Coding and Compliance

1. Coding and Compliance Credentialing and Recredentialing Program for Anesthesia Faculty School of Medicine Compliance Office 843-8638

3. Why coding and complianceis important to you and your practice

4. Reimbursement Doing only what is medically necessary Documenting what you do Billing what you document

5. Residents are paid through the hospital by Part A Medicare. Medicare pays a portion of the residents’ salaries based on the proportionate share of Medicare at the teaching hospital. Teaching physicians are paid by Part B Medicare on a fee-for-service basis. The government, through Medicare, will pay for both resident and TP services if both participate. If the TP does not participate in a given patient service, the TP cannot bill. Why Compliance

6. Why Compliance Medicare and Medicaid require teaching physician presence for key parts of anesthesia services and personal documentation of that presence in order to bill for the service Medicare requires similar personal presence and documentation for billing of evaluation and management services (consultations) and other procedures Medicaid consultations and other evaluation and management (E&M) services require that the TP be "immediately available" to the resident and use "direct supervision" for procedures. The teaching physician must co-sign the resident note and assume responsibility for the patient’s care.

7. Documenting Anesthesiology Services This short course will focus on the services below which account for over half of the dollar volume of all anesthesia billings General anesthesia services Consultations Daily inpatient follow-up Regional Anesthesia Procedure Note Subsequent Daily Management of Catheters

8. General Anesthesia Services

9. General Anesthesia-medical direction Medicare and Medicaid physician requirements for coverage of medical direction of nurse anesthetists

10. Medicare and Medicaid require the billing physician to document the following: Medical direction - documentation

11. Medicare/Medicaid require a concurrency modifier -AA    -   Physician personally performed. -QY    -   Medical direction of one CRNA by an anesthesiologist. -QK   -    Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. -AD    -   Medically supervised by a physician for more than four concurrent procedures. -QX    -   CRNA with medical direction by a physician. -QZ    -   CRNA without medical direction by a physician. -QS    -   Monitored anesthesiology care services (can be billed by a CRNA or a physician).

12. Medical direction or supervision Medical direction of one CRNA payment at 50% of each provider’s allowable Medical direction of two, three or four concurrent procedures Physician services are not payable by Medicare or Medicaid if the billing physician: leaves the immediate area of the operating suite for more than a short duration devotes extensive time to an emergency case or is otherwise not available to respond to the immediate needs of the patient Supervision of more than four concurrent procedures Anesthesiologists are reimbursed at a lower rate CRNA will get paid at the above rate

13. Medicare and Medicaid payment may be made for attending physician services when a resident is involved in the patients care if the teaching physician: personally examines the patient is present at induction and emergence performs other activities that distinguish an attending physician relationship The teaching physician must personally document h/her involvement in the record.

14. Basic value + Time units + Physical status modifier + Any qualifying circumstances + Any additional modifiers for unusual procedures or services How anesthesia services are paid

15. A basic value is listed for anesthetic management of most surgical procedures Base unit includes pre and post anesthesia care administration of fluids and/or blood products incident to anesthesia care interpretation of non-invasive monitoring Base unit does not include placement of arterial, central venous and pulmonary artery catheters use of transesophageal echocardiography (TEE) How anesthesia services are paid

16. Time units Begins when the anesthesiologist begins to prepare the patient Ends when the patient may be safely placed in post-anesthesia supervision Generally reported in units of 15 minutes, Medicare requires actual minutes

17. Physical status modifiers All anesthesia services are reported using one of the following modifiers How anesthesia services are paid

18. Qualifying circumstances Bill as many as apply for extraordinary conditions, unusual risk factors or notable conditions in addition to the procedure code How anesthesia services are paid

19. How anesthesia services are paid Additional modifiers for unusual procedures or services 22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedures, it may be identified by adding modifier “22” to the usual procedure code. Documentation is required to be sent with claim. 23 Unusual Anesthesia: Occasionally a procedure which usually requires either no anesthesia or local anesthesia, because of unusual circumstances, must be done under general anesthesia. 25 Significant, separately identifiable evaluation and management service performed by the same physician on the same day as a procedure. Added to the E&M service for both to be paid.

20. The Anesthesia Record

22. The back side of the Anesthesia Record blue striped copy - for reimbursement

24. Evaluation and Management (E&M) Services

25. Evaluation and Management Categories Inpatient E&M categories for anesthesiologists: Inpatient consultations (5 levels) 99251- 99255 Subsequent hospital care (3 levels) 99231-99233

26. Consultations A consultation is an E&M service provided by a physician whose opinion and advice is requested by another physician or appropriate source involved in that patient’s care Consultations should be viewed as a three-part cycle (1) a request is made (2) an evaluation is undertaken and (3) an opinion is rendered and sent to the requesting physician. The consultant may initiate diagnostic and/or therapeutic services at the same visit.

27. Medicare Outpatient E&M Allowables The consultation statement of request is very important because reimbursement for consult services, as you see in the far right column, is substantially more than for established patients or even new patients. The difference in reimbursement for the five levels of service are another reason to accurately reflect the complexity of visits in your notes. All payers strive to reimburse for the amount of effort it takes to treats the patient at the particular visit so new patients are paid at a higher rate than established patients and require more extensive support in documentation.The consultation statement of request is very important because reimbursement for consult services, as you see in the far right column, is substantially more than for established patients or even new patients. The difference in reimbursement for the five levels of service are another reason to accurately reflect the complexity of visits in your notes. All payers strive to reimburse for the amount of effort it takes to treats the patient at the particular visit so new patients are paid at a higher rate than established patients and require more extensive support in documentation.

28. E&M Components History Physical examination Medical decision making

29. E&M Components (continued) History Physical examination Medical decision making

30. E&M Levels - Subcomponents

31. E&M Levels – History Subcomponents History History of present illness Review of systems Past family and social history

32. E&M Levels – Physical Examination Subcomponent the 1995 Medicare guidelines or the 1997 Medicare guidelines

33. E&M Levels – Medical Decision Making Subcomponent Number of diagnostic or management options Amount and complexity of data reviewed Overall risk of the treatment plan or patient’s condition

34. E&M Levels, Other billing information Though not required, there is a detailed E&M coding course at www.med.unc.edu/compliance/education-resources-1 The laminated, lab coat pocket-sized physician’s coding cards are valuable guides to correct coding and documentation. Additional training on anesthesiology billing from Per-Se Technologies is available on the Department’s network. It can be found on anesdata/shared/compliance and documentation training/physician anesthesia coding inservice

35. Consultations The attending physician must personally perform or observe the key portions of the history, physical exam and medical decision making and write a personal note so indicating in the record for Medicare patients. Inpatient anesthesia service consults should be documented on the WebCIS “create note” template for Inpatient Consultation Notes. When entered by a resident they are forwarded to the attending anesthesiologist’s activity list for the appropriate personal attestation and signature.

37. Complete “Subsequent Daily Management of Catheter” form each day the patient is seen for an epidural placed solely for post-op pain Write the reason you are seeing the patient in the diagnosis blank For Medicare to be billed, the attending must be present for the key portions of the service and document h/her involvement in the note. A preprinted statement does not suffice.