Best Practices: Physician Billing/Coding for Hospice ... › handouts › hen › 1231... · Medical Necessity & E/M • Documentation software may facilitate carry-overs and repetitive

Best Practices:Physician Billing/Coding for Hospice & Palliative Care

Presented by:

Christopher P. Acevedo, CHC, CPC

Objectives

• Describe the circumstances that allow physician visits to be separately billable

• List common pitfalls made by providers in hospice and palliative care

• Differentiate the hospice benefit from billable physician services

• Discuss how to substantiate the medical necessity of physician visits through thorough documentation

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Billable Physician Visits

© ACI 2009

Hospice Education Network - Best Practices: Physician Billing/Coding for Hospice & Palliative Care

Hospice Education Network (c) 2009

What Physician ServicesAre NOT/Are Billable?

• Are NOT:– Medical director

• General supervisory services– Physician member of IDG (team physician)

• Participation is establishing or revising plan of care• Supervision of care and services• Establishment of governing policies

CFR 418.304 (a)

– Visits to Hospice patients performed by a Nurse Practitioner (NP), if the specific NP has not been formally elected as the Hospice Attending

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E/M Services

• Billable encounters/visits– Medically necessary– Face-to-face

• Code sets by type of service and/or place of service– New patient vs. established patient

• Home visits• ALF, domiciliary, rest home visits

– Initial care vs. subsequent care• Inpatient hospital• SNF/NF

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“Medically Necessary” Defined*

• MEDICALLY NECESSARY“Services or supplies that are needed for the diagnosis or treatment of your medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of you or your doctor.”

http://www.medicare.gov/Glossary/search.asp?SelectAlphabet=M&Language=English

© ACI 2009



CMS’ FAQ

• Q: For hospice services, why are rounds not considered a patient care visit?

• A: Rounds are an administrative activity rather than a patient careactivity. A visit provided during rounds would not be considered a patient care visit unless a patient required a physician’s assessment and/or intervention during the visit. Rounds performed in a facility for the purposes of writing orders or any other non-patient care required services, do not count as visits. (Revised) Reference:

http://www.cms.hhs.gov/transmittals/downloads/R1494CP.pdf

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Medical Necessity

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• Reason for visit – May/May Not Mirror Subjective Complaint– May/May Not be Related to Terminal Dx– May/May Not be Related to Level of Care

Medical Necessity

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Reason for Today’s Visit

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Medical Necessity

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Medical Necessity & E/M

• Documentation software may facilitate carry-overs and repetitive fill-ins of stored information.

• Even when a “complete” note is generated, only medically necessary services for condition of patient at time of encounter as documented can be considered when selecting appropriate level of E/M service.

• Information not pertinent to patient’s condition at time of encounter cannot be counted.

© ACI 2009



Medical Necessity & E/M, cont.

• However, providers are entitled to appropriate level of reimbursement for medically necessary services that are supported by documentation.

• Should not down code or code “middle of the road”when a higher level of service has been rendered.

• Remember: down coding is as much of a billing error as up coding!

© ACI 2009

E/M Services

• Once the right “type” is identified– Location of the patient– New vs. Established– Initial vs. Subsequent

• Must choose right “level” of service– 3, 4 or 5 levels;– Based on documentation of history, exam,

and medical decision making; or– Time and counseling/coordination of care

Pitfalls

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Common Pitfalls –Documentation

• An Incomplete Hx Can Easily Sabotage an Encounter – Example:

• Upon admission to your IPU, a medically necessary physician visit takes place and an H&P is documented. The physician bills 99223. The documentation consists of a comprehensive Physical Exam and MDM is high, however the Hx lacks a documented Social Hx & Family Hx. How does this effect what should be billed?

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• Even a 99221 requires these be documented…

• With the minimum documentation requirements not met for even a 99221, all that’s left is 99499: an unlisted E/M service.– Good luck getting paid!

© ACI 2009


• An Incomplete PE Can Also Easily Sabotage an Encounter – Example:

• A medically necessary MD visit takes place in a patient’s home. The physician bills 99345. The documentation consists of a comprehensive Hx and MDM is high, however the documented PE only consists of 7 OS. How does this effect what should be billed?

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• With both a 99344 & 99345 requiring a comprehensive PE, the highest level new-pt. home visit supported by the documentation is 99343.

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Common Pitfalls –Type of Patient

• Established patient billed as New patients– Common occurrence as a pt may be

“new to me”

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Common Pitfalls –Respite

• The million dollar question…

Would I be seeing this patient if they were not under our care for Respite?

If yes, it becomes even more essential to document a clear reason for TODAY’s visit.

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Common Pitfalls –Assumptions

• Most Common Pitfall!– Physicians Know How to Document

• “They run their own private practice, they must know how to do it…”

• Documentation from a coding/documentation compliance perspective is not inherent to Physicians!

© ACI 2009

WHO IS LOOKING AT US?

XYZ Hospice

The Fight Against Fraud & Abuse

• CMS– MACs

• Probe Audits– Prepayment Review– Statistical Valid Random Sampling (SVRS)

– ZPICs• Formerly Program Safeguard Contractors (PSCs)

– Recovery Audit Contractors (RACs)– Comprehensive Error Rate Testing (CERT) contractor– Medicaid Integrity Program (MIP)

• Don’t forget the Private Payers!– Special Investigative Units (SIU)– Contracted audit companies



2010 OIG Work Plan

PHYSICIAN BILLING FOR Medicare HOSPICE BENEFICIARIES

We will review the extent of Part B billing for physician services provided to Medicare hospice beneficiaries. Physicians may receive reimbursement for hospice services under Medicare Part Aor Part B. This study is a follow-up to recent OIG studies on hospice care. We will determine the frequency of and total expenditures for physician services under Part A and Part B for hospice beneficiaries. We will identify whether physicians double-billed hospice services to Part A and Part B.

2010 OIG Work Plan

TRENDS IN Medicare HOSPICE UTLIZATION

When the hospice benefit was created in 1982, Medicare did not cover more than 210 days of hospice care per beneficiary. Congress changed the benefit to eliminate the limit on the number of days covered by Medicare. Since then, the number and types of diagnoses associated with hospice utilization have increased and longer stays have become more common. We will examine the characteristics of hospice beneficiaries, geographical variations in utilization, and differences between for-profit and not-for-profit providers.OEI 00-00-00000; expected issue date: FY 2011; new start

Some Numbers

• 2006 Presidential Review – Hospice Services– Trends from FY 1995 – FY 2005

• Most dramatic annual increases between 21% to 26% occurred from FY ‘01 – ’05

• The greatest increases by provider:– Freestanding hospices – 28% in FY ’01 and 31% in FY ‘03 and ’04– Skilled nursing facility (SNF) based hospices – 25% in FY ‘03

• The greatest increases by care type:– Physician services - exceeded all other care types – 43% in FY ‘02 and

30% in FY ‘03– Continuous home care (CHC) – 33% FY ‘03 and 31% in FY ’04



Cause for Concern?

• The average length of stay:– Continues to rise

• National average of 64 days in FY ’05 vs. 53 in FY ’02• Freestanding facilities - 69 days in FY ’05 vs. 57 in FY ’02

• Expenditures continue to rise at double digits each year– Number of beneficiaries/amount of outlay per beneficiary has

been increasing at a much more modest rate.

Staggering Numbers

• 491% increase in total outlays for freestanding hospices

• Outlays for physician services have risen 641%!

Decrease in Cancer Related Dx

Source CMS Hospice Data



Some Additional Numbers

Source CMS Hospice Data

Internal Controls

© ACI 2009

Best Practices in Billing/Coding

• Identify the Internal Experts (you may be surprised)• Identify Physician Champions of Compliance

– Your Best Ally

• Education– For Providers (you will be surprised!)

• Include Appropriate Billing Staff– For Leadership Team

• Documentation is the Key– Provide Cheat Sheets (trying to teach new tricks!)

• QAPI• Consider Outside Audit

– Mock Payer Review



Auditing/Monitoring

• What type of quality checks do you have in place?– Assessing physician/NPP documentation– Assessing contract physician documentation

• YOU are billing for these services? Are they being documented appropriately?

– Annual Code Changes• Changes to coding rules

– Annual Rule Changes• Are we in compliance today?

Compliance Guidance

• What codes do we look at? – a random sample of claims/services?– all claims/services from a particular payer?

• Identify risk areas– Use these risk areas as the universe of claims/services from

which to select the sample • OIG recommends an evaluation to determine if the

codes billed and reimbursed were accurately ordered, performed, and reasonable and necessary for the treatment of the patient

What are you looking for?

• Evaluation & Management– Consultation vs. Referral– Levels of E/M service

• Can you read it?• Can you tell who provided the service?• Can you tell in what setting service was provided?



Compliance Guidance

• Must make appropriate response when problem identified– Timely

• Specific action depends on circumstances – May be straight forward

• repayment with appropriate explanation to payer– May need to involve a Qualified Health Care Attorney

• to determine the next best course of action

Post Audit Follow-Up

• Education– Physicians, NPPs, nurses– Staff (registration, coding/billing, administrative)

• Processes to prevent identified errors from reoccurring

• Monitoring techniques– Correspondence from the carriers and insurers challenging the medical

necessity or validity of claims – Check productivity reports for illogical patterns or unusual changes the

pattern of CPT, HCPCS or ICD.9 code utilization – Review monthly A/R reports for high volumes of unusual charge or

payment adjustment transactions.

Follow-up

• Focused review– Targeted area of coding, documentation– W/in 30-90 days of education– New physician, new service

• Progressive action– One CPT code on 100% prospective review– All coding on 100% prospective review

• Comparisons• Rewards!• Start all over again



Auditing/Monitoring

• At what point do we hire a coder?• What credentials should he/she have?• Experience?• Where do we look?• How do we monitor the coder?

– How do we know what we don’t know???

Education Needs

• Recognize the importance of continued education

• Educate physicians/NPPs as new hires!• Regulations change frequently – have a

plan to keep up with changes• Develop templates that incorporate coding

requirements• Use billing/coding “Cheat sheets”

Assessing Providers

• Who are your outliers• What are the most frequent E/M codes• Keep track w/ benchmarks



Education Needs –Provider Meetings

• Case studies• Selective review of random charts• Time allotted each quarter to billing/coding

teaching• Focus on basics

Agency Education Needs

• Assign someone to “own”• Knowledgeable about provider billing• Become familiar w/ nuances• Review transmittals from Medicare• Benchmark your provider billing/coding• CME yearly

© ACI 2009

Christopher P. Acevedo, CPC, CHCAcevedo Consulting Incorporated

561.278.9328Cacevedo@acevedoconsulting.comwww.AcevedoConsultingInc.com



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Best Practices: Physician Billing/Coding for Hospice ... › handouts › hen › 1231... · Medical Necessity & E/M • Documentation software may facilitate carry-overs and repetitive