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Practice Management Pearls
OPSO 2015 Annual Conference Presented by:
Cynthia Penkala CMM, CMPE, CMSCS, CPOM
American Osteopathic Information Association
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Disclaimer
• The lectures and presentations are intended for educational purposes only.
Speakers and presenters provide their viewpoint and opinion and have not
consulted with the hosting Association in developing the presentation. This
presentation is targeted at the audience as a whole and not to the specific
circumstances of individuals attending the program. The presentations do
not replace independent professional judgment and study of the specific
details an attendee may be confronting. Statements of fact and opinions
expressed are those of the individual presenters and, unless expressly
stated to the contrary, are not the opinions or position of the hosting
Association, its cosponsors, or its committees. The hosting Association
does not endorse or approve, and assumes no responsibility for, the
content, accuracy or completeness of the information presented
Reviewed by the Division of Socioeconomic Affairs, in conjunction with the General Counsels’ office in January 2015.
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Join today.
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or join online
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3
Objectives
1. Hear the top practice management concerns
2. How to address the concerns
3. Provide information to help keep your doors
open
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Objective 1
1. Hear the top practice management concerns
2. How to address the concerns
3. Provide information to help keep your doors
open
5
Top 10 Challenges in 2015 According to Medical Economics, December 1, 2014
1. ICD-10 preparation
2. HIPAA
3. Meaningful Use
4. Getting Paid
5. Maintaining Certification
6. Collecting Co-pays & Deductibles
7. Administrative Burdens
8. Rising Operational Costs
9. Pay for Performance
10.Independence v Employment
AOA Top Challenges
1. ICD-10 preparation
2. HIPAA
3. Meaningful Use
4. Getting Paid
5. Maintaining Certification
6. Collecting Co-pays & Deductibles
7. Administrative Burdens
8. Rising Operational Costs
9. Pay for Performance
10.Independence v Employment
Service Call Activities
Jan 2013 – Dec 2014
72% Denials & Audits
93% Billing & Coding
52% ICD-10
Objectives 2
1. Hear the top practice management concerns
2. How to address the concerns
3. Provide information to help keep your doors
open
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Top AOA
practice management concerns
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ICD-10 52%
#1
Just Around The Corner
October 1, 2015 11
What is ICD-10?
International Statistical Classification of
Diseases and Related Health Problems
(ICD)
10th Edition
12
Why the change to ICD-10?
• ICD-9-CM Limitations – ICD-9-CM running out of codes
– 36 years old
– Not descriptive enough
– Not able to accurately reflect advances in medical knowledge or technology
– Uses outdated and obsolete terminology
– Can not accurately describe the diagnoses and care in the 21st century
– Inability to expand to capture additional advancements in clinical medicine
– Will not meet health care needs of the future
• Ebola 078.89: other specified diseases due to viruses
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ICD-10 Avoidance Syndrome
Diagnosis
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Chief Complaint
• “There so many codes?”
• “We should just wait until ICD-11?”
• “There are a bunch of dumb codes
that don’t make sense.”
• “Documentation for ICD-10 is just
another burden.”
Source: Health Data Consulting © 2012 15
“Why are there so many Codes?”
• There are lots of words in the dictionary, but that doesn’t
seem to trouble authors…
• 34,250 (50%) of all ICD-10CM codes are related to the
musculoskeletal system
• 17,045 (25%) of all ICD-10CM codes are related to
fractures
• ~25,000(36%) of all ICD-10-CM codes distinguish ‘right’
vs. ‘left’
• Only a very small percentage of the codes will be used
most providers
Source: Health Data Consulting © 2012 16
“Why don’t we wait for ICD-11?”
• ICD-9 (WHO) Published in 1978
• ICD-10 (WHO) – Endorsed in 1990
• ICD-10-CM draft released in 1995
• ICD-10 used for Mortality in the US since 1999
• Proposed rule for ICD-10 adoption in 2008
• The gap between ICD-9 and ICD-10 is not nearly as
dramatic as the gap between ICD-9 and ICD-11
• Based on historical implementations by the time we get
to ICD-11-CM and from there to implementation, it will be
2040.
Source: Health Data Consulting
Source: Health Data Consulting © 2012 17
““There are a bunch of dumb
codes that don’t make sense.”
• Hit by a Space Ship
Suicide by paintball gun
Source: acclaim images 18
““There are a bunch of dumb
codes that don’t make sense.”
– ICD-9 codes
E845
Accident involving spacecraft
E955.7
Suicide and self-inflicted injury by
paintball gun
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“Documentation for ICD-10
is an unnecessary burden.”
• The number and type of new concepts required for
ICD-10 are not foreign to clinicians
• More complete documentation = more accurate
billing for services
• Protection in case of audit – “if it isn’t documented
it didn’t happen”
• Improved information flow for transitions of care
• Justify medical necessity
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Bottom Line
If your practice is not ready,
you won’t get paid!!!!
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Exam and Treatment
for
Avoidance Syndrome
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Project Plan
Step 1 - Stakeholder support
Step 2 - Practice assessment
Step 3 - Diagnosis patterns
Step 4 - ICD-10 requirements
Step 5 - Training
Step 6 - Testing
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Moving Forward
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10 DAYS
Get a Book
• Hints
• Tips
• Conventions
• Guidelines
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ICD-10- CM guidelines
• ICD-10-CM Official Guidelines for Coding and Reporting
FY 2016
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-ICD-
10-CM-Guidelines.pdf
• 30-35 pages
• Read and Understand
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ICD-10 CM Hints and Tips
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ICD-10 CM
CDI
Documentation
Code Selection
Conventions, general coding
guidelines and chapter specific
guidelines
“The conventions and instructions of classification
take precedence over guidelines”
• General rules
• Instructional notes
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ICD-10- CM Conventions • Excludes 1
– “NOT CODED HERE”
– Code excluded should never be used at the same time as the code above the Excludes 1 note
– Used when two conditions cannot occur together
– Ex. Congenital form versus acquired form of same condition
• Excludes 2 – “Not included here”
– Not part of the condition represented by the code
– Can use both the code and excluded code when appropriate
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ICD-10- CM Conventions
• “X” Placeholder character
• 7Th characters
• NEC - specific code does not exist
• “Other” codes - specific code does not exist
• NOS - documentation insufficient
• “Unspecified” codes - documentation insufficient
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ICD-10- CM Conventions
7Th Character
• Chapter 19 – Injury, Poisoning and Certain Other
Consequences of External Causes
• Episode of care - injury
o A – Initial encounter ( pt. receiving active treatment)
o D – Subsequent encounter ( pt. in healing phase)
o S – Sequela (complications due to injury)
Contusion of liver initial encounter
S36.112A
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ICD-10- CM Conventions 7Th Character
• Chapter 19 – Injury, Poisoning and Certain Other Consequences of External Causes
• Episode of care - fracture o A – Initial encounter for closed fracture
o B – Initial encounter for open fracture
o D – Subsequent encounter for fracture with routine healing
o G – Subsequent encounter for fracture with delayed healing
o K – Subsequent encounter for fracture with nonunion
o P – Subsequent encounter for fracture with malunion
o S – Sequela
Greenstick fracture of shaft of humerus left arm subsequent encounter for fracture with delayed healing
S42.312G
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ICD-10- CM Conventions 7th Character
• Chapter 15 – Pregnancy, Childbirth and the
Puerperium
– Fetus. Used for certain complications of pregnancy with
multiple gestation to identify which fetus(es) is(are)
affected by the condition described by the code.
o 0 = not applicable or unspecified 4 = fetus 4
o 1 = fetus 1 5 = fetus 5
o 2 = fetus 2 9 = other fetus
o 3 = fetus 3
Decreased fetal movements third trimester fetus 2
O36.8132
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ICD-10- CM guidelines
• “all documented conditions that coexist at
the time of the encounter/visit and require
or affect patient care treatment or
management””
Diabetes? Pregnancy? Cancer?
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ICD-10- CM guidelines
• “Code signs and symptoms when a related
definitive diagnosis has not been
established”
Found mostly in R00-R99
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ICD-10 CM Hints and Tips
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ICD-10 CM
CDI
Documentation
Code Selection
• the crux of the issue
– Efficiency in patient care
– Improved coding (reductions in unspecified codes)
– Faster payments; less rejections
– Interoperability – exchanging more complete
information
– Protection for audits
– Potential for improved quality scores
– Better quality of data analysis and research
Documentation Improvement
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Documentation Improvement
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• Laterality
• Encounter type
• Anatomical details
• Severity
• Disease relationships
• Diagnosis for every procedure
performed
• Diagnosis for every test ordered
Documentation Improvement
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• It is not the quantity of information documented it is the accuracy and quality
• Each visit is unique and must be able to stand alone
• What if …
Documentation Improvement
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Coding Tips
• Keep your ICD-9 book
• CPT/HCPCS Codes will not be impacted – continue to
follow CPT/HCPCS guidelines, including modifiers
• Look up new NCD and LCD www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html
• Choose the right code not necessarily the first code
listed
• Acute condition should always be listed before chronic if
both documented
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CMS Grace Period
• CMS will not deny claims solely based on
the specificity of dx codes as long as you
are in the family
• Medicare claims will not be audited in the
first year based on the specificity of dx
codes as long as you are in the family
Note: Most large commercial payers have NOT
agreed to follow this
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Top AOA
practice management concerns
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Billing and Coding 93%
#2
Reporting E/M Services and
OMT Procedures
• Report the appropriate E/M service code
(99201-99215) based on the documentation
• Append Modifier-25 to the E/M service code
• Report the appropriate OMT procedure code
(98925-98929) based on the physical
examination findings
Modifier-25 Language Located in the
CPT Guidelines for Reporting OMT
Evaluation and Management services, including a
new or established patient office or other
outpatient services, may be reported separately
using modifier -25 if the patient’s condition requires
a significant, separately identifiable E/M service
above and beyond the usual preservice and
postservice work associated with the other
procedure.
99213 Work Description Description of Pre-service Work:
• Review medical history form completed by the patient & vital signs obtained by clinical staff.
Description of Intra-service Work:
• Obtain an expended problem focused history (including response to treatment at last visit and
reviewing interval correspondence or medical records received).
• Perform an expended problem focused examination. Consider relevant data, options, and risks
and formulate a diagnosis and develop a treatment plan (low complexity medical decision
making).
• Discuss diagnosis and treatment options with the patient. Address the preventive health care
needs of the patient.
• Reconcile medication(s). Write prescription(s). Order and arrange diagnostic testing or referral
as necessary.
Description of Post-service Work:
• Complete the medical record documentation.
• Handle (with the help of clinical staff) any treatment failures or adverse reactions to medication
that may occur after the visit.
• Provide necessary care coordination, telephonic or electronic communication assistance, and
other necessary management related to this office visit.
• Receive and respond to any interval testing results or correspondence. Revise treatment
plan(s) and communicate with patient, as necessary.
98927 Work Description
Description of Pre-Service Work:
The physician determines which osteopathic techniques (e.g., HVLA, Muscle energy, Counterstain, articulatory, etc.) would be most appropriate for this patient, in what order the affected body regions need to be treated and whether those body regions should be treated with specific segmental or general technique approaches. The physician explains the intended procedure to the patient, answers any preliminary questions, and obtains verbal consent for the OMT. The patient is placed in the appropriate position on the treatment table for the initial technique and region(s) to be treated.
Description of Intra-Service Work:
The patient is initially in a side-lying position on the treatment table. Motion restrictions of identified joints are isolated through palpation and treated using a variety of techniques as follows: acromioclavicular joint is treated with articulatory technique; glenohumeral and costal dysfunctions are treated with muscle energy technique; cervical spine is treated with counterstain technique; thoracic and lumbar dysfunctions are treated with passive thrust (HVLA) technique. Patient position is changed as necessary for treatment of the individual somatic dysfunctions. Patient feedback and palpatory changes guide further technique application as appropriate.
Description of Post-Service Work:
Post-care instructions related to the procedure are given, including side effects, treatment reactions, self-care, and follow-up. The procedure is documented in the medical record.
Procedure Note
• OMT is a procedure, and although it’s distinct from other
procedures, nevertheless it is a procedure and should be
documented in that manner
• As such, it may be beneficial to prepare a procedure
note for the OMT detailing which regions were treated,
which techniques were utilized, and how the patient
tolerated the treatment
• Documenting in this fashion meets the requirements for
reporting any procedure that is performed and assists in
an audit situation when OMT is being challenged from a
documentation perspective
Osteopathic Manipulative
Treatment Codes • M99.00 Segmental and Somatic Dysfunction of Head Region
• M99.01 Segmental and Somatic Dysfunction of Cervical Region
• M99.02 Segmental and Somatic Dysfunction of Thoracic Region
• M99.03 Segmental and Somatic Dysfunction of Lumbar Region
• M99.04 Segmental and Somatic Dysfunction of Sacral Region
• M99.05 Segmental and Somatic Dysfunction of Pelvis Region
• M99.06 Segmental and Somatic Dysfunction of Lower Extremity
• M99.07 Segmental and Somatic Dysfunction of Upper Extremity
• M99.08 Segmental and Somatic Dysfunction of Rib Cage
• M99.09 Segmental and Somatic Dysfunction of Abdomen and other
regions
51
Top AOA
practice management concerns
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Denials & Audits 72%
#3
Denials
What is a Denial?
– the refusal of an insurance company or carrier to
honor a request by an individual (or his or her
provider) to pay for health care services obtained
from a health care professional.
– Can be entire claim or line item
Denials
• Only 35% of providers appeal denied
claims
• 95% of appealed claims get paid on first
appeal
54
Top Denials
• Duplicate claim = abusive biller
• Missing modifier
• Insurance not active
• Not primary carrier
• Medical necessity
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Appeal Tips
• Review claims before they go out the door
• Appeal ALL denials
• If needed appeal through all levels
• Use the word APPEAL in your written
correspondence
• Hold payers accountable to timely filing
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Audits
If you are audited does it mean you have done
something wrong:
A. True
B. False
Audits
What is a health care audit?
– A mechanism of review to determine compliance:
• Coding
• Documentation
• Other payment guidelines
– The primary payer issues:
• appropriate coding
• documentation
Audits
• FACT: Medical audits are a challenge and
burden to physician practices.
• FACT: Standard business operation as
federal and state governments and private
payers all search for ways to control
healthcare spending.
• FACT: You can and should anticipate and
be prepared to be audited.
59
Who Are The Auditors?
• Commercial Insurance Audits
• Comprehensive Error Rate Testing (CERT)
• Department of Justice (DOJ)
• Federal Bureau of Investigation (FBI)
• Medicare Administrative Contractors (MACs)
• Medicare Contractor Review (MR)
• Office of the Inspector General (OIG)
• Recovery Audit Contractors (RACs)
Why Audits Are Initiated?
• Suspicious Billing
Pattern
• Outlier Physicians
• Whistleblowers
• Procedure Codes
What Auditors Look For?
• Billing for services or supplies that were not
provided
• Billing for non-allowable or non-covered services
• Altering claim forms to receive a higher payment
amount
• Unbundling services
Most common errors
RAC auditors see
• Place of service – inpatient, outpatient,
observation
• E/M during global period
• Pharmaceutical unit billing
63
Audits
What Should You Do If You Get An Audit Letter?
• Ensure your staff is aware of the significance of an
audit request
• Identify the requester (e.g. governmental organization
or a private insurance carrier)
• Determine the magnitude of the request
• Request additional time to submit requested
information!
How To Respond To An Audit
• You may want to conduct an internal audit
• If you did not request additional time reply to the audit
notice in a timely fashion
• If the guideline states respond within 30 days, that
does not mean 31 days, you must follow the rules
• Gather and submit only the requested documentation
• Keep a record of and/or a copy of the information
submitted
• Be cooperative
Audit Tips
• Don’t miss any deadlines
• Ask for one auditor to be your contact
• Keep copies of ALL audit
communications from start to finish
• HIPAA applies – remove or redact
patient-identifying data
• Date and page stamp copied or
scanned documents before submission
Audit Tips
• Send only the records that were requested
• Save the ‘because’ for the appeal
• Send and present documentation in a clear and
orderly way
• Review records before you send out
• Send documents certified mail or another delivery
mechanism that includes tracking and verification
of receipt.
• Send emails using confirmation receipts and/or
“read” receipts
• Retain receipt verification
How to Respond to the Audit Findings
If the findings are not favorable:
• Attempt to discuss the findings with the reviewer
• If necessary request a redetermination
• If necessary request a next level appeal
• If necessary involve State, Specialty or National
Association
Extrapolation
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Extrapolation
Extrapolation is the process of estimating, beyond the original observation range, the value of a
variable on the basis of its relationship with another variable.
Objective 3
1. Hear the top practice management concerns
2. How to address the concerns
3. Provide information to help keep your doors
open
70
HOMEWORK
• Read ICD-10-CM Official Guidelines for Coding and
Reporting
• Diagnosis Patterns
• Crosswalk
• Gap Analysis
• Cheat Sheet
• Shadow Code
• Clean up your AR
• Sept 30 – send out all claims at end of day
• No vacation or PTO
• Oct 10 – 30th – rework staff schedules 71
November 2015
• Track denials
– Type
– Code & category
– Payer
– provider
72
AOA
ICD-10 Resources
• ICD-10 Webinars at
www.osteopathic.org/ondemandwebinars
• ICD-10 Web page at
www.osteopathic.org/icd-10
• ICD-10 Coding question?
73
Other ICD-10 Resources
• CMS - www.cms.gov/ICD10/ – Coding Documentation (Indexes, Coding Guidelines, Code Files)
– General Equivalency Mapping [GEM] (Mapping files, Guidelines, Procedure and Diagnosis)
– FAQ, Coordination and maintenance Committee minutes
– ICD-10 Clinical Concept Series
• WEDI - www.wedi.org/ – List serves
– Workgroups
– White papers
– Implementation forums
– Industry advocacy and issue
– Access to standards leaders
• AHIMA – www.ahima.org/ – Training and certification
– Extensive documentation libraries
– Bookstore
– Communities of practices
– ICD-10 focused conferences
Source: Health Data Consulting
74
AOA
Audit Resources
• Audit Toolkit
www.osteopathic.org/audits
• AOA contracted vendors offering
discounted audit help
– SCG Health [email protected]
– EHRPMC [email protected]
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AOA
Denial & Appeal Resources
www.osteopathic.org/buildingblocks
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Practice Management Upcoming Live Webinars
www.osteopathic.org/PMwebinars
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Oct. 7 The Direct Pay Primary Care Practice
Oct. 14 The Concierge Practice
TBD Locum Tenens
Nov 4 Latest Practice Trends to Increase Profitability
Nov 11 Micro Practice and Other Strategies for Reducing Overhead Costs
Nov 18 Physician Extenders: Working with an NP or PA to Increase Profitability
Practice Management On-Demand Webinars
www.osteopathic.org/ondemandwebinars
• Building Blocks of Medicine
• Power-up for practice growth and
profits
• HIPAA
• Meaningful Use
• ERISA
• ICD-10
• Coding
• Value Based Modifiers
• Healthcare Literacy
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Practice Management Communications
• Free, timely and relevant practice management e-mail communications from the AOA.
• Office Management Tidbits Newsletter
• Physicians, practice staff, consultants and other health care partners are invited to sign up.
Register at:
www.osteopathic.org/pmsubscribe
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Objectives Met
Learn the top practice management
concerns
How to address the concerns
Provide information to help keep your doors
open
80
Cynthia (Cindy) Penkala CMM, CMPE, CMSCS
Director, Practice Management & Vendor Relations
312-202-8088 81
