Basic Billing and Coding

Susan MooreFaculty Indiana UniversityAdapted fromThe Coker GroupAlpharetta, GA

A Nurse Practitioner Faces Risks at Each Patient Encounter

Clinical Risk Treatment plan errors Patient outcomes Perceived bad treatment by patient

Compliance Risk False claims HIPAA compliance issues

Financial Risk Authorizations and certifications Private payer regulations Patient/payer mix Can’t pay, won’t pay, late payments

OIG Reports that for First Half of 2007

Collected $2.9 billion in investigations Excluded 1,278 providers Prosecuted 209 criminal actions Won 123 civil actions

OIG Semi-annual report www.oig.hhs.gov/publications/docs/semiannual/2007

Resources

CPT – Identifies the services which are provided during an encounter (Annual)

ICD-9 – Identifies why a service was provided during an encounter (Medical Necessity) (Semi-annual)

Regulations

All health care professional regulation is:

Performed at the state level Enacted by state legislature Administered by state regulatory

agency U.S. Congress is not involved in

health care profession regulation

Regulation

States will specify: Education requirements Certification/Licensure DEA registration Prescribing restrictions Physician/NP supervisory ratio Scope of practice

Medicare Guidelines

NPs who treat Medicare patients Must have National Provider Identifier

(NPI) Can choose to bill “incident to” or

under own number When billing under MD PIN = 100% When billing under own PIN= 85%

When NP Bills Under Physician PIN (“Incident To”)

Use carrier guidelines for “incident to” New patient – see MD for care plan establishment Follow up – see NP for “incident to” New problem – see MD or bill under NP number

Office/clinic when physician on site Within ‘shouting’ distance Physician on site does not have to be who initiated

care plan but does have to be part of the practice May be independent contractor May be W-2 leased employee Practice must cover expense of NP salary

“Incident To” Is Never Appropriate In A Hospital Setting

BUT“Shared” visits are!

Both MD & NP see patient face to face Both document their findings on the

chart Combine documentation & bill under MD

PIN Consults can NOT be shared anywhere

Shared Services

Apply “shared visit” rule (patient seen by several providers) to services provided in the place-of-service:

21 (hospital inpatient) 22 (hospital outpatient) 23 (emergency room) 24 (ambulatory surgical center)

Third Party Payers Guidelines For Payments Differ Among Carriers

Do they recognize NPs Amount of supervision of NP Who can render that supervision Where the service needs to be rendered The scope of services the NP is permitted

to render They can be different from state

regulations Generally differ among carriers

Coding Overview

CPT Codes (with modifiers) 99254 - Inpatient Consult

What you did

ICD9 Codes (to 4th or 5th digit) 786.50 - Chest Pain

Why you did it

Coding = using numbers to tell a story

Coding causing no payment

Wrong code used Incorrect use of CPT code Inappropriate unbundling of CPT Required modifier omitted Diagnosis does not support service 2 providers bill for same service Insufficient documentation

Who is Responsible for Coding?

Appointment schedulers Receptionist/patient intake specialist Clinical staff/ancillary staff Nurse practitioners/physician assistants Physicians Billers/coders Managers/administrators

CPT – Coding and sites

The CPT code assigned Depends on nature of presenting problem Work physician performed (History, Exam,

Medical Decision-making) Documentation in chart

Physician/NP/PA services provided in Office Inpatient Nursing home Outpatient Home

Undercoding

E/M codes can impact revenues by this example of under coding

For example, Average reimbursement 99212 = $36.20 Average reimbursement 99213 = $50.32 Average reimbursement 99214 = $78.91

Coding 1000 visits a year as 99212 when supported 99213 = $ 14,120

Lost revenue

Provider Utilization Comparison

0%10%20%30%40%50%60%70%80%90%

99211 99212 99213 99214 99215

Level of Service

% o

f T

imes

Use

d

PracticeNational

http://www.cms.hhs.gov/statistics/feeforservice/default.asp

Implications

If your practice is much different than the national practice norms for your specialty then your practice is a red flag.

Therefore, know the national averages for what is happening with your type of practice

Evaluation & Management of CodingCharting tells the reviewer

History CC, HPI, ROS, Family, Social

Exam System(s) & Detail

Decision Making Complexity & Risk

E&M Charting – How Staff Can Help but NP is KEY

History HPI – must be recorded by provider CC,ROS, F&SH – Can be recorded by staff and/or

patient with new patient form and reviewed by provider

Exam Staff can perform & record three of seven vital signs

Decision Making Documentation of lab, x-ray, etc. Medication list update Problem list update

Coding

Level of History + Level of Examination +Complexity of Medical Decision

Making =

Correct Code !

Nature of presenting problem

How long does it take you to discern how involved a visit is going to be?

How often do you review the past medical, family, and social history?

When do you do a complete 8 organ system examination?

How much time do you spend with each patient?

CPT Clinical Examplesin the CPT Book

The clinical examples, when used with E/M descriptors, provide a comprehensive and powerful tool for reporting services provided to patients

Submitted by specialty associations to the AMA for the CPT book

Must be used with documentation guidelines

Clinical Examples - 99212

10 year old female, established patient, who has been swimming in a lake, now with 1 day history of L ear pain with purulent drainage

Established patient follow up of clearing patch of localized contact dermatitis

65 year old, established patient, with eruptions on both arms from poison oak exposure

Straight forward, brief, focused

Clinical Examples - 99213

60 year old, established patient, with chronic essential hypertension on multiple drug regimen, for blood pressure check

62 year old female, established patient, for follow-up for stable cirrhosis of the liver

Expanded, low complexity, 2 to 4 systems evaluated

Clinical Examples - 99214

32 year old female, established patient, with new onset right lower quadrant pain

68 year old established patient, for routine review and follow up of non-insulin dependent diabetes, obesity, hypertension and congestive heart failure. Complains of vision difficulties and admits dietary noncompliance. Patient is counseled concerning diet and current medications adjusted.

77 year old male, established patient, with hypertension, presenting with 3 month history of episodic substernal chest pain on exertion

Clinical Examples - 99215

Evaluation of recent syncopal attacks in a 70 year old woman, established patient

30 year old male, established patient with 3 month history of fatigue, weight loss, intermittent fever, and presenting with diffuse adenopathy and splenomegaly.

70 year old female, established patient, with diabetes mellitus and hypertension, presenting with a two-month history of increasing confusion, agitation and short term memory loss

Important is the medical necessity

“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.

The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported

Try Your Knowledge

33 year old female, established patient, follow up for recently started treatment for hemorrhoid complaints, resolving

50 year old, established patient with diabetes, diet controlled. Now complains of frequency of urination and weight loss, blood sugar 320 and negative ketones on dipstick

65 year old, established patient, with stable diabetes and stable coronary artery disease, for monitoring

Decision Making from Coker Group 2007

Medical Decision Making (2 of 3): Documented DM _________ Diagnosis(es): Decision Making SF Low M High # diagnosis/mgmt options Minimal

(1) Limited (2)

Multiple (3)

Extensive (4+)

Amt of data to be reviewed Minimal/None (1)

Limited (2)

Multiple (3)

Extensive (4+)

Risk (refer to table of risk) Minimal (1)

Low (2)

Moderate (3)

High (4)

Dx and Management Options: Amt and/or Complexity of Data:

Counseling and Coordination of Care: Yes No Times Documented Yes N0

Problem Categories Number X Points = Score

Self-limited, minor (Max = 2) 1

Est.problem; stable, improved

1

Est. problem; worsening

2

New prob; no add’l workup (Max = 1)

3

New prob.; add’l workup planned

4

Total =

Points Type of Data 1 Review and/or order of clinical lab tests 1 Review and/or order tests in 7xxxx of CPT 1 Review and/or order of tests in 9xxxx of CPT 1 Discuss test results with performing MD 2 Independent review of image, tracing or specimen 1 Decision to obtain old records and/or obtain Hx from others 2 Review and summarize old records, and/or ________ obtain Hx Total

Risk Table

History from Coker Group, 2007

Examination summary from Coker Group, 2007

New or Established Patient

“New Patient” is a patient who has not received any professional services from the physician within the previous 3 years.

Physicians in Group Practice In same specialty – bill and be paid as

though they were a single physician In different specialties – bill and be paid

without regard to membership in the same group

Consultations

Performed at the Request of a physician or other appropriate source (must be documented)*

Report of findings provided to requesting physician

Recommendations for treatment are made

*guidelines further clarified in CMS Transmittal 788, January 2006

Documenting Counseling Visits

Total face-to-face time choose level of service by total face time

Show counseling took > 50% of time List medically appropriate topic(s)

“I spent 35 minutes total time with this patient, over half involved in discussing importance of compliance with diet instructions.”

Medically Appropriate Counseling

Diagnostic results Prognosis Risk & benefits of management option Instructions for mgmt &/or follow-up Importance of compliance Risk factor reduction Patient & family education

New ICD-9 CodesOctober 1, 2007

144 revised or new codes Published May 3, 2007 Federal

Register No grace period! Failure to use may result in rejected

claims after October 1, 2007

Have You Seen Services Denied Because:

“The information in your case does not support the need for this treatment”

“Medicare does not pay for this service for this illness or condition”

“Medicare does not pay for this many services in this time period”

“Services for same illness by more than one doctor are denied”

Then you have been denied payment because of lack of medical necessity.

Diagnosis Coding Must…

Support and be “mapped” to the service rendered

Be carried to the 4th or 5th digit if applicable

Be reported to the highest degree of specificity

For Medicare payment, must be supported by Local Medical Review Policy

CMS Guidelines and Medical Necessity

“The rationale for ordering diagnostic and other ancillary services should be easily inferred if not documented.”

“The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be reflected by the documentation in the medical record.”

Most Over-Reported ICD-9-CM Diagnoses

285.9 Anemia, unspecified 401.9 Unspecified hypertension 429.2 Arteriosclerotic cardiovascular

disease 786.50 Chest pain 724.9 Unspecified disorder of the back 784.0 Headache 786.05 Shortness of breath 789.00 Abdominal pain

Example:

Patient comes into office complaining of a burning pain in his stomach. He describes as moderately severe and improves when he takes antacid. Nurse Practitioner suspects an ulcer and refers the patient to a gastroenterologist for endoscopy. Today’s diagnosis is:

Code to highest degree of specificity

Abdominal pain 789.00 unspecified site 789.01 RUQ 789.02 LUQ 789.03 RLQ 789.04 LLQ 789.05 periumbilic 789.06 epigastric 789.07 generalized 789.09 other unspecified

Concurrent Care

May be denied “services not separately payable”

Documentation must reflect that each provider managed separate problem

For example: 484.3 pneumonia 033.3 pertussis

Compliance Issues with Diagnosis Coding

Coding a “rule out” or “suspected” condition as a confirmed diagnosis

Using a slightly higher level of diagnostic code in order to support the care given

Coding diagnoses that are no longer applicable

Not supplying diagnosis or reason for service when ordering ancillary tests

Not obtaining a signed waiver from Medicare patient before rendering a service that may not be covered for the diagnosis given

Summary Follow “incident to” and “shared visit” guidelines

when billing for Nurse Practitioner services Select the E/M code based on the level of service

performed and medical necessity Document the work according to CMS

Documentation Guidelines Use consultation and new patient codes

appropriately Add modifiers to indicate something “out of the

ordinary” took place Code only documented diagnoses