Moving Targets: Coding Advice To Take You From The Complex To The Simple

1. Moving Targets:Coding Advice To Take You From The Complex To The Simple T. Brian Callister, M.D., F.H.M. National Medical Director, LifeCare Hospitals President-Elect, Nevada State Medical Association Nevada State Chair, AMA-OMSS Chairman, ALTHA Clinical Committee Associate Professor, University of Nevada

2. Objectives: At the end of the lecture, the attendee will be able to: Understand how the recent coding changes effect your practice Describe how to appropriately code for consultative services List the documentation requirements for billing from the simple to the highly complex Identify techniques for appropriately maximizing reimbursement Summarize the changes necessary to convert specialty codes to new patient or follow up codes for inpatient, outpatient, nursing home, and observation levels of service

3. WAIVER: • This presentation is informational only and may not be used in differences of opinion or disputes with CMS, insurance carriers, or any other party. No implied or expressed warranty regarding this content is made, and you are urged to consult the constantly changing regulations, laws, and policies regarding coding on a regular basis.

4. Coding “101” If You Get It, They Will Change It • ICD-9 and ICD-10 • E/M and CPT • Maximizing Reimbursement • CMS – Fraud and Abuse

5. Coding “101” If You Get It, They Will Change It • Evaluation and Management Defined • Current Procedural Terminology • Medicare Physician Fee Schedule • Recovery Audits

6. The Nature of E/M Services: The ICD-9 and CPT Relationship • ICD-9 codes explain WHY the service was performed • CPT codes explain WHAT service was performed • Diagnosis codes must support the CPT code(s) assigned

7. The Nature of E/M Services: Medical Necessity • Patient’s presenting problem or reason for the visit • Level of service IS medically reasonable AND necessary • Demonstrated IN the documentation – not by the amount of documentation • Must be supported by ICD-9 diagnosis

8. The Nature of E/M Services: Evaluation and Management Defined • “Face to Face” Services • “Visit” – Examination, Evaluation, and Delivery of Care • Interaction and Independent Judgment • Documentation

9. The Nature of E/M Services: Evaluation and Management Components • History* • Examination* • Medical Decision Making* • Counseling • Coordination of Care • Nature of Presenting Problem • Time • * Key Component

10. The Nature of E/M Services: Evaluation and Management Components • Concurrent Care • Similar services, same day • Unit/Floor Time • Observation, inpatient, nursing home • Includes chart, exam, writing notes, discussion with family and/or other professionals

11. Medical Decision Making: CMS and CPT Descriptions • Elements • Number of diagnoses & management options • Amount of data reviewed and orders • Level of risk of complications/morbidity/mortality • Levels • Straightforward • Low • Moderate • High • To qualify for a given type of decision-making, two of the three elements must be met or exceeded

12. Leveling Medical Decision-Making

13. Overall Leveling

14. Consultations • CMS “inactivated” consultation codes • Office Consultations: 99241-99245 • Inpatient Consultations: 99251-99255 • Exception: “telehealth” initial – G0425-7

15. Outpatient Consultations • New patient – not seen within 3 years • - use codes 99201-99205 • Established patient – 99212 - 99215 • No modifier required • Exceptions • Extended time -99358-99359 • - no longer “add on” • - can be used independently • - may be used before or after • - MUST document

16. Crosswalk for Outpatient ConsultationsNew Patients

17. Crosswalk for Outpatient Consultations Established Patients

18. Inpatient Consultations • Use admit codes 99221-99223 • NO modifier unless admitting • Modifier “AI” for admitter • Same process for nursing home consults • Follow up codes are the same 99231-99233 • Critical Care codes often legitimate 99291-99292 • Use extended time when appropriate!!! • 99356-99357

19. Inpatient Consultations • Requesting and consulting physicians must document request for consult – put it in the orders too! • Consulting physician must document opinion and/or advice • Concurrent care denials: Issue with more than one physician in the same specialty seeing patient with the same diagnosis • Document THE problems for which YOU are seeing the patient!

20. Inpatient Consultations • Time documentation is mandatory – TOTAL TIME • Especially important in documenting PROLONGED service • 99356-99357 inpatient prolonged service codes • Greatly increase reimbursement • Legitimate use is often under utilized! • Revenue can increase 35% or more • Use with 99232 and 99233 when appropriate • Do NOT use with 99231

21. Crosswalk for Inpatient Consultations

22. Crosswalk to Time:Some Comparisons • 99255 was 110 minutes…..99223+99356 is 70 + 30 minutes • 99254 was 80 minutes…….99222+99356 is 50 + 30 minutes • 99253 was 55 minutes…99221 OR 99233 are 30 and 35 minutes • 99252 was 40 minutes……99232 is 25 minutes • 99251 was 20 minutes…....99231 is 15 minutes

23. Nursing Home Visits • 99304-99310, 99315-99316, 99318 • No longer “face to face” time only • Now definition of time is “at the bedside AND on the patient’s facility floor or unit”

24. Telehealth Consultations • By law, CMS had to retain these codes • Initial inpatient telehealth consultation codes • G0425 initial inpatient 30 minutes • G0426 initial inpatient 50 minutes • G0427 initial inpatient 70 minutes • Crosswalks to initial hospital codes 99221-99223 • Prolonged service codes NOT applicable

25. Preventative Health • G0402 – new to Medicare • Approximately equivalent to 99204 • First 12 months of Medicare enrollment • Includes body mass index • Includes end of life planning with consent • Removed EKG as mandatory service

26. Preventive Services 99397 – GY PREVENTATIVE EXAM – 65 AND > YEARS 99396 - GY PREVENTATIVE EXAM - 40 – 64 YEARS G0101 – GA PELVIC AND BREAST EXAM Q0091 – GA OBTAIN PAP SMEAR 99406 TOBACCO COUNSELING, 3-10 MINUTES 99407 TOBACCO COUNSELING > 10 MINUTES

27. Examples of OtherPreventive Services • Initial Preventive Physical Exam • EKG • Pelvic examination • Pap - obtain • Occult Blood • Flu vaccine • Pneumonia vaccine • Hepatitis vaccine • Colonoscopy patient at high risk • Colonoscopy screening exam • Prostate exam • DM self-management • Bone Mass Measurement (DEXA) • Mammogram • Smoking Cessation 3-10 minutes • Smoking Cessation > 10 minutes • Cardiovascular screening • Diabetes screening

28. G0179 - Home Health Recertification - $50 G0180 - Home Health Certification - $65 G0181 – Home Health Agency – >30 Min -$110 G0182 – Hospice Care – >30 Minutes - $116 Home Health

29. G0372 – Physician service required to establish and document the need for a power mobility device - $18 There must be an in-person physician-patient encounter. The physician must perform a medical examination for the specific purpose of assessing the beneficiary’s mobility limitation and needs. The results of this exam must be recorded in the patient’s medical record. The prescription must only be written after the in-person visit has occurred and the medical evaluation is completed. This prescription has seven required elements. The prescription and medical records documenting the in-person visit and examination report must be sent to the equipment supplier within 45 days of the completion of the examination. Power Mobility Device

30. Commercial Payers • Commercial primary and secondary – continue to bill consultation codes • Commercial primary and Medicare secondary • Bill consultation codes • Intercept and change secondary claim • Follow Medicare Rules • Medicare primary and Commercial secondary • Bill outpatient visit or inpatient visit codes OR • Intercept and change secondary claim

31. Healthcare Reform • Outcomes and Criteria Development • Accountable Care Organizations (ACO) • “Bundling” • Budget “Neutral”

32. Moving Forward… • ICD-10 and a whole new level of complexity • The “Provider” and “Doctor Nurse” • Hospitalists and the separation of primary care • Employed physicians, group practice, and the solo practitioner

33. Summary Coding rules will continue to change rapidly You have a right to legitimately maximize your reimbursement just as your patient has a right to expect high quality medical care With an aging population straining our ability to provide high quality care, it is more important than ever that we also learn to provide efficient care that is fairly compensated

34. CPT® Professional Edition, American Medical Association 2010-2011 Coding Resources and References ICD-9/HCPCS codebooks As hundreds of coding changes occur every year in E/M and ICD codes, please keep informed on an ongoing basis! For more information, visit: https://www.cms.gov/nationalcorrectcodinited/ MGMA CMS National Correct Coding Initiative Federal/State/OIG Regulations ACP 6/9/2014