Billing and Coding for Optimal Reimbursement in the EMR/ICD-10 Era Webinar

1. Welcome! • To join the call: Dial (866) 740-1260, passcode 8055841#. • All participants are placed on mute for the duration of the webinar. • If you have questions, type them in the chat box at the bottom left hand side of your screen. • They will be answered at the end of the presentation. • This conference is being recorded for future use. • The recording will be made available on the ASPHO website after the Webinar.

2. Billing and Coding for Optimal Reimbursement in the EMR/ICD-10 Era ASPHO Webinar August 21, 2017

3. Introduction of Speakers • Dianne Gregory, CCS-P • HIM Physician Advocate • University of California Davis Health • Mona D. Shah, M.D. • Associate Professor • Associate Clinical Director, Quality/Safety Officer • Texas Children’s Hospital/Baylor College of Medicine • Amanda Termuhlen, M.D. • Professor of Clinical Pediatrics • Children’s Hospital Los Angeles/Keck School of Medicine

4. Why is this important? • Sustainable practice • Efficient workflow • Optimal reimbursement for complexity • Procedures • Family conferences • It’s too complicated to learn on the go!

5. Learning Objectives • Describe approaches to optimize reimbursement in your practice • Understand ways to document that will support your billing • Understand optimal billing/documentation for Pediatric Hematology Oncology procedures

6. Webinar Outline • Clinical Documentation Improvement (CDI) • Linking the symptom to diagnosis • Pediatric Hematology Oncology Diagnoses: be specific and complete! • Case examples • Admission History and Physical Examination • Consultation • Family conference • Other PHO specific billing items • Procedures • Mid-levels

7. CDI: Clinical Documentation Improvement • CDI: Improvement, Initiative, Integrity • Hospital wide committees to optimize reimbursement • Documentation review to support billing

8. Why Does This Matter? • Patient 1: “Medulloblastoma with cerebellar metastases” • Initial Admission Reimbursement: $14,461.59 • After amendment, adding “neutropenia secondary to chemotherapy”: $23,090.41 • Patient 2: “Febrile neutropenia, likely secondary to Ara-C use, needs sepsis work-up” • Initial Admission Reimbursement: $13,658.10 • Adding “CLABSI: E. coli bacteremia and Candida tropicalis fungemia”: $22,741.95 • Adding “severe malnutrition” from Dietician Note (BMI 13.4, underweight): $56,366.32 Source: TCH/BCM, Communication with M. Shah

9. When Do You Document? 1) If the condition meets one of the following criteria: • It is evaluated, monitored, treated OR increases the length of stay 2) Using Official Coding Guideline approved terms including: • Likely • Probable/possible • Suspected/questionable • Rule out/To be ruled out 3) Documenting, if the condition has been: • Ruled out • Treated and resolved • Still under treatment

10. Link Symptoms to Diagnosis/Cause • If you are using an abbreviation, spell it out at least once in the medical record, as coders cannot make assumptions. • ACS (Acute Chest Syndrome or Acute Coronary Syndrome?) • AKI (Acute Kidney Insufficiency, Acute Kidney Injury?) • ARF (Acute Renal Failure or Acute Respiratory Failure?) • Link a medical symptom to a medical diagnosis • Skin rash due to Acute/Chronic Graft Versus Host Disease secondary to bone marrow transplant • Indicate Disease Specificity • Specific type of Anemia: Aplastic Anemia, Hemolytic Anemia, Acute Blood Loss Anemia, Iron Deficiency Anemia

11. Document the Highest Degree of Specificity

12. Document the Highest Degree of Specificity

13. Be Specific with your diagnoses • Neutropenic Fever • Specify the cause of the neutropenic fever (i.e. chemotherapy, leukemia, infection (Type) • Neutropenic fever due to otitis media • Neutropenic fever due to chemotherapy • Neoplastic Disease Specificity • Documentation of type of neoplasm, primary site and all metastatic sites is crucial to capturing severity of illness and risk of mortality • Osteosarcoma (Type, Site and all Metastatic Sites) • Neuroblastoma (Site and all Metastatic Sites)

14. The Admission History and Physical Examination

15. Case 1: Patient with liver mass admitted for work up. What are Coders looking for? • What must the Admission H&P include? • Evaluation for possible malignant liver tumor • Include the differential • Include reason for inpatient work up • This is a fatal condition if left untreated. • Risk of life threatening complications such as hemorrhage, respiratory distress from mass effect, liver dysfunction.

16. What are Coders looking for in High Complexity Admission History and Physical Exam? Extended HPI, complete ROS, complete Past Medical, Family, and Social History COMPREHENSIVE HISTORY 8 body/organ systems COMPREHENSIVE EXAM Data review, consultants, number of diagnoses, new diagnoses, evaluation and monitoring COMPLEX MEDICAL DECISION MAKING

17. What are Coders looking for in a High Complexity Admission History and Physical Exam? • Does the patient have a condition that is Present on Admission? • If certain conditions are not documented as being present on admission the assumption is that it is a hospital-acquired condition and may not be reimbursable. • Specificity about the complexity • This affects the Diagnosis Related Group, which affects the risk of mortality/severity of illness, which affects the reimbursable length of stay.

18. Case 2: Admission H and PName the Opportunities for Improvement! 7 year old boy admitted with Very High Risk-ALL treated according to COG AALL1131 in Delayed Intensification part II admitted for neutropenic fever, clinically stable Neutropenic fever Most likely viral illness - respiratory panel pending Continue Vancomycin/Cefepime for empiric coverage pending blood cultures Neutropenia secondary to chemotherapy ANC < 500, monitor clinically, neutropenic precautions Continue chlorhexidine/HOMW regimens Anemia secondary to chemotherapy Hgb 9 g/dL, continue to monitor clinically Transfuse 10 mL/kg PRBCs for Hgb < 8g/dL

19. Case 2: Name the Opportunities for Improvement! Hyponatremia Na 131 in ED, Na 134 after placed on MIVF Possibly secondary to SIADH or diarrhea Follow-up Chem10 in AM to monitor sodium trends Continue MIVF until tolerating PO History of Depression Continue Prozac as per home regimen History of Osteopenia Continue Oscal as per home regimen

20. The Outpatient Consultation Case 3: 13 year old female with pancytopenia: Referring doctor is requesting evaluation of the patient and possible management.

21. What are Coders looking for in outpatient consultations? • Who requested the consult? Must list name. • Consult must be ordered by requesting service • Reason for consult: symptom or condition • Must include PMH, Family Hx, Social Hx • Recommendations • Report

22. Family conference/counseling and Prolonged Time

23. Case 4: Patient with osteosarcoma off therapy here for routine surveillance. What are Coders looking for to document complexity of visit? • List cancer diagnosis with LOCALIZATION and METASTASTIC SITES (specific) • History of antineoplastic chemotherapy • History of limb salvage procedure • Time spent counseling: late effects, secondary malignancies, disease surveillance, catch up vaccines (> 50% of visit)

24. Billing for Prolonged Time • Usually use for face-to-face and on the floor time. • Example: “More than __ minutes were spent reviewing medical records, labs, roadmap and chemotherapy plans, discussing the care/care plan with the nursing team and other healthcare providers and the patient/family and coordinating care in addition to face to face encounter with patient discussing the diagnosis and medical plan.”

25. What are the Coders looking for to bill prolonged time? • Time Spent: Documentation of the amount of time spent beyond 30 minutes on a given date • The time spent does not have to be continuous • Service Provided: Documentation of what was done that took more time than the usual evaluation and management service • Add increments of 30 minutes if needed

26. Procedures

27. Case 5: Patient with ALL in maintenance here for spinal tap with intrathecal chemotherapy, counts, and vincristine. What are Coders looking for? • Spell out the abbreviation: ALL, AML, MDS, SSD, PNA, AKI • Coding for procedure • Procedure note • Infusion of chemotherapy • Be specific in what you are monitoring • What must be included in an outpatient clinic note for higher level billing?

28. What are Coders looking for in procedure documentation? • A complete clinic note that outlines, if appropriate, the separately identifiable evaluation and management service provided during the office visit where a procedure was also performed • A clearly labeled procedure note, or • A section of the clinic note that is clearly identified as documentation of a procedure, not just mixed in with the narrative of the note

29. Billing with others

30. Billing with residents/fellows • The attestation should include your full name and that YOU did the exam yourself. • Make sure the date you did the exam is listed if you sign the note the next day • Example: “I was present and participated in the care of the patient on __. I have confirmed the interval history with the patient and caregivers directly. I have performed my own physical examination and my findings are identical to those documented by the resident save for any corrections or additions given below. The assessment and plan of care was developed together with the resident on rounds held with the resident, nursing staff, pharmacist, dietician and other team members on the same date. See resident’s note for full details of this visit.”

31. Billing with NPs and PAs • Very region specific: dual billing is not always possible • RVU claiming can have regional differences • Contact us if you have region specific questions

32. Use your key phrases! • Smart phrases, auto texts, macros, smart texts • Optimize EMR and work with EMR team to share these shortcuts among your team • PHO specific note templates (Cerner and EPIC) • Can have solid, liquid, BMT, heme templates!

33. Coded Cases • Coming in September! • Log into ASPHO and join the Practice Management Community for a monthly coding case submitted by members of the Practice Committee • Compare experiences with colleagues around the country

34. QUESTIONS? Please type them in the chat box at the bottom left hand side of your screen.

35. 2018 ASPHO Conference Save the Date 2018 Conference May 2 - 5, 2018 David L. Lawrence Convention Center Pittsburgh, PA