07 Am09 Presentations Hamburger & Lawson

Code for Documentation! Audit for Compliance!

Richard J Hamburger MDProfessor Emeritus of Medicine

Indiana UniversityIndianapolis IN

Debra H. Lawson, CPC, PCSNephrology Billing & Management

Services, LLCRogersville, TN

ObjectivesObjectives interaction requested

Session I

1. Review Changes in codes

1. ESRD

2. Infusion

2. Consultation v. referral1. New patient v. your

patient

2. Hospitalist care

Session II

1. Discharge day

2. Hospital dialysis

3. Intensive care1. Definition & rules

2. Tips

4. Compliance Assessment

ESRD Codes Where are we?

• Previous CPT family (1995-2003)– 90918-90925

• G-code living (2004-2008)– G0308-G0327

• The new times (2009- )– 90951-90970

End Stage Renal Disease Services End Stage Renal Disease Services (ESRD)

• CPT codes 90918 – 90925 have been deleted and new codes are under a new section entitled End Stage Renal Disease Services

• G codes for ESRD disappeared

• CPT codes 90951 – 90970 have been added with new code descriptors

What are we trying to capture?

• Physician work for patients on dialysis

• Excluded:– Inpatient services– E&M services that cannot be furnished on

dialysis (non-renal related)– Non-ESRD dialysis services performed in an

outpatient setting

Approach to the family

• CPT groupings by age

• Youngest to oldest

• In center code values first

• Home dialysis values to follow

• Daily visit code values to conclude

End-Stage Renal Disease ServicesEnd-Stage Renal Disease Services

Codes 90951-90962 are reported once per month to distinguish age-specific services related to the patient's end-stage renal disease (ESRD) performed in an outpatient setting with three levels of service based on the number of face-to-face visits. ESRD-related physician services include establishment of a dialyzing cycle, outpatient evaluation and management of the dialysis visits, telephone calls, and patient management during the dialysis provided during a full month. In the circumstances where the patient has had a complete assessment visit during the month and services are provided over a period of less than a month, 90951-90962 may be used according to the number of visits performed.


Evaluation and Management services unrelated to ESRD services that cannot be performed during the dialysis session may be reported separately. Codes 90967-90970 are reported to distinguish age-specific services for end-stage renal disease (ESRD) services for less than a full month of service, per day, for services provided under the following circumstances: home dialysis patients less than a full month, transient patients, partial month where there was one or more face-to-face visits without the complete assessment, the patient was hospitalized before a complete assessment was furnished, dialysis was stopped due to recovery or death, or the patient received a kidney transplant. For reporting purposes, each month is considered 30 days.


● 90960 End-stage renal disease (ESRD)

related services monthly, for

patients 20 years of age and

older; with 4 or more face-to-face

physician visits per month

● 90961 with 2-3 face-to-face physician

visits per month

● 90962 with 1 face-to-face physician

visit per month

Adult In Center codes: Adult In Center codes: >>20 y.o.20 y.o.

• G code Value CPT 2009 Value

• G0317 5.09 90960 5.18

• G0318 4.24 90961 4.26

• G0323 3.39 90962 3.15


● 90966 End-stage renal disease (ESRD)

related services for home dialysis

per full month, for patients 20

years of age and older

• G code Value CPT Value

• G0323 4.24 90966 4.26

Pediatric In Center codes: <2 y.o.Pediatric In Center codes: <2 y.o.


• G0308 12.7490951 18.46

• G0309 10.6 90952 C.P.

• G0310 8.49 90953 C.P.

• C.P.=Carrier Priced

Pediatric Home Dialysis codesPediatric Home Dialysis codes


• G0320 10.61 90963 10.56

• G0321 8.11 90964 9.14

• G0322 6.90 90965 8.69

• G0320/90963 = <2 y.o. G0321/90964 = 2-11 y.o.• G0322/90965 = 12-19 y.o. All are FULL month of service

MCP GUIDELINES

A POLICY REVIEW

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MONTHLY CAPITATION MONTHLY CAPITATION PAYMENTPAYMENT

Not included in MCP• Non-renal related evaluation and management

• Hospital inpatient services

• All non-renal procedures

• Evaluation for transplant or LRD evaluation

• Training of patients to perform home dialysis

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MONTHLY CAPITATION PAYMENT

Included in the MCP• All renal-related outpatient services rendered to the

dialysis patient• Interpretation of ancillary testing (nerve conduction

studies, bone density, doppler studies)• Services rendered to the dialysis patient while on

dialysis• Physicals required by the dialysis facility for the

renal patient


Included in the MCP

• Certification of the need for items & services such as DME & home health care

• Care plan oversight services described by CPT code 99375

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Included in the MCP• Periodic visits (at least one per month) to the patient

during dialysis to determine if the dialysis is working well both physiologically & psychologically.

During this encounter the physician will determine if any elements of the plan need to be revised to optimize the patient’s treatment and/or care.

• Coordination & direction of the multi-disciplinary team involved in the patient’s care.

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OUTPATIENT SETTINGSOUTPATIENT SETTINGS

• The MCP covers all outpatient services related to the patient’s renal condition

• Services may be rendered in the in-center dialysis unit, patient’s home, practitioner’s office, outpatient hospital, observation care, emergency room and outpatient surgery– Inpatient services cannot count as MCP

encounters

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PRACTITIONER DEFINITIONS

• MCP physician is the physician who performs the “major” (care plan) visit during the month. This physician is the billing physician

• Non-physician practitioner – NP/PA who is employed by the same entity as the physician– Must be able under statute to furnish services that would be

physician services

• Non-MCP physician – must have a relationship with the MCP physician such as partner

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USE OF NON-PHYSICIAN USE OF NON-PHYSICIAN PRACTITIONERSPRACTITIONERS

• MCP physician (billing physician) must provide the visit with the complete assessment of the patient, establish the plan of care, and submit the bill for the monthly service – Must see the patient at least once a month– Non-physicians can provide some of the visits to equal total #

submitted

– Non MCP physician can provide some of the visits

– Non-physician must have a relationship with the physician (employee)

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PARTIAL MONTH RULEPARTIAL MONTH RULE• 90967-90970 ESRD related services for dialysis less

than a full month of service • Use limited to:

– Transient patients– Home dialysis patients– Patients who have a permanent change in their MCP

physician during the month– Partial month with one or more face-to-face visits without the

comprehensive visit but only in patients with• Dialysis stopped due to death. • Dialysis patient transplanted• Dialysis patient hospitalized during the month

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PARTIAL MONTH RULEPARTIAL MONTH RULE

• Partial month rule does not apply to patients who start dialysis during the month

• Without a complete assessment, these patients cannot be billed for this first month on dialysis

• Cannot bill 90967-90970

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TRANSIENT PATIENTSTRANSIENT PATIENTS

• Only one physician can bill for the management of a patient per month

• Bill 90970 daily for the number of days the patient is under the transient physician’s care

• If the transient patient is in the transient dialysis unit for a full month, then transient MD becomes MCP physician and the same rules apply as with any other in-center patient.

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PATIENTS WITH LESS THAN A FULL MONTH MCP

• Bill as if the patient had a full month of dialysis with the appropriate CPT code for the number of encounters if:– Dies during the month– Transplants during the month – Transfers during the month

Patient must have complete assessment to bill using the appropriate CPT code

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HOSPITAL OBSERVATION HOSPITAL OBSERVATION STATUSSTATUS

• ESRD-related visits furnished in hospital observation status count as an MCP encounter

• Visit will count towards the total number of encounters submitted (CPT code)

• Describe (document) in the medical record the type of ESRD-related service rendered in observation status

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HOSPITALIZATION HOSPITALIZATION & the & the MCP MCP inin IN-CENTER PATIENTSIN-CENTER PATIENTS

• ESRD patients, other than home dialysis patients, hospitalized during the month will be billed for the number of face-to-face encounters that occurred when the patient was not hospitalized

• Since the MCP is no longer “time” dependent, but based on encounters face-to-face, the practitioners no longer “carve out” hospital days.

• Bill inpatient care and the CPT code for the number of outpatient face-to-face encounters

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HOME DIALYSIS

• Payment similar to 2-3 visit payment level approximately $221.66

• Monthly visit is the routine – bill using full month code (90966 for 20+ years old)

• If patient has less than full month at home– bill using daily code – (90970 for 20+ years old)

• Home patients are billed similarly to how MCP was billed historically

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HOME DIALYSISHOME DIALYSIS

• If the home patient receives in-center dialysis during the month, the provider would still bill the management fee for the month under the home dialysis provision

• The physician cannot bill the in-center CPT code or CPT 90935-90937 for the encounters in-center

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HOSPITALIZATION & the

MCP - HOME DIALYSIS• Home patients continue to be billed in a full

month or partial month format similar to previous coding

• If the patient is home for the 1st -10th hospitalized from the 11th-20th, then back home from the 21st-30th, you would bill for the 90970 (adult) for the 1-10 (10 days), inpatient codes for 11-20, then 90970 for the 21-30 (10 days)

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TEACHING PHYSICIANSTEACHING PHYSICIANS

• Patient visits by residents or fellows who are counted towards an institution’s Medicare graduate medical education (GME) payment may not be counted towards the MCP visits in place of the MCP physician

TEACHING PHYSICIANS• **NEW** Patient visits furnished by residents &

fellows may be counted toward the MCP comprehensive visit if the teaching MCP physician is physically present during the visit.

• The teaching physician may utilize the resident’s notes, HOWEVER, the teaching physician must document his or her physical presence during the visit(s) and that he/she reviewed the notes.

• This then may be used for the MCP note. Change request 5932

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MODALITY CHANGESMODALITY CHANGES

• If a patient switches modalities during the month, bill the entire month using the appropriate HOME dialysis code 90963-90966

• If partial month care bill using 90967-90970

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CHANGES IN DOCUMENTATION CHANGES IN DOCUMENTATION REQUIREMENTSREQUIREMENTS

• CMS stopped short of dictating documentation requirements however were very specific on what was necessary

• With requirements now for verification of physician’s face to face visits, documentation of encounters will be necessary

• RPA offers a documentation tool to meet CMS recommendations

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CHANGES IN DOCUMENTATION REQUIREMENTS (cont)

• Document what is clinically relevant including but not limited to:– patient's current status and complaints,

– a clinically appropriate physical examination, assessment of the patient's treatment for ESRD that includes assessment of the adequacy of the dialysis treatment, the status of the patient's vascular access, assessment and treatment of the other conditions associated with ESRD, such as anemia, electrolyte management, and bone density, as well as changes to the patient's management

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ADDITIONAL ADDITIONAL DOCUMENTATION NEEDED DOCUMENTATION NEEDED FOR PEDIATRIC PATIENTSFOR PEDIATRIC PATIENTS

• In addition to the requirements for adult patients, pediatric nephrologists also need to:– Monitor the patient for adequacy of nutrition– Assess for growth and development– Counsel parents

Documentation must show these elements In addition to the adult documentation requirements

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CHANGES IN DOCUMENTATION REQUIREMENTS (cont)

• Documentation of the “major” visit is required

• Documentation that the physician performed a service for the patient is required for the other encounters

• Signing a dialysis flow sheet or any other form if not enough…the physician must document they are performing a service at each encounter

IMPORTANT TIP!

• Patients starting new with you or your facility CANNOT be brought into your office prior to going on dialysis and a new patient E&M billed.

• This service is done because they are ESRD (renal related), in the outpatient setting, it is part of the MCP

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HOME DIALYSIS HOME DIALYSIS TRAININGTRAINING

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HOME TRAINING DIALYSIS HOME TRAINING DIALYSIS MANAGEMENTMANAGEMENT

• 90989 - Dialysis training, patient, including helper where applicable, any mode, complete course

• 90993 - Dialysis training, patient, including helper where applicable, any mode, course not completed, per training session (billed by units completed)

• Physician must have direct participation in the training to bill

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HOME TRAINING DIALYSIS MANAGEMENT

• Example of billing for training

– Patient on hemodialysis March 1-15, 2009• Seen with comprehensive visit 2 times

– Patient began home PD training March 16 continued through March 21, 2009.

• Physician participated directly in training – 90989, PD training complete, March 16,17,19,20,21, 2009

– Patient at home for the full month (90963-90966)

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HOME TRAINING DIALYSIS MANAGEMENT

• A completed course is reimbursed with a maximum $500 allowable

• A completed course should be reported with 90989 with a quantity of “one”

• For a training course not completed bill 90993 for the number of sessions completed and reimbursed at a $20 per session allowable

Infusion CodesInfusion Codes

Non facility codes where physician work involves affirmation of treatment plan and direct supervision of staff

• Hydration 96360 31min-1 hr 96361 > 1hr

• Therapeutic, prophylactic or diagnostic IV infusion of substances or drugs 96365-96376

CONSULT CONSULT VV REFERRAL REFERRAL

CORRECT CODING

CAN MEAN

$$$$

INCORRECT CODING….

http://www.lawranceordnance.com/security/images/handcuffs/M100Handcuffs.jpg

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CONSULTATIONCONSULTATION

• At the request of a referring physician or other

appropriate source for opinion or advice

• Requires evaluation and/or management of a

specific problem

• Requires written communication to the

requesting physician or other appropriate source

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• Documentation must properly reflect work

done according to CPT description of

consultation (key and contributing

components)

Concurrent Care and Transfer of Concurrent Care and Transfer of CareCare

Currently accepted for CPT 2010

• Concurrent care is the provision of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. When concurrent care is provided, no special reporting is required.

Concurrent Care and Transfer Concurrent Care and Transfer of Careof Care


• Consultation codes should not be reported by the physician who has agreed to accept transfer of care before an initial evaluation, but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial consultation evaluation, regardless of site of service.

Concurrent Care and Transfer Concurrent Care and Transfer of Careof Care


• Transfer of care is the process whereby a physician who is providing management for some/all of a patient’s problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility, and who from the initial encounter is not providing consultative services. The physician transferring care is then no longer providing care for these problems, though may continue providing care for other conditions when appropriate



• A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition/problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition/problem



• The written or verbal request for consultation may be made by a physician or other appropriate source and documented in the patient's medical record by either the consulting or requesting physician or appropriate source.

• The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated by written report to the requesting physician or other appropriate source.

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• The service meets the requirement for a consult

when:

– The service is not simply a continuation of care by a

consultant for an established clinical problem of an

established patient• For example, treatment in a different clinical

setting such as an E/M service for continuation of previously established outpatient care in the inpatient setting for patients admitted by another physician for a separate reason

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• The opinion rendered is of such a nature that it will be used by, and in some manner will affect, the requesting physician’s own management of, or decision-making about, the patient.

• When the referring physician will not be involved in any subsequent decision-making about the problem for which the referral has been made, the service should not be coded as a consultation.

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NON-PHYSICIAN NON-PHYSICIAN PRACTITIONERS & CONSULTS PRACTITIONERS & CONSULTS • Initial consults in the outpatient setting must be

performed entirely by the physician• Non-physician practitioners cannot perform any

portion of an initial consult and bill the consult under the physician’s provider number

• “Incident to” requires non-physician practitioner’s services to follow the treatment plan of the physician and the physician must continue to have ongoing care and update with the patient

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NON-PHYSICIAN NON-PHYSICIAN PRACTITIONERS & CONSULTSPRACTITIONERS & CONSULTS

• Consults performed in the inpatient setting cannot be shared services between the non-physician practitioner and the physician

• If the non-physician practitioner is involved, the consult must be billed under the NPP’s provider number

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PRE-OPERATIVE PRE-OPERATIVE CLEARANCECLEARANCE

• Covered Medicare service• Record must demonstrate preoperative

medical evaluation is reasonable and necessary given the patient’s medical condition and the nature of the proposed surgical procedure

• Opinion of the consultant will be used by the requesting surgeon in perioperative management of the patient

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PRE-OPERATIVE PRE-OPERATIVE CLEARANCECLEARANCE

• The E/M service documented must not constitute any of the following:– E/M service provided to fulfill the mandatory

preoperative or preadmission H&P (part of the operating surgeon’s global)

– Substitute for proper preoperative clearance by surgeon

– E/M is a continuation of outpatient services which would not affect the operating surgeon’s decision-making regarding the patient

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WHAT IS NOT A CONSULTWHAT IS NOT A CONSULT

• Initiated by patient and/or patient’s family

• If initiated at the request of a third party payer

visit is reported as a consult Requires use of Modifier “-32”, mandated services

(not recognized by Medicare)

Requires report back to third party payer

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REFERRALREFERRAL

Physician refers a patient to another physician for

the management of a particular condition –

concurrent care

• First visit is reported as new patient visit

• Referring physician relinquishes care for that

particular condition to the new physician

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CONSULTATION CODESCONSULTATION CODES

• 99241-99245 – Office or Outpatient

Consult

• 99251-99255 – Inpatient Consult Codes

• 99251-99255 – Initial Consults in the

Skilled Nursing Facility/Nursing Facility

USE OF HOSPITALISTSUSE OF HOSPITALISTS

• Many facilities in an effort to retain monies within the hospital system have added hospitalists to their staff

• Facilities are encouraging associated providers to utilize hospitalists for admitting their patients

• Many physicians are utilizing hospitalists because it eliminates the “extra” work of an admission


• As a substitute for this “quality of life” issue for the nephrologist using hospitalists there is a economic issue

• When you initiate a “consult” by requesting a hospitalist admit, it is difficult to meet the criteria for a consultation thus making the initial encounter in the inpatient setting subsequent care or dialysis


• There are arguments for using hospitalists, including hospital relations

• One must weigh the positives and negatives to determine if this is a choice the individual nephrologist or group makes

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CONSULT TIDBITSCONSULT TIDBITS

• Inpatient consultation may only be reported once per consultant per facility admission

• If the consultant continues to care for the patient following the initial consultation, report additional visits using established patient visit codes

• Reason for the consultation must be documented in the medical record along with the name of the requesting provider

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TIPS FOR PREVENTING CODING ERRORS WITH E/M CODING

• Consultation – before coding a consult ask these questions about the service – if the answer is “NO” to any, do not report as a consult– Did you receive a request for an opinion from

another provider?– Does your documentation of the service clearly

demonstrate who made the request and the nature of the opinion requested?

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• Consults – cont.– Have you provided a written report of your

opinion/advice to the requesting physician?– Though the requesting physician may have asked

for a “consultation” should the service provided be reported as a consult?

• Will your opinion be used by, and in some manner effect the requesting physician’s own management of the patient or is it a transfer of care for a particular problem?

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• Consults – cont.• Will the requesting physician be involved in

subsequent decision making about the problem for which the request has been made?

• For pre-operative “consultations”, is the service requested specifically for pre-operative clearance that is medically necessary considering the patient’s condition and the procedure planned?

• Is the pre-operative “consultation” a substitute for the mandatory H&P to be provided by the operating surgeon?

– THIS IS NOT A SEPARATELY BILLABLE SERVICE

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DISCHARGE DISCHARGE MANAGEMENTMANAGEMENT

SERVICESSERVICES

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DISCHARGE CRITERIADISCHARGE CRITERIA

• The hospital discharge day management codes are to be used to report the total duration of time spent by a physician for final hospital discharge of a patient. The codes include, as appropriate, final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms.

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• **NEW** - CHANGE REQUEST 5794 – TRANSMITTAL 1460 – Effective Date April 1, 2008 – Implementation Date April 7, 2008

• Discharge services are considered a face-to-face service• Billable only by the attending physician• Discharge day services by other physicians are billing

used 99231-99233• Bill on the day the visit by the physician is done even if

the patient is discharged on a different calendar day

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• Medicare pays for the paperwork of patient discharge as part of the pre- and post-work of the E&M service

• Medicare does not pay for a subsequent hospital visit (99231-99233) on the same day as a discharge

• Medicare pays for the hospital discharge in addition to a nursing home admit when billed by the same physician on the same date of service

• Change request 5794, transmittal 1460

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DISCHARGE CRITERIA

• Medicare pays only for the physician who personally performs the pronouncement of death for the discharge day management service. The date of pronouncement shall reflect the calendar date of service on the day it was performed even though the paperwork is delayed.

• This can be the attending or any other physician• These changes are reflected by CR 5794,

Transmittal 1460

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DISCHARGE MANAGEMENT

• 99238 – Discharge management – 30 minutes or less

• 99239 – Discharge management – over 30 minutes

• Since time driven code requires documentation of services rendered and time spent performing services

• If time is not documented, 99238 is billed

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NEPHROLOGYNEPHROLOGY SPECIFIC SPECIFIC

CPT CPT CODINGCODING

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INPATIENT DIALYSIS CODESINPATIENT DIALYSIS CODES• 90935 - Single physician evaluation of hemodialysis

• 90937 - Multiple physician evaluation of hemodialysis

• 90945 - Single physician evaluation of continuous

forms of dialysis

• 90947 - Multiple physician evaluation of continuous

forms of dialysisIncludes E&M services rendered on the same day except

admission, consultation or discharge services

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INPATIENT DIALYSIS CODESINPATIENT DIALYSIS CODES

To bill the physician must meet the following:

1.Be present during the dialysis treatment

2.Documentation must reflect presence during the treatment

3.The need for repeated visit should be noted in the patient’s chart. The note should include the problem or anticipated problem which required the physician’s repeat evaluation

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INPATIENT DIALYSIS CODESINPATIENT DIALYSIS CODESFour E/M services that can be billed on the

same day as dialysis services

1.Hospital admission

2.Hospital discharge

3. Inpatient consultation

4.Critical CareMost carriers require the use of a “-25” modifier on the E/M

code on the same day as a procedure

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EXAMPLE: DIALYSIS NOTE 90935• Date: 20 February 2009, 1225 h• Procedure: Patient seen on Hemodialysis• Location: Surgical intensive care unit• Physician: Paul Nephron, MD• Indication: Acute renal failure, glomerulonephritis• Rx: Qb=350, Qd=800, Td=255 min, dialyzer=F8,

dialysate=2 K, 2.5 Ca, 35 HCO3, target= -3.5 L– Transfuse 2 units PRBCs, 25 g SPA– Anticoagulation=2000 units bolus, 1000 units

continuous infusion– Target: ACT 1.5-2X baseline

• Access: Right femoral vein double lumen catheter• Comments: BP 165/98, P 88, wt 154 lb

– Chest: bibasilar rales; Cor: S1 S2 RR– Exts: 5 mm bilateral pitting into thighs– Hb 7.8, K 6.3, Alb 2.2

• Sign and time stamp note

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EXAMPLE: JUSTIFICATION 90937 • 20 February 2009, 1445 h• Chest pain

– Seen again on dialysis• Pleuritic chest pain 2 h into treatment• 1.5 L fluid removed, SPA given, PRBCs pending• NTG SL given x 1 with minimal relief in 10 min

– BP 108/64, P 105 reg• Chest: bibasilar rales, left anterior chest wall pain reproduced with palpation• Cor S1, S2, no rubs; Exts: 5 mm edema bilaterally• ECG: no interval changes• Chest pain, most likely non-cardiac in origin

– Continue dialysis• Transfuse 2 units PRBCs as planned

– Sign and time stamp note

90937 vs CRITICAL CARE

WHEN IS EACH APPROPRIATE?

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CODING FOR CRITICAL CODING FOR CRITICAL

CARECARE

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9929199291

• Critical care, evaluation and management of the

critically ill or critically injured patient; first 30-

74 minutes

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99292

• Critical care, evaluation and management of the

critically ill or critically injured patient; each

additional 30 minutes

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CPT DEFINITIONCPT DEFINITION CRITICAL ILLNESS OR INJURY CRITICAL ILLNESS OR INJURY

• “A critical illness or injury acutely impairs one

or more vital organ system(s) such that there is

a high probability of imminent or life

threatening deterioration in the patient’s

condition.”

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CPT DEFINITIONCPT DEFINITION CRITICAL CARE SERVICES CRITICAL CARE SERVICES

• “Critical care is the direct delivery by a physician(s) of medical care for a critically ill or injured patient.”

• “Involves decision making of high complexity to assess, manipulate, and support system function(s), to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.”

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CPT DEFINITIONCPT DEFINITION CRITICAL CARE SERVICES CRITICAL CARE SERVICES

Examples of Vital Organ System Failure

• Central nervous system failure

• Shock

• Circulatory failure

• Renal failure

• Hepatic failure

• Respiratory failure

• Metabolic failure

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CPT DEFINITION CRITICAL CARE SERVICES

• Critical care may be provided on multiple days,

even if no changes are made in the treatment

rendered to the patient, provided that the

patient’s condition continues to require the level

of physician attention as previously described.

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WHERE CRITICAL CAREWHERE CRITICAL CARE IS PROVIDED IS PROVIDED

• Critical care is usually, but not always, given in

a critical care area, such as the coronary care

unit, intensive care unit, pediatric intensive care

unit, respiratory care unit, or the emergency care

facility.

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CRITICAL CARE CRITICAL CARE TREATMENT CRITERIONTREATMENT CRITERION

• Critical care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician.

• Failure to provide these interventions on an urgent basis would result in life threatening deterioration in the patient’s condition.

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CRITICAL CARE CRITICAL CARE “FULL ATTENTION” “FULL ATTENTION”

REQUIREMENTREQUIREMENT• “Critical care is used to report the total duration

of time spent by a physician providing critical care services to a critically ill or injured patient, even if the time spent by the physician on that date is not continuous. For the time spent, the physician must devote his or her full attention to the patient…”

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WHERE IS CRITICAL CARE WHERE IS CRITICAL CARE PROVIDEDPROVIDED

• Time spent with the individual patient must be recorded in the patient’s record.

• Time spent can be reported if spent is at the bedside or on the unit or floor, i.e.. Coordinating care, but cannot be in caring for another patient.

• Can include time spent with family, etc. when the patient cannot make decisions for self.

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CRITICAL CARECRITICAL CAREDOCUMENTIONDOCUMENTION

FOR MEDICAL REVIEW FOR MEDICAL REVIEW• Must indicate full attention provided• Since time based, must contain documentation of total

time involved • Time involved with family to gain pertinent history or

make decisions must be documented• Telephone calls to family members to be considered

must meet same criteria as face-to-face

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SERVICES SERVICES NOTNOT INCLUDED IN INCLUDED IN CRITICAL CARE TIMECRITICAL CARE TIME

• Time spent providing services not bundled into critical care time

such as dialysis or access placement are not included

• Services rendered earlier in the day prior to the patient’s need

for critical care. This service can be reported separately, but

documentation needs to be sent with the claim and a modifier (-

25) needs to be appended to this service. CR 5792

• Time spent updating patient’s family about status not meeting

previous criteria regardless of how lengthy

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CRITICAL CARE & DIALYSIS

• Dialysis (90935, 90937, 90945, 90947) is not included in Critical Care time

• Make sure a separate note is made for dialysis and all the criteria for billing dialysis are met…physical presence during the treatment

• Append a “-25” modifier to the Critical Care code

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CRITICAL CARE TIDBITSCRITICAL CARE TIDBITS

• 99291 is used to report first hour (30-74 minutes) of critical care

• 99292 is used to report each additional 30 minutes• 99292 is used to report final 15-30 minutes of critical

care• Critical care of less than 30 minutes is reported using

appropriate E/M code • Only one physician may bill for a given hour of critical

care even if more than one physician is providing care

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• Critical Care – Before coding for critical care, ask the following questions. If the answer is “NO” do not report as critical care.– Does the record documented show work

performed to be more intense than work of other E/M services of the same time duration?

– Does the record demonstrate the patient has acute impairment of one or more vital organ systems and has a high probability of imminent or life-threatening deterioration?

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• Critical Care – cont.– Does the documentation demonstrate all of the

following?• Direct personal management.• Frequent personal assessment and manipulation (not

just the general once-a-day visit).• High-complexity decision-making to assess,

manipulate and support vital system function(s) to treat single or multiple organ system failure or to prevent further deterioration.

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• Critical Care – cont.• Interventions of a nature that failure to initiate these interventions on

an urgent basis would likely result in sudden clinically significant or life-threatening deterioration in the patient’s condition.

– What about the time spent providing critical care?• Is specifically recorded?

• Is it reasonable considering the documented work provided?

• Does it exclude time spent performing procedures separately billable?

• If it includes time spent with family, was the family members operating as a surrogate decision-maker because the patient was unable to make decisions?

Compliance Compliance AssessmentAssessment

Compliance AssessmentCompliance Assessment

• Who

• What

• Where

• When

• Why


Why

1.To get paid for your work you must document

2.Audit and review within a practice produces better coding and billing

3.PQRI will be replaced by deductions so –be prepared

2009 Nephrology Specific PQRI 2009 Nephrology Specific PQRI MeasuresMeasures

MEASURE NUMBER

MEASURE DESCRIPTIONREPORTING OPTIONS

END STAGE RENAL DISEASE (ESRD)

79 Influenza Immunization in Patients with ESRD Claims, Registry

81 Plan of Care for Inadequate Hemodialysis Registry

82 Plan of care for Inadequate Peritoneal Dialysis Registry

CHRONIC KIDNEY DISEASE (CKD)

121Laboratory Testing (calcium, phosphorus, intact parathyroid hormone (iPTH) and lipid profile)

Claims, measures group (MG), and Registry

122 Blood Pressure ManagementClaims, MG, and Registry

123Plan of Care for Elevated Hemoglobin for Patients Receiving ESA Therapy

Claims, MG, and Registry

135 Influenza Immunization in Patients with CKDClaims, MG, and Registry

153 Referral for AV FistulaClaims, MG, and Registry

2009 Claims Based Reporting2009 Claims Based Reporting• Same reporting requirements from 2007 and 2008

programs– Must report at least 3 quality measures on at least 80% of

claims where PQRI measures could be reported.– Validation through denominator coding. Applicable cases

defined by CPT codes included in the denominator of each PQRI measure.

• ESRD PQRI measures – denominator codes include all MCP codes as well as inpatient dialysis codes

• CKD PQRI measures – denominator coding includes E/M codes • Diabetes PQRI measures – denominator coding includes E/M codes

as well as diabetes self management codes

• Claims must contain a line-item ICD-9 diagnosis code accompanied by a specific CPT patient encounter code along with PQRI quality data codes (QDCs)

03 17 09 03 17 09 11 99213 1 50 00 123456789 03 17 09 03 17 09 11 3278F 1 0 00 123456789

585.5

03 17 09 03 17 09 11 3281F 1 0 00 123456789

Make sure that diagnosis is included in the PQRI measure specifications

Each PQRI measure must have individual NPI #

PQRI claims MUST contain a service (CPT) code that is included in the PQRI measure denominator

03 17 09 03 17 09 11 4171F 1 0 00 123456789

03 17 09 03 17 09 11 4037F 1 0 00 123456789

PQRI and eRx resources PQRI and eRx resources available on RPA’s websiteavailable on RPA’s website

www.renalmd.org/pqri Contains nephrology-specific information on

PQRI and eRx incentive programsProvides information

http://www.renalmd.org/pqri


What

1.Hospital records v billing

2.Office records v billing

3.Dialysis services v billing

4.Receipts v billing

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BILLING FOR BILLING FOR

ERYTHROPOIETIC STIMULATINGERYTHROPOIETIC STIMULATING

AGENTSAGENTS

CAUTIONCAUTION!

• POLICIES CHANGE QUICKLY!!

• Please review your own carriers LCD on a monthly basis.

• Also review the NCD regularly.

• Knowledge in this arena is vital.

• An ounce of prevention……….

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110

• Pretreatment HCT

Level of less than 30

• Creatinine of 3.0 or

greater OR

• Documented renal

insufficiency (stage 3-

5)

• Patient’s current weight

in kilograms

• Date of lab (within 7

days - this may vary by

location)Please understand this is an example &

not intended to be taken as policy!

INITIALINITIAL ESA ESA (Epoetin Alfa & (Epoetin Alfa & Darbepoetin Alfa)Darbepoetin Alfa) ADMINISTRATION ADMINISTRATION

EXAMPLEEXAMPLE GUIDELINESGUIDELINES

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FOLLOW-UP ESA FOLLOW-UP ESA (Epoetin Alfa & (Epoetin Alfa & Darbepoetin Alfa)Darbepoetin Alfa) ADMINISTRATION ADMINISTRATION

EXAMPLEEXAMPLE GUIDELINESGUIDELINES

• Current HCT level to max of 36 or multiply of Hgb x 3

• Date of Laboratory Data (within the last 30 days)

• ICD-9 code appropriate for state– Please understand this is an example & not intended to be taken

as policy!

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COMPLETING HCFA 1500 FormCOMPLETING HCFA 1500 Form

• Diagnosis codes– 285.21 Anemia in CKD & stage of CKD if required

• Dates of service• HCPCS code: J0885 (Procrit); J0881(Aranesp)• Units administered – per 1000 units• Other data as required

– Intermediary/carrier specific– Hct or Hb, SCr with date, weight in kg, exceptions

requests (altitude, comorbid condition), EJ modifier

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DRUG CODESDRUG CODES

• J0881 – Darbepoetin alfa, 1 mcg (non-ESRD)

• J0882 – Darbepoetin alfa, 1 mcg (ESRD use)

• J0885 – Epoetin alfa, 1000 units (non-ESRD)

• J0886 – Epoetin alfa, 1000 units (ESRD use)

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BILLING FOR BILLING FOR ADMINISTRATION OF ESAADMINISTRATION OF ESA

• Drug and administration is covered “incident

to” physician service

• If the purpose of the visit is for an injection, use

96372 for the subcutaneous administration of

either Procrit or Aranesp

• 99211 is only used when another service, not

protocol for the injection, is provided

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BILLING FOR BILLING FOR ADMINISTRATION OF ESAADMINISTRATION OF ESA

• When the drug is administered “incident to” a physician’s visit, bill the appropriate level of E&M for the physician visit with a “-25” modifier (CCI edit effective 10/1/05), the administration fee 96372 and the drug.

• REMEMBER: The provider must be physically present in the suite when the injection is given to bill for the administration or the drug

CHANGES IN BILLING FOR CHANGES IN BILLING FOR ESAESA

• Effective January 1, 2008• Effective for all non-ESRD claims with J0881 and

J0885• EA : ESA, anemia, chemo-induced• EB : ESA, anemia, radio-induced• EC : ESA, anemia, non-chemo/radio induced• Without modifier will deny w/MA130 (no appeal

rights submit new claim)

CHANGES IN BILLING FOR CHANGES IN BILLING FOR ESAESA

• Test results are reported in Item 19 of the CMS 1500

• For electronic claims (837P) report H/H readings in Loop 2400 MEA segment

• MEA01=TR (test results), MEA02=R1 (hemoglobin) R2 (hematocrit), and the most recent result (3-digits)

• Ex: 10.5 hgb (TR/R1/10.5)

Health & Medicine

07 Am09 Presentations Hamburger & Lawson