noted that it intends to work to develop "a comprehensive plan to detect and reduce fraud in EHRs.“
2014 OIG Work Plan will be published in January
Allergy practices and Audits Number of Test performed
Number of Doses charged
Medical Necessity for allergy testing and an E/M on the same calendar date
Incident to services with mid levels
Incident To Guidelines Applicable to ALL government entities – medicare,
medicaid, Champus, Federal employees ----
Incident to - physician has established a plan of care for an employee to follow.
Physician must be on site when the service is provided
NP, PA may not supervise diagnostic test under incident to guidelines and bill the service under the physician.
OIG Work plan for2014 Evaluation and management services—Inappropriate
payments. We will determine the extent to which selected payments for evaluation and management (E/M) services were inappropriate. We will also review multiple E/M services associated with the same providers and beneficiaries to determine the extent to which electronic or paper medical records had documentation vulnerabilities. Context—Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the billing code for the service on the basis of the content of the service and to have documentation to support the level of service reported. (CMS’s Medicare Claims Processing Manual)
OIG Work Plan 2014 Imaging services—Payments for practice expenses
Billing and Payments. We will review Medicare Part B payments for imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate.
OIG Work plan 2014 Physicians and suppliers—Noncompliance with
assignment rules and excessive billing of beneficiaries
Billing and Payments. We will review the extent to which physicians and suppliers participated in Medicare and accepted claim assignment during 2012. We will also assess the effects of their participation and claim assignments on the Medicare program (such as noncompliance with assignment rules) and on beneficiaries (such as excessive billing of beneficiaries’ share of charges). Context—Physicians participating in Medicare agree to accept payment on “assignment” for all items
OIG Work plan for 2014 Physicians and suppliers—Noncompliance with
assignment rules and excessive billing of beneficiaries
Billing and Payments. We will review the extent to which physicians and suppliers participated in Medicare and accepted claim assignment during 2012. We will also assess the effects of their participation and claim assignments on the Medicare program (such as noncompliance with assignment rules) and on beneficiaries (such as excessive billing of beneficiaries’ share of charges). Context—Physicians participating in Medicare agree to accept payment on “assignment” for all items
OIG Work plan for 2014 Improper Medicare payments for beneficiaries with other
insurance coverage Medicare as Secondary Payer. We will identify Medicare
payments made for services to beneficiaries who have certain types of other insurance coverage to assess the effectiveness of Medicare’s controls to prevent such payments. We will determine whether selected non-Medicare health plans properly reported insurance coverage information to Medicare as required. Context—The provisions underlying the objectives are in the Social Security Act, § 1862(b), and the Medicare, Medicaid and SCHIP Extension Act of 2007, §111. (OAS; W-00-14-35317; various reviews; expected issue date: FY 2014; work in progress)
RAC Reviews and Audits RAC scope includes pre-payment fraud, waste and
abuse efforts not limited to credit balance audits, incorrect billing and processing errors, and lack of medical necessity.
Post payment RAC work includes data mining, medical records review, identifying overpayments
RAC Reviews and Audits – Connelly Consulting Incorrect billing of Evaluation and Management Claims
Physician Evaluation and Management Services During Same Day Global Period
Place of Service Errors for Physician claims for service performed in an ASC or outpatient Hospital
Place of Service Errors for Physician claims for service performed in Hospital Inpatient setting
Duplicate Claims - Physician (Carrier) CMS
Modifier 59 – Know when you can use it appropriately
• Excessive Units-Untimed Codes
RAC and other payer audits Focusing on allergy doses and testing
E/M on the same date as a testing –
Some allergist have been reviewed back for three years from Medicaid or Medicare.
CMS may go back seven years for review
“Cloned” records in the EHR.
ALLERGIST CODING CURVE National National
99201 .47 % 99241 .52 %
99202 5.00 % 99242 3.48 %
99203 30.15% 99243 30.42%
99204 51.32% 99244 54.02%
99205 13.06% 99245 11.56%
41 41
ALLERGIST CODING CURVE
National
99211 3.98 %
99212 6.77%
99213 55.25%
99214 31.09%
99215 2.91 %
42 42
Preparation for a RAC Audit
1. Know Where Previous Improper Payments Have Been Found:
Look to see what improper payments were found by the Recovery Auditors:
Demonstration findings: www.cms.hhs.gov/rac
Look to see what improper payments have been found in OIG and CERT reports:
OIG reports: www.oig.hhs.gov/reports.html
CERT reports: www.cms.hhs.gov/cert
What Can Providers do? 2. Know If You Are Submitting Claims With Improper
Payments:
Conduct an internal assessment to identify if you are in compliance with Medicare rules
Identify corrective actions to promote compliance
Appeal when necessary
Learn from past experiences
Response to RAC Request Tell your Recovery Auditor the precise address and
contact person they should use when sending Medical Record Request Letters:
Call Recovery Auditor – take names
Use Recovery Audit Programs’ Websites
When necessary, check on the status of your medical record (Did the Recovery Auditor receive it?):
Use Recovery Audit Programs’ Websites
Appeal when Necessary
The appeal process for Recovery Audit denials is the same as the appeal process for Carrier/FI/MAC denials
Do not confuse the “Recovery Audit Programs’ Discussion Period” with the Appeals process
If you disagree with the Recovery Auditor’s determination:
Do not stop with sending a discussion letter
File an appeal before the 120th day after the Demand letter.
Learn From Past Experiences
Keep track of denied claims
Look for patterns
Determine what corrective actions you need to take to avoid improper payments.
Audit Response Know your risk
Seek counsel if you are high risk
Review your records
Have a third set of unbiased eyes read the notes
Respond in a timely manner
Communicate with the payer performing the review.
Negotiate
Ancillary services Allergy testing
Interpret the test because the code includes interpretation and report as part of the code.
Have name and/or initials of the supervising provider on the test
Nebulizer treatments, MDI instruction Separate document
CT Scans, radiographs If billing for it as a separate service, there should be a report
as a separate document in the chart.
Scopes Separate procedure note
Ancillary Services Immunotherapy – make sure billings for CMS are per
cc – limit per billing are 10 cc’s
Make sure there is documentation of the “recipes” for each patient.
Document on the allergy injection record the beginning of a new vial.
Document review of allergy injection record.
If more than “normal” number of injections, make sure medical record supports the necessity of the higher number of vials manufactured.
Aerosol Demo/Eval pt utiliz 94664
Bronchodilation responsiveness 94060
Bronchospasm Eval - Prolonged 94070
Laryngoscopy - flexible, dx 31575
Nasal endoscopy 31231
Nasopharyngoscopy 92511
Non pressured Inhalation trmt less than 1 hour 94640
Continuous inhalation tx with RX> 1hr 94644
Continuous inhalation tx with Rx ea addt'l 1hr 94645
Oximetry, single 94760
Oximetry, multiple 94761
Pulmonary Stress Test, Simple 94620
Respiratory Flow Volume Loop 94375
Spirometry, base 94010
Vital Capacity, total (separate P.) 94150
Nitric oxide expired gas determination 95012
ALLERGY TESTING
Puncture/Prick allergenic extract #_______ 95004
Intradermals allergenic extract #_________ 95024
Allergy test Prick and ID - venoms # 95017
Allergy test Prick & ID biologicals & drugs #____ 95018
Skin end point titration 95027
Delayed ID testing #_______ 95028
Patch Test #_______ 95044
Inhalation bronchial challenge 95070
with antigens 95071
Ingestion challenge test initial 120 minutes 95076
Ingestion challenge test: ea additional 60 min 95079
ALLERGEN IMMUNOTHERAPY
Allergen-Mult. Dose #_____Doses 95165
Allergen - Single Dose #_____ 95144
Venom Antigen - 1 single stinging 95145
Venom Antigen - 2 single stinging 95146
Venom Antigen - 3 single stinging 95147
Venom Antigen - 4 single stinging 95148
Venom Antigen - 5 single stinging 95149
Whole Body - biting insect 95170
Rapid Desensitization #Hr______ 95180
INJECTIONS
Allergy Injection - 1 95115
Allergy Injections - 2+ 95117
Allergy Inj + Antigen 95120
Allergy Inj + Antigen 2+ 95125
Xolair Injection 96372 96401
OTHER INJECTIONS
Antibiotic Inj (____) 96372
Immun. admin. Single with counseling 90460 90471
Immuno admin, ea add'l. with counseling 9056` 90472
Flu Vac under 3yr pre free 90655
Flu Vac under 3yr 90657
Flu Vac 3yr +, split virus V04.81 – V06.6 90658
Flu Vac intranasal 90660
IV Med Admin push 96374
Infusion Therapy 1st hr 96365
ea. add'tl hr._______ 96366
Pneumovax V03.82 – V06.6 90732
Therapeutic Inj 96372 55
SUPPLIES/ MISCELLANEOUS
Lab Handling 99000
Nasal Smears 89190
Solumedrol J2930
Syringes A4206
Special Reports 99080
Triamcinolone J3301
Xolair J2357
Portable peak flow meter (A4614) S8096
Peak flow expir. flow physician service S8110
Nebulizer & supplies A7003
through A7017
56
Diagnosis Coding
The diagnoses need to be specific – ICD-10 is here Remember place the diagnosis with the most acuity first
Acute precedes chronic
Co-morbidities – you need to address how the comorbidity affect the allergy/asthma issues
List the co-morbidities after your dx
If you code it make sure it is in the documentation
Medical necessity is defined with diagnosis codes
Chart Auditing –How to analyze your chart notes Chief Complaint – make sure your note leads the
reader down the appropriate path
CC – “Patient is here for retesting for allergies”
HPI – Make sure your HPI is for today’s encounter.
HPI – Make sure it is clear what information is for today. Previous information is ok but only for your information.
HPI – The provider is required to obtain the information for the HPI.
Past, family and social history – make sure it is applicable to the patient for your questions.
ROS – if the patient is filling out the information or your staff, make sure there is documentation to support the providers review of the information obtained.
Chart Auditing –How to analyze your chart notes Exam – 2014 tell the reader what you see
Normal is ok but describe – templates
Make sure templates match the rest of the note for complaints
You may use either the allergy specific or the general medical exam (1995 or 1997 guidelines)
Difference between a 99204 and a 99205
99204 99205
Comprehensive hx Comprehensive hx
Comprehensive exam Comprehensive exam
Moderate medical High medical
decision making decision making
Moderate Medical Decision making (need two at same level or higher)
Number of Diagnosis 3 or more
Amount of Data 3 or more Lab
Radiographs
Medical records
Medicine tests not billed
Risk Moderate: Prescription drug management,
undiagnosed new problem, one or more chronic conditions with mild exacerbation, progression or side effects of treatment
High Medical Decision Making need two at the same level or higher
Number of diagnosis 4 or more
Amount of data 4 or more
Risk
High:
Drug therapy requiring intensive monitoring for toxicity
One or more chronic illness with severe exacerbation, progression or side effects of treatment
Acute or chronic illness or injuries that pose a threat to life or bodily function
Medical decision cheat sheet 99213 1. Two diagnosis doing well on RX – allergic rhinitis
and asthma; allergic rhinitis and conjunctivitis
2. one diagnosis worse on RX – dermatitis not responding
Medical Decision making cheat sheet 99214 Three diagnosis doing well – allergic rhinitis, asthma,
anaphalysis to foods; or allergic rhinitis, asthma, dermatitis
One new problem requiring an RX - urticaria requiring a RX
One diagnosis doing well and one diagnosis not responding or worse. Both diagnoses are RX treatment – allergic rhinitis worse, asthma stable
Medical decision making cheat sheet 99215 New problem – pt acutely ill and needs labs, radiology
studies, review of chart notes consultation with another health care provider. OR pt presents with additional workup planned and is high risk –
Time Time is appropriate if more than 50% is counseling
and coordination or care
Document total face to face time
Percentage is greater than 50% of the encounter
Document the discussion with the patient.
CONSULT-HOSPITAL 99251 99252 99253 99254 99255
CONSULT-3 of 3 99241 99242 99243 99244 99245
NEW PT- 3 of 3 99201 99202 99203 99204 99205
HISTORY
CHIEF COMPLAINT Required Required Required Required Required
HX of PRESENT ILL Brief(1-3) Brief(1-3) Extended(4+) Extended(4+) Extended(4+
REVIEW OF Problem Extended Complete Complete
SYSTEMS Pertinent (1) (2-9 System) (10 + system) (10+ system)
PAST HX Pertinent-1 Complete-1ea Complete-1ea
FAMILY HX Pertinent-1 Complete-1ea Complete-1ea
SOCIAL HX Pertinent-1 Complete-1ea Complete-1ea
Perform/ Perform/ Perform/ Perform/ Perform
EXAM document document document document document
1 organ sys 2-4 organ
sys 5-7 organ sys. 8 organ systems 8 organ systems
MED. DEC MAKING (2 of the 3 must be met or exceeded)
MGMT OPT. & DX. Minimal (1) Minimal (1) Limited (2) Multiple (3) Extensive(4)
AMT DATA &COMPLEX Minimal(1) Minimal (1) Limited (2) Moderate (3) Extensive(4)
RISK OF COMPLICAT. Minimal Minimal Low Moderate High
ESTABLISH PT
2 OF 3 99211 99212 99213 99214 99215
HISTORY
CHIEF COMPLAINT Required Required Required Required Required
HX PRESENT ILL. Brief Brief Extended Extended
SYSTEM REVIEW Prob. Pertinent Extended Complete
PAST HISTORY Pertinent-1 Complete:
FAMILY HISTORY Pertinent-1 Choice of 2
SOCIAL HISTORY Pertinent-1 ele PFS Hx.
Perform/ Perform/ Perform/ Perform/
EXAM document document document document
1-3 systems 4-6 systems 5-7 systems 8 systems
MED. DEC MAKING
MGMT/OPTION DX Minimal (1) Limited (2) Multiple (3) Extensive(4)
AMT DATA/COMPLEX Minimal(1) Limited(2) Moderate(3) Extensive(4)
RISK OF COMPLICAT. Minimal Low Moderate High
70 70
Questions??? Thank you,